Combination anticoagulation strategy in pregnancy with mechanical valves: The KYBELE study.

BACKGROUND: Optimal first-trimester anticoagulation is still challenging in pregnant women with mechanical heart valves (MHVs) requiring high-dose warfarin. This multicenter prospective study aims to determine the optimal anticoagulation regimens for pregnant patients with MHVs. METHODS: All women were allocated to one of three treatment options during first trimester including lone low-molecular-weight heparin (LMWH), combination of LMWH + 2.5 mg warfarin, and LMWH+4 mg warfarin. Primary maternal outcome included a combination of death, thromboembolism, severe bleeding, and need for treatment of mechanical valve thrombosis (MVT). Any fetal loss was determined as primary fetal outcome. RESULTS: The study included 78 pregnancies in 65 women with MHVs. Primary maternal outcome rate was 44%, 12.5%, 3.5%, respectively. The rates of primary maternal outcome (44 vs 3.5%, P < .001), obstructive MVT (16 vs 0%, P = .04), MVT requiring treatment (28 vs 0%, P = .003), and cerebral embolism (24 vs 3.4%, P = .041) were found to be significantly higher in lone LMWH group compared to LMWH + 4 mg warfarin group. Moreover, the rates of primary maternal outcome (12.5 vs 44%, P = .015) and treatment for MHV thrombus (4.2 vs 28%, P = .049) were significantly lower in LMWH + 2.5 mg warfarin group compared to lone LMWH group. The incidences of fetal loss were 8 (32%) in the lone LMWH group, 8 (33.3%) in LMWH + 2.5 mg warfarin group, and 11 (37.9%) in LMWH + 4 mg warfarin group (P = .890 for 3-group).Warfarin related-embryopathy was not observed in any case. CONCLUSIONS: The combined anticoagulation strategy of LMWH plus low-dose warfarin during the first trimester of pregnancy may result in less maternal complications with comparable fetal outcomes in patients with MHVs. CONDENSED ABSTRACT: Low-molecular-weight heparin (LMWH) is thought to be safer for the fetus, however it is suspected to be less protective for the mother. To solve this dilemma, the authors suggested a novel anticoagulation strategy in pregnant women with prosthetic valves. Seventy-eight pregnancies of 65 women (median age 32 [27-35] years) were included in the study. A combination of LMWH and a reduced dose warfarin were associated with low rates of thrombus-related complications in pregnant patients with mechanical heart valves.

Predictive value of P wave parameters, indices, and a novel electrocardiographic marker for silent cerebral infarction and future cerebrovascular events.

BACKGROUND: Silent cerebral infarction (SCI) is a neuronal injury without a clinically apparent stroke or transient ischaemic attack. Left atrial cardiomyopathy is closely associated with SCI. P wave changes in the electrocardiogram (ECG) provide significant information about the development of atrial cardiomyopathy. This study evaluated the role of P wave parameters and indices and a novel ECG parameter in predicting SCI, future cerebrovascular events, and atrial fibrillation/flutter. MATERIALS AND METHODS: A total of 272 patients were retrospectively screened and divided into two groups according to SCI. Cerebrovascular events and atrial fibrillation/flutter were defined as the study's outcomes. P wave parameters, indices, and a novel ECG parameter called the P wave ratio (PWR) were calculated from ECGs, and the relationship between SCI and outcomes was investigated. RESULTS: The maximum P wave duration (PWD), P wave dispersion (PWdisp), PWD measured from the D2 lead (PWDD2), P wave peak time measured from the D2 lead (PWPTD2), PWPT measured from the V1 lead (PWPTV1), and P wave terminal force (PWTFV1) were significantly longer in the SCI group. Both partial and advanced inter atrial block (IAB) were significantly high in the SCI group. The novel parameter P wave ratio (PWR) was significantly longer in the SCI group (0.55 ± 0.08 vs. 0.46 ± 0.09; p < 0.001). In multivariate regression analysis, PWdisp (OR: 1.101, p < 0.001), PWPTD2 (OR: 1.095, p = 0.017), and PWR (OR: 1.231, p < 0.001) were found to be independent predictors of SCI. Cox regression analysis revealed that the PWR (HR 1.077; 95% CI 1.029-1.128; p = 0.001) was associated with cerebrovascular events and atrial fibrillation/flutter. CONCLUSION: In our study, we observed that PWR could be a valuable parameter for predicting SCI and future cerebrovascular events.

Prognostic efficacy of C-reactive protein/albumin ratio in ST elevation myocardial infarction.

OBJECTIVE: Although the prognostic efficacy of C-reactive protein (mg/L) and albumin levels (g/L) has been previously associated with poor prognosis in ST elevation myocardial infarction (STEMI), to the best of our knowledge, the prognostic efficacy of C-reactive protein/Albumin ratio (CAR) (mg/g) has not been investigated yet. Thus, this study aimed to investigate the potential efficacy of the CAR in predicting prognosis in STEMI patients. METHOD: We conducted a detailed investigation of 2437 patients with first STEMI treated with a primary percutaneous coronary intervention. After evaluation regarding to exclusion criteria, 2243 patients were found to be eligible for analysis. The mean follow-up of the study was 34 ± 15 months. RESULTS: The median CAR value of the study population was 2.70 (range: 1.44-4.76), and the patients were divided into three tertiles according to their CAR values. Kaplan-Meier survival analysis showed significantly lower in-hospital and long-term survival rates for the patients in a high CAR tertile. In addition, the CAR was found to be an independent predictor of all-cause mortality (Hazards ratio: 1.033, 95% Confidence Interval: 1.007-1.061, p = .033), and the prognostic performance of the CAR was superior to that of C-reactive protein, albumin, and neutrophil to lymphocyte ratio in the receiver operating characteristic curve comparison. CONCLUSION: The CAR, a newly introduced inflammation-based risk index, was found to be a potentially useful prognostic tool for predicting a poor prognosis in STEMI patients. However, this finding needs to be validated in the future prospective studies.

A novel ECG parameter for diagnosis of acute pulmonary embolism: RS time: RS time in acute pulmonary embolism.

OBJECTIVES: Pulmonary embolism (PE) is one of the leading causes of cardiovascular mortality worldwide. Electrocardiography (ECG) may provide useful information for patients with acute PE. In this study, we aimed to investigate the diagnostic value of the QRS duration and RS time in inferolateral leads in patients admitted to the emergency department, and pre-diagnosed with acute PE. METHODS: We retrospectively enrolled 136 consecutive patients, admitted to the emergency department, pre-diagnosed with the clinical suspicion of acute PE, and underwent computerized tomographic pulmonary angiography (CTPA) to confirm the PE diagnosis. The study subjects were divided into two groups according to the presence or absence of PE, and the independent predictors of PE were investigated. RESULTS: Sixty-eight patients (50%) had PE. Patients with PE had a longer RS time. Among the ECG parameters, only RS time was an independent predictor of PE (OR: 1.397, 95% CI: 1.171-1.667; p < 0.001). The ROC curve analyses revealed that the cut-off value of RS time for predicting acute PE was 64.20 ms with a sensitivity of 85.3% and a specificity of 79.4% (AUC: 0.846, 95%CI: 0.749-0.944; p < 0.001). In the correlation analyses; the RS time was correlated with RV end-diastolic diameter (r = 0.422; p < 0.001), RV/left ventricle (LV) ratio (r = 0.622; p < 0.001), and systolic pulmonary artery pressure (SPAP) (r = 0.508; p < 0.001). CONCLUSION: As a novel ECG parameter, RS time could be measured for each patient. A longer RS time can be a very useful index for diagnosing acute PE as well as for estimating the RV end-diastolic diameter and SPAP.

Evaluation of the potential predictors of embolism in patients with left atrial myxoma.

INTRODUCTION: Cardiac myxomas are the most common primary intracardiac tumors. Although myxomas are histologically benign, they are potentially dangerous due to potential risk of systemic and cerebral embolism. In this study, we aimed to investigate the potential predictors of embolism in patients with left atrial myxoma. METHODS: This single-center retrospective study enrolled 93 patients (mean age: 52.9 ± 15.3 years, female: 70 [75.3%]) with left atrial myxomas between 2014 and 2018. The patients were classified into two groups (embolic vs nonembolic) to investigate possible predictors of embolism. Demographic, laboratory, and echocardiographic parameters were recorded into a dataset and compared between patients with and without embolism. RESULTS: The study population was composed of 13 (14%) patients in embolic (11 cerebrovascular and 2 peripheral) and 80 (86%) patients in nonembolic group. Demographic and laboratory parameters were similar between the groups. Tumor sizes were significantly higher in the embolic group than in the nonembolic group (5.59 ± 1.08 vs 4.29 ± 0.61; P = 0.001). By multivariate analysis, increased tumor size, increased left atrial diameter, and the presence of atrial fibrillation and irregular tumor surface were identified as independent predictors of embolism. In ROC curve analyses, tumor size above 4.6 cm predicted embolism with a sensitivity of 77% and a specificity of 73% (AUC: 0.858; 95% CI: 0.752-0.964; P < 0.001). CONCLUSION: The presence of atrial fibrillation, irregular tumor surface, increased tumor size, and increased left atrial diameter is associated with increased risk of embolism in patients with left atrial myxoma. Early surgery should be scheduled for such patients due to increased potential for embolism.

The C-Reactive Protein to Albumin Ratio Predicts Acute Kidney Injury in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

BACKGROUND: The relationship between acute kidney injury (AKI) and C-reactive protein (CRP) and albumin has been previously demonstrated in patients with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). However, to our knowledge, CRP to albumin ratio (CAR), a newly introduced inflammation-based risk score, has not yet been studied. In this study, we aimed to investigate the possible relationship between the CAR and AKI. METHOD: A total of 815 consecutive STEMI patients treated with pPCI were reviewed. RESULTS: One hundred ten 110 (13.5%) patients developed AKI in the study population. The subjects were divided into two groups according to AKI development. The in-hospital mortality rate was higher in patients with AKI than those without AKI (15.5% vs. 1.3%; p<0.001). The patients with AKI had significantly higher mean value of CRP and CAR (0.29 [0.16-0.50] vs. 0.55 [0.37-1.05]; p<0.001) and lower mean levels of albumin than those without AKI. Age, diabetes mellitus, haematocrit, left ventricular ejection fraction, hypotension, and CAR (Odds ratio [OR]2.307, 95% confidence interval [CI] 1.397-3.809, p=0.001) were independent predictors of AKI. CONCLUSION: The CAR may be a useful inflammation-based risk score to predict AKI development in STEMI patients treated with pPCI.

Usefulness of The C-Reactive Protein/Albumin Ratio for Predicting No-Reflow in ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: The ratio of serum C-reactive protein (CRP) to albumin has been proven to be a more accurate indicator than albumin and CRP levels alone in determining the prognosis of patients with cancer and critical illness. The aim of this study was to determine whether the CRP/albumin ratio (CAR) can be linked to imperfect reperfusion that can worsen the prognosis of ST-elevation myocardial infarction (STEMI) in patients treated with primary percutaneous coronary intervention (pPCI). MATERIALS AND METHODS: A total of 1217 consecutive STEMI patients who achieved epicardial vessel patency with pPCI were recruited to this study. RESULTS: The study population was divided into 2 groups: reflow (n = 874) and no-reflow (NR) (n = 343) groups. The white blood cell count (WBC), neutrophil-to-lymphocyte ratio (NLR) and CAR (0.03 [0.01-0.04] vs 0.06 [0.03-0.12] (P < .001) were significantly higher in the NR group than in the reflow group, and these factors were found to be independent predictors of NR development. The best cut-off value of CAR predicting NR was 0.59 with a sensitivity of 54.7% and specificity of 86.7. The predictive power of CAR surpassed that of CRP, albumin, WBC count and NLR in the receiver operator curve (ROC) curve comparison. CONCLUSION: No-reflow can be predicted by systemic inflammation markers including WBC count, NLR and CAR measured from the blood sample obtained on admission. CAR has a higher clinical value than CRP, albumin level, WBC count and NLR in NR prediction.

Relationship Between Pulmonary Venous Flow and Prosthetic Mitral Valve Thrombosis.

BACKGROUND: Prosthetic valve thrombosis (PVT) may impair pulmonary venous flow (PVF) and left atrial appendage (LAA) functions. An investigation was conducted to determine the association between left superior PVF and LAA functions and mitral PVT. METHODS: This observational case-control study included 100 consecutive patients (87 females, 13 males; mean age 59 years; range 35-71 years) with mechanical mitral PVT, and 50 age- and gender-matched otherwise healthy controls with normally functioning mitral prostheses. All patients were included after comprehensive transesophageal echocardiography (TEE) examinations for the presence and quantification of PVT, the left atrial diameter, and LAA length. Peak systolic velocity (PSV), velocity-time integral of systolic flow (VTI-s), peak diastolic velocity (PDV), velocity-time integral of diastolic flow (VTI-d), systolic fraction (SFr) of the left upper PVF and the flow of the LAA orifice were each recorded using color-guided pulsed-wave Doppler imaging during TEE. RESULTS: The PSV [30 cm/s (range: 13-77 cm/s) versus 44 cm/s (range: 16-71 cm/s)], respectively (p = 0.002), VTI-s [(2.85 cm (range: 0.5-10.7 cm) versus 5 cm (range: 1.3-12.7 cm)], respectively (p <0.001), VTI-d [(3 cm (range: 0.6-9.7 cm) versus 4.2 cm (range: 1.5-8.3 cm)], respectively (p <0.001), SFr (45.5% (range: 15.66-67.44%) versus 50 % (range: 21.11-82.61%)], respectively (p = 0.008), and LAA orifice velocity [(23 cm/s (range: 11-75 cm/s) versus 34 cm/s (range: 10-112 cm/s)], respectively (p = 0.011) were each significantly lower in patients with PVT compared to controls. The PDV was similar between groups. Patients with obstructive PVT (n = 21) had a lower PDV and a higher VTI-d compared to those with non-obstructive PVT. CONCLUSIONS: Mitral mechanical PVT is associated with decreased systolic PVF and LAA function. The presence of obstructive PVT is associated with further limitations of diastolic flow velocity, and a compensatory prolongation of diastolic flow of the left upper pulmonary vein.

Propensity score matching analysis of the impact of Syntax score and Syntax score II on new onset atrial fibrillation development in patients with ST segment elevation myocardial infarction.

BACKGROUND: New-onset atrial fibrillation (NOAF) is a common complication in the setting of ST segment elevation myocardial infarction (STEMI), and worsened short/long-term prognosis. Several clinical parameters have already been associated with NOAF development. However, relationship between NOAF and coronary artery disease (CAD) severity in STEMI patients is unclear. This study evaluates the relationship between NOAF and CAD severity using Syntax score (SS) and Syntax score II (SSII) in STEMI patients who were treated with primary percutaneous coronary intervention (pPCI). METHOD: We enrolled 1,565 consecutive STEMI patients who were treated with pPCI. Patients with NOAF were compared to patients without NOAF in the entire study population and in a matched population defined by propensity score matching. RESULTS: Patients with NOAF had significantly higher SS and SSII than those without, both in the matched population (18.6 ± 4 vs 16.75 ± 3.6; p < .001 and 42 ± 13.4 vs 35.1 ± 13.1; p < .001, respectively), and in all study population (18.6 ± 4 vs 16.5 ± 4.6; p < .001 and 42 ± 13.3 vs 31.5 ± 11.9; p < .001 respectively). SSII, compared to its components, was the only independent predictor of NOAF (OR: 1,041 95% CI: 1.015-1.068; p = .002). In the long-term follow-up, all-cause long-term mortality was significantly higher in patients with NOAF than those without NOAF (23.3% vs. 11%; p = .032). CONCLUSION: This is the first study to comprehensively examine the relationship between NOAF development and CAD severity using SS and SSII. We demonstrated that, in STEMI patients, high SSII was significantly related to NOAF and was an independent predictor of NOAF. Furthermore, patients with NOAF were associated with poor prognosis.

Successful treatment of massive thrombosis in different locations with prolonged thrombolytic therapy: A life-saving intervention.

Venous thrombosis is recognized as one of the most important complications of nephrotic syndrome (NS). In patients with NS, venous thrombosis may develop in the renal veins, the deep veins of the lower limb, and the inferior vena cava. Here, we describe a case report of an NS patient with multiple venous thrombosis in the right renal vein, the left iliac vein, the vena cava inferior, the right atrium, and the pulmonary arteries. Moreover, we describe the successful treatment of multiple venous thrombosis with prolonged thrombolytic treatment in spite of an increased risk of bleeding due to renal biopsy.

Diagnostic value of QRS and S wave variation in patients with suspicion of acute pulmonary embolism.

BACKGROUND: This study aimed to investigate the diagnostic value of QRS and S wave variation in patients admitted to the emergency department with suspicion of acute pulmonary embolism (APE). METHOD: Computerized tomographic pulmonary angiography (CTPA) was performed in 118 consecutive patients to evaluate patients with suspected APE, and 106 subjects with appropriate electrocardiogram and CT images constituted the study population. RESULTS: Using CTPA, APE was diagnosed in 48.1% (n:51) of the study population. The comparison of patients with APE and those without APE revealed that increased heart rate, right axis deviation of QRS axis, complete or incomplete right bundle branch block, prominent S wave in lead D1, increased QRS duration, percentage of QRS (9,8[4,8-19,0] vs 3,8[2,7-71]; p<0,001), S wave variation (22,3[9,6-31,9] vs 4,8 [2-8]; p<0,001) and ΔS wave amplitude (1.1[0.5-1.5] vs 0.2[0.1-0.5]; p<0.001) were significantly associated with APE, but no relationship was detected with respect to the presence of atrial arrhythmias, clockwise rotation of the horizontal axis, fragmentation, ST segment deviation, T wave inversion, and S1Q3T3 and S1S2S3 patterns. The percentage of S wave variation (OR: 1072 per 1% increase, 95% CI:1011-1137) was found to be an independent predictor of APE. ΔS wave amplitude>0.5mm predicted APE with a sensitivity of 72.6% and a specificity of 74.6% (AUC:0.805, 95% CI: 0.717-0.876; p<0.001). CONCLUSION: The present study demonstrated that QRS and S wave variation could be useful electrocardiographic signs for the diagnosis of APE.

Relationship between C-reactive protein/albumin ratio and coronary artery disease severity in patients with stable angina pectoris.

BACKGROUND: Syntax score (SS), which is an angiographic tool used in grading the complexity of coronary artery disease (CAD), has prognostic importance in coronary artery disease (CAD) and provides important information regarding selection of revascularization strategy. C-reactive protein (CRP) and albumin are indicators of inflammation, and high levels of them are associated with high SS. We aimed to investigate whether baseline CRP to albumin ratio C-Reactive Protein/Albumin Ratio (CAR), an easily available and novel inflammatory marker, is associated with SS. METHOD: A total 403 consecutive patients with stabile angina pectoris, who underwent coronary angiography for suspected CAD from January 2015 to June 2016, were classified into two groups, low SS (≤22) and intermediate-high SS (>22). RESULTS: C-Reactive Protein/Albumin Ratio was significantly higher in patients with intermediate-high SS group (P < .001). In multivariate regression analysis, CAR remained an independent predictor of intermediate-high SS group together with hypertension and LDL. The predictive performance of CAR, CRP, and albumin was compared by ROC curve analysis. CAR surpassed CRP and albumin in predicting intermediate-high SS group. CAR >6.3 predicted an intermediate-high SS with sensitivity and specificity of 86.8% and 43.4%, respectively. CONCLUSION: C-Reactive Protein/Albumin Ratio was more tightly associated with the complexity and severity of CAD than CRP and albumin alone and was found to be an independent predictor for intermediate-high SS group.

Fragmented QRS may predict new onset atrial fibrillation in patients with ST-segment elevation myocardial infarction.

BACKGROUND: Fragmented QRS (fQRS) has been shown to be a marker of local myocardial conduction abnormalities, cardiac fibrosis in previous studies. It was also reported to be a predictor of sudden cardiac death and increased morbidity and mortality in selected populations. However, there is no study investigating the role of fQRS in the development of atrial fibrillation in patients with ST segment elevation myocardial infarction (STEMI). In this study we aimed to investigate the relationship between the presence of fQRS after primary percutaneous coronary intervention (pPCI) and in-hospital development of new-onset atrial fibrilation (AF) in patients with STEMI. MATERIAL AND METHODS: This study enrolled 171 patients undergoing pPCI for STEMI. Among these patients 24 patients developed AF and the remaining 147 patients were designated as the controls. All clinical, demographical and laboratory parameters were entered into a dataset and compared between AF group and the controls. RESULTS: The presence of fQRS was higher in the AF group than in the controls (P=0.001). Diabetes mellitus and fQRS was significantly more common in the AF group (P=0.003 and P=0.001 respectively) Logistic regression analysis demonstrated that the presence of fQRS was the independent determinant of AF (OR: 3.243, 95% CI 1.016-10.251, P=0.042). CONCLUSIONS: Increased atrial fibrillation was observed more frequently in STEMI patients with fQRS than in patients without fQRS. fQRS is an important determinant of AF in STEMI after pPCI.

The relationship between fragmented QRS complexes and syntax II scores in patients with ST-segment elevation myocardial infarction.

BACKGROUND: Even though the relationship between syntax score (SS) and fragmented QRS (fQRS) has been studied, the relation between syntax score II (SS II) and fQRS in patients with ST elevation myocardial infarction (STEMI) is undefined. We aimed to define the relationship between fQRS and SS II for the evaluation of extension and complexity of coronary artery disease. MATERIAL AND METHODS: This study enrolled 167 patients undergoing primary percutaneous coronary intervention (pPCI) for STEMI. The standard 12-lead electrocardiograms (ECGs) were obtained from all patients before and after PCI. SS and SS II were calculated in all patients. Transthoracic echocardiography was performed to all patients. RESULTS: Thirty-nine patients (23.4%) had fQRS on their ECGs. The median SS II was 27 (22.9-33.9). SS II values in the fQRS(+) group were statistically significantly higher than that of the fQRS(-) group (35.2 (26.4-47.2) vs. 25.7 (22.1-30.7), p < 0.001). Also, in patients with higher SS II, there was significantly higher number of ECG derivations with fQRS. CONCLUSIONS: The presence of fQRS and high number of derivations with fQRS on ECG may be associated with high SS II in patients undergoing pPCI for STEMI.

The association between electrocardiographic R wave peak time and coronary artery disease severity in patients with non-ST segment elevation myocardial infarction and unstable angina pectoris.

BACKGROUND: We aimed to evaluate possible association between QRS duration (QRSD), R wave peak time (RWPT), and coronary artery disease severity identified using the SYNTAX score (SS) in patients with unstable angina pectoris (USAP) or non-ST segment elevation myocardial infarction (NSTEMI). METHOD: A total of 176 USAP/NSTEMI patients were enrolled in the study. RESULTS: The high SS group (>22, n:45) patients had a higher prevalence of diabetes mellitus (DM); presence of ST segment depression ≥0.5 mm and 1 mm; ST segment elevation in the AVR lead (AVRSTE); longer QRSD and RWPT; and lower left ventricular ejection fraction (LVEF) than the low SS group (≤22, n: 131). The LVEF, AVRSTE, and RWPT (OR: 1.035, 95% CI: 1.003-1.067; p = 0.030) were independent predictors of high SS. CONCLUSION: The present study demonstrated that RWPT and AVRSTE could be used as predictors of high SS.

The Association between Monocyte HDL-C Ratio and SYNTAX Score and SYNTAX Score II in STEMI Patients Treated with Primary PCI.

BACKGROUND: Monocyte to high-density-lipoprotein cholesterol ratio (MHR) simply reflects proatherogenic and antiatherogenic balance and high level of this ratio is associated with severity of coronary atherosclerosis and cardiac events. We investigated the association between MHR and coronary artery disease severity using SYNTAX score and SYNTAX score II (SSII) in ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (pPCI). METHODS: A total of 315 consecutive patients with STEMI who underwent pPCI from January 2014 to January 2016 were enrolled. After exclusion 264 patients remained in the study population. Patients were divided into 2 groups according to median SSII [SSII ≤ 34.2 as low group (n = 132) and > 34.2 as high group (n = 132)]. RESULTS: Median value of MHR was 10.5 in SSII low group and 16.1 in SSII high group (p < 0.001). There was a strong correlation between MHR and SSII (r = 0.580, p < 0.001). Diabetes mellitus [odds ratio (OR): 8.604; 95% confidence interval (CI): 2.469-29.978], glomerular filtration rate (OR: 0.961; 95% CI: 0.939-0.983), infarct related artery of left anterior descending (LAD) (OR: 7.325; 95% CI: 2.262-23.723), SYNTAX score (OR: 1.422; 95% CI: 1.275-1.585), neutrophil to lymphocyte ratio (NLR) (OR: 1.156; 95% CI: 1.058-1.264) and MHR (OR: 1.027; 95% CI: 1.013-1.041) were independent predictors of SSII > 34.2 in multivariate analysis. CONCLUSIONS: MHR could be a better parameter than NLR and C-reactive protein at predicting severity of coronary artery disease in STEMI patients treated with pPCI.

The Role of Protein Z and Protein Z-Dependent Protease Inhibitor Polymorphisms in the Development of Prosthetic Heart Valve Thrombosis.

BACKGROUND AND AIM OF THE STUDY: Protein Z (PZ) is a vitamin K-dependent factor that is synthesized mainly by the liver. It acts as an activator of serpin, the protein Z-dependent inhibitor (ZPI), which inhibits factor Xa. The potential role of alterations in protein Z and/or ZPI levels in the pathogenesis of thrombotic and/or hemorrhagic diseases has been previously investigated, but results have been conflicting. The study aim was to evaluate the role of PZ/ZPI polymorphisms in the development of prosthetic valve thrombosis (PVT). METHODS: This prospective, observational cross-sectional study included 50 consecutive patients with PVT [non-obstructive thrombosis (NOT) in 35 patients; obstructive thrombosis (OT) in 15] and 50 consecutive healthy subjects with normally functioning prostheses. gDNA was extracted from ca. 5 × 106 leukocytes, using the QIAamp DNA Mini Kit (Qiagen), according to the manufacturer's recommendations. For mutational analysis, a minisequencing method was employed. Results of the analyses were compared between the PVT and control groups, and also between the OT and NOT subgroups. RESULTS: The frequency of A allele (mutant type) of PZG79A was equal in all PVT patients and in controls. With regards to PZ-A13G polymorphisms, frequency of the mutant G allele was 22% in PVT patients and 19% in controls. Serpina-R67X polymorphism was observed in 8% of PVT patients and 6% of controls. Normal variant CC was present in 47 controls (94%), whereas a heterozygotic mutation (CT) was detected in four PVT patients (8%). Frequency of the ZPI-R67X mutation was significantly higher in patients with OT than in those with NOT (p = 0.041). CONCLUSIONS: The present study was the first to evaluate the potential impact of PZ (PZ-A13G, PZG79A) and ZPI (R-67X, W303X) polymorphisms in the development of PVT. Based on the results of this small observational case-control study, PZ/ZPI polymorphisms do not appear to play an active role in the development of PVT. Hence, further extensive studies are necessary.

P wave peak time; a novel electrocardiographic parameter in the assessment of coronary no-reflow.

OBJECTIVES: Coronary no-reflow (NR) following primary percutaneous coronary intervention (pPCI) is associated with worsened prognosis in patients with ST segment elevation myocardial infarction (STEMI). Despite rapid developments in cardiovascular area; there are limited data regarding prediction of NR before pPCI. P wave duration and dispersion (PWD, PWDIS, respectively) have been studied in STEMI patients and found to be associated with reperfusion success; however none of them has been found to predict NR before PCI. In our study we aimed to evaluate whether PWD, PWDIS and a novel parameter P wave peak time (PWPT) could predict NR development in STEMI patients. METHOD: Fifty six patients who were admitted with anterior STEMI constituted study populations. The diagnosis and treatment of STEMI was made on the basis of current guidelines. P wave parameters including PWD, PWDIS and PWPT were calculated from electrocardiograms that were obtained on admission and 60 min after pPCI. RESULTS: Patients were divided into two groups according to the development of NR. We observed that PWPT that were obtained from D2 (PWPTD2) and V1 (PWPTV1) leads were longer in NR group than reflow group. There were significant correlations between PWPT and reperfusion parameters regarding percent of ST segment resolution, peak CKMB level and TIMI frame count of infarct related artery. Preprocedural PWPTD2 was found to be an independent predictor of NR development. CONCLUSION: In our study we observed that PWPT could be a useful parameter in the assessment of reperfusion success and prediction of NR development.

Evaluation of Aortic Paravalvular Leak: A Special Reference for Anatomical Localization.

BACKGROUND AND AIM OF THE STUDY: Paravalvular leakage (PVL) remains an unavoidable complication of heart valve surgery and in its severe forms may lead to heart failure and hemolysis. The study aim was to evaluate the echocardiographic, clinical, surgical and laboratory characteristics of patients with aortic PVL. METHODS: A total of 77 aortic PVL patients underwent transthoracic and transesophageal echocardiography examinations. Clinical, echocardiographical and surgical findings were also recorded. RESULTS: Among the 77 patients, 21 (27.3%) had mild, 33 (42.8%) had moderate and 23 (29.9%) had severe aortic PVL. Seventeen patients (22.1%) had moderate-to-severe hemolysis and had a higher incidence of multiple PVL compared to those with no or mild hemolysis. Moderate- to-severe PVL was more frequent between the non-coronary and the left coronary sinus annuli, especially adjacent to the left main coronary artery ostium. Percutaneous closure was performed in five patients. Eleven patients underwent surgical repair, and the localizations of PVL were in accordance with echocardiographic findings. CONCLUSIONS: Aortic PVL occurs more frequently between the non-coronary sinus and the left coronary sinus annuli, which may be associated with multiple factors. Difficulties in seating the prosthesis due to the steep angulation of the commissure and annulus, the avoidance of deep sutures, and focal annular calcification may make this region prone to injury and leakage.

Histopathological and Immunohistochemical Evaluation of Pannus Tissue in Patients with Prosthetic Valve Dysfunction.

BACKGROUND: Prosthetic valve dysfunction due to pannus formation is a rare but serious complication. Currently, limited data are available concerning the pathogenesis and immunohistochemical properties of pannus. The study aim was to investigate the morphological, histopathological and immunohistochemical characteristics of pannus formation in patients with prosthetic valve dysfunction. METHODS: A total of 35 patients (10 males, 25 females; mean age 44 ± 16 years) who had undergone re-do valve surgery due to prosthetic valve obstruction was enrolled in the study. Immunohistochemical studies were aimed at evaluating the expression of alphasmooth muscle actin (α-SMA) and desmin in myofibroblasts and smooth muscle cells; epithelial membrane antigen (EMA) in epithelial cells; and CD34, Factor VIII and vascular endothelial growth factor (VEGF) in endothelial cells. Matrix metalloproteinases (MMPs) -2 and -9, and transforming growth factor-beta (TGF-ß) were used to demonstrate cytokine release from macrophages, leukocytes, fibroblasts and myofibroblasts. RESULTS: Pannus appeared as a tough and thick tissue hyperplasia which began from outside the suture ring in the periannular region and extended to the inflow and outflow surfaces of the prosthetic valves. Histopathological analysis showed the pannus tissue to consist of chronic inflammatory cells (lymphocytes, plasma cells, macrophages and foreign body giant cells), spindle cells such as myofibroblasts, capillary blood vessels and endothelial cells laying down the lumens. Calcification was present in the pannus tissue of 19 explanted prostheses. Immunohistochemical studies revealed positive α-SMA expression in all patients, whereas 60.5% of patients were positive for desmin, 50% for EMA, 42.1% for VEGF, 39.5% for TBF-ß, 42.1% for MMP-2, 86.8% for CD34, and 97.4% for Factor VIII. MMP-9 was negative in all patients. CONCLUSIONS: Pannus tissue appears to be formed as the result of a neointimal response in periannular regions of prosthetic valves that consist of periannular tissue migration, myofibroblast and extracellular matrix proliferation with vascular components. It is a chronic active process in which mediators such as TGF-ß, VEGF and MMP-2 play roles in both matrix formation and degradation.