Value of Renal Vascular Doppler Sonography in Cardiorenal Syndrome Type 1.

OBJECTIVES: Worsening of renal function in a patient with acute decompensated heart failure is called cardiorenal syndrome (CRS) type 1. Recent studies have shown an association of persistent systemic venous congestion with renal dysfunction. This trial was set up to investigate the changes of renal Doppler parameters with diuretic therapy in patients with CRS type 1. METHODS: Cases of CRS type 1 were identified among patients hospitalized for decompensated heart failure. Serial measurements of the renal venous impedance index (VII) and arterial resistive index (ARI) were calculated by pulsed wave Doppler sonography. RESULTS: A total of 30 patients who had creatinine improvement with diuresis (group 1) and 34 patients without any improvement (group 2) were analyzed. Patients in group 1 had higher median VII and ARI (VII, 0.86 versus 0.66; P < .001; ARI, 0.78 versus 0.65; P < .001) on admission. A high ARI on admission (odds ratio, 6.25; 95% confidence interval, 1.84-14.3; P = .003) predicted the improvement of serum creatinine levels with diuretic therapy independent of confounding factors in patients with CRS type 1. CONCLUSIONS: Renal vascular Doppler parameters might offer guidance on the diagnostic and therapeutic strategies in prescribing decongestive therapy for decompensated heart failure.

Evaluation of global function of the heart in scleroderma patients.

OBJECTIVE: Scleroderma is a connective tissue disease characterized by diffuse vascular lesions and fibrosis of the skin and major organs including lungs, kidneys, and heart. When cardiac involvement is clinically evident, it is recognized as a poor prognostic factor. The early detection of cardiac involvement in scleroderma would be desirable both for implementation of preventive measures in the early stages of the disease and for optimal treatment. METHODS: Left (LV) and right (RV) ventricular function were examined in 31 scleroderma patients and 21 healthy controls. Conventional and tissue Doppler echocardiography was used to evaluate systolic and diastolic function. Systolic indices including systolic (S) velocity, isovolumetric acceleration (IVA), ejection time (ET), and isovolumetric contraction time (IVCT) were measured. Early diastolic (E) velocity, late diastolic (A) velocity, E/A and E'/A' ratios, isovolumetric relaxation time (IVRT), and deceleration time (DT) were the diastolic measurements obtained. Myocardial performance index (Tei index) calculated by 2 different methods was used to assess global ventricular function. RESULTS: In our study; mitral S velocity, biventricular ET, E', E/A, E'/A', RV IVA, LV IVA, and tricuspid S velocity were significantly lower in scleroderma patients. Mitral DT, IVCT, and biventricular IVRT, were significantly higher in scleroderma patients (P < 0.0001). In addition, RV and LV Tei indices were significantly increased in scleroderma patients compared with the control group (P < 0.0001 and P < 0.001, respectively). CONCLUSIONS: In scleroderma patients, global function was depressed prior to the onset of clinical symptoms. Biventricular diastolic and systolic function abnormalities were also observed.

Effects of Hemodialysis on Tei Index: Comparison between Flow Doppler and Tissue Doppler Imaging.

OBJECTIVE: Myocardial performance index (MPI, Tei index) has been described as a noninvasive measurement of left ventricle (LV) function. Our aim was to investigate the influence of preload on the LV MPI obtained by pulsed-wave tissue Doppler imaging (PWTDI) and determined by flow Doppler waveforms in patients with end-stage chronic renal failure (CRF). The second aim of this study was to investigate the relationship between the Tei indices obtained by both methods. METHODS: Eighty-four patients on regular hemodialysis (HD) treatment were included (mean age of 45.3 ± 14.5 years). Standard echocardiographic measurements, the Tei indices obtained by conventional flow Doppler and PWTDI methods, mitral inflow velocities, and mitral lateral annulus tissue Doppler velocities were measured immediately before and after hemodialysis. RESULTS: After HD, weight loss in patients was significantly revealed (predialysis 63.6 ± 13.3 kg; postdialysis 60.9 ± 13.0 kg; P < 0.001). Left ventricle and left atrium diameters were significantly decreased after HD. Transmitral E and A velocities decreased after HD. Although Tei index measuring by conventional flow Doppler method significantly increased, Tei index measuring by PWTDI did not change after HD. CONCLUSIONS: The conventional flow Doppler-derived LV Tei index is influenced by hemodialysis. However, PWTDI-derived LV Tei index is not influenced by hemodialysis. The loading status of a patient should be taken into account during the application of the Tei index to the evaluation of myocardial performance.

[Heterozygous familial hypercholesterolemia]. / Heterozigot ailevi hiperkolesterolemi.

Heterozygous familial hypercholesterolemia (HeFH) is an autosomal co-dominant inherited disease associated with increased risk of early cardiovascular disease. Plasma low-density lipoprotein concentrations of the affected individuals are 2 to 3 times higher than the normal population. The prevalence of the HeFH is 1/500 and only 20% of the cases are diagnosed. A minority of the diagnosed patients (16%) are able to reach treatment. Early identification of the patients with HeFH enables exact treatment and prevention of the premature coronary artery disease. So, screening of the relatives of the index cases is essential. HeFH is diagnosed by the use of clinical criteria like family history, physical examination, and cholesterol levels. Mutation analysis may provide an accurate diagnosis in suspicious cases. Treatment strategies mostly aim to provide a reduction of low-density cholesterol levels of >50% from baseline. First-line treatment is statins. However, most of the patients with HeFH do not achieve target cholesterol levels with maximum tolerated doses of statins. Combinations of statins with ezetimibe, niacin or bile acid sequestrants have limited value. New classes of drugs for the treatment of hypercholesterolemia include microsomal triglyceride transfer protein inhibitors, apolipoprotein B synthesis inhibitors, and pro-protein convertase subtilisin/kexin 9 inhibitors. This review aims to discuss the updated information regarding the diagnosis and treatment of HeFH.

Left ventricular inferoapical diverticulum associated with normal coronary arteries.

Isolated congenital left ventricular (LV) diverticulum, which is characterized by the local failure of the ventricular muscle, is a rare cardiac abnormality with a reported prevalence of 0.4%. Clinically, it has been reported to follow an asymptomatic course in the majority of cases; however, it may cause heart failure, thrombus formation, arrhythmia, rupture or chest pain in some patients. Due to its asymptomatic course, it is difficult to diagnose an isolated LV diverticulum. Our patient was admitted to hospital with the complaint of typical chest pain and no any electrocardiogram ischemic changes. Transthoracic echocardiogram showed a diverticulum in the inferoapical wall. Coronary computed tomography angiography was performed, which revealed LV diverticulum at inferoapical region and normal coronary anatomy.

Marked narrowing of right heart chambers due to compression by giant hepatic hydatid cyst.

External compression of the heart may be presented as valvular heart disease. A 50-year-old woman with signs and symptoms of tricuspid stenosis was diagnosed with giant hepatic hydatid cyst. Symptoms were resolved after surgical excision. Echinococcosis should be in mind while evaluating patients with external cardiac compression.

How accurate are manufacturers' recommendations in determining ineligibility for transfemoral transcatheter aortic valve implantation?

INTRODUCTION: Up to one-third of patients indicated for transcatheter aortic valve implantation (TAVI) may be unsuitable for transfemoral TAVI (TF-TAVI) according to manufacturers' recommendations and numerous professional societies. OBJECTIVE: This study aimed to investigate the predictive value of manufacturers' guidelines for major vascular access site complications using the Perclose ProGlide device. METHODS: Among 208 patients undergoing TF-TAVI, 144 patients (69.2%) were deemed eligible for TF-TAVI according to the manufacturer's instructions. A minimal lumen diameter (MLD) of the femoral artery below the manufacturer's specified limits and/or the presence of circumferential calcification were the reasons for ineligibility. Calcium score (CS), sheath-to-femoral artery ratio (SFAR) and MLD were estimated from computed tomography imaging. Vascular complications (VCs) (defined according to VARC-2 criteria) were retrospectively compared. RESULTS: Patients in the ineligible group had higher SFAR (1.13±0.15 vs. 0.88±0.107, p<0.001) and CS (1.66±0.99 vs. 1.24±0.73; p=0.003), and significantly lower MLD (7.72±1.03 vs. 6.31±0.96 mm; p<0.001) compared to the eligible group. Major (6.3% vs. 12.3%, p=0.13) and minor VCs (10.4% vs. 15.6%, p=0.29) were similar in the eligible and ineligible groups. The ineligible group had higher rates of rupture (0.7% vs. 6.3%; p=0.03). SFAR was the only independent predictor of major VCs (OR 469.1, 95% CI 4.95-44466.57, p=0.008). CONCLUSION: The TAVI team should not decide whether the patient is suitable for a femoral approach based solely on the manufacturer's criteria, and should incorporate additional factors that could be predictive of major VCs.

Intracoronary versus intravenous high-dose bolus plus maintenance administration of tirofiban in patients undergoing primary percutaneous coronary intervention for acute ST elevation myocardial infarction.

We aimed to examine whether intracoronary high-dose bolus of tirofiban plus maintenance would result in improved clinical outcome in STEMI patients undergoing primary PCI in this pilot trial. A total of 56 patients were enrolled to receive either intracoronary high-dose bolus plus maintenance (n = 34) or intravenous high-dose bolus plus maintenance (n = 22) of tirofiban. Pre and post intervention TIMI flow grades, myocardial blush grades, peak CKMB and troponin levels, time to peak CKMB and troponin, time to 50% ST resolution and major composite adverse cardiac event rates at 30 days were recorded. Although incidence of major adverse cardiac events was not different, post intervention TIMI flow and TIMI blush grades, peak CKMB and troponin levels, and time to peak CKMB and time to peak troponin were significantly different, favoring intracoronary strategy. In conclusion, this regimen improved myocardial reperfusion and coronary flow, and reduced myocardial necrosis, but failed to improve clinical outcomes at 30 days.

Vascular complications after transcatheter transfemoral aortic valve implantation: Modified sheath-to-femoral artery ratio as a new predictor.

OBJECTIVE: Vascular complications (VCs) contribute to increased morbidity and mortality in patients who have undergone transcatheter aortic valve implantation (TAVI); however, studies on their incidence and predictors show conflicting results. In this study, we sought to assess the incidence, impact, and predictors of VCs in transfemoral (TF) TAVI and also investigated the predictive role of manufacturer's size charts and a new predictor modified sheath-to-femoral artery ratio. METHODS: A total of 223 patients undergoing TF-TAVI were categorized into 2 groups. The patients were divided as eligible and ineligible according to the manufacturer's guidelines (MG), and the same patient cohort was dichotomized into eligible and ineligible on the basis of sheath-to-femoral artery ratio (SFAR) value of less than or greater than or equal to modified SFAR (md-SFAR). VCs (defined according to the Valve Academic Research Consortium II criteria) were retrospectively compared. RESULTS: According to the manufacturer's size charts, 65 patients were unsuitable; however, 35 patients were ineligible for TF-TAVI per the md-SFAR criteria. Although VCs occurred in 42 (18.8%) patients, 17 (27.7%) of those patients were classified as ineligible according to MG, whereas 14 (41.2%) were classified as ineligible in the md-SFAR group. In a multiple logistic regression analysis that included md-SFAR, MG, SFAR ≥1.05, peripheral artery disease, and minimum iliofemoral artery diameter, only md-SFAR was the independent predictor of VCs (odds ratio=3.71, 95% confidence interval=1.13-12.53, p=0.031). CONCLUSION: According to our results, md-SFAR might provide better patient selection to prevent VCs and improve outcomes in TF-TAVI procedures.

Cystatin C and uncontrolled hypertension.

OBJECTIVE: Increased serum level of cystatin C, a sensitive biomarker for renal function, seems to predict adverse cardiovascular events. We investigated the predictive value of serum cystatin C for controlling hypertension in an observational study. METHODS: We screened 1037 adults residing in both rural and urban communities. They were grouped based on their diagnosis and control of hypertension. RESULTS: Serum cystatin C levels in patients with uncontrolled hypertension were higher than those in patients with controlled hypertension (0.98±0.23 mg/L vs. 0.89±0.19 mg/L, p=0.001). However, serum creatinine levels were similar between these groups (0.72±0.20 mg/dL vs. 0.70±0.18 mg/dL, p=0.89). Serum cystatin C levels increased the probability of uncontrolled hypertension independent from confounding factors (odds ratio, 1.48; 95% confidence interval, 1.09-5.64; p=0.03). CONCLUSION: Subtle kidney dysfunction may be detected using serum cystatin C concentrations among patients with poor blood pressure control and normal serum creatinine levels.

Long-term comparison of everolimus- vs. novolimus-eluting bioresorbable vascular scaffolds in real world patients.

INTRODUCTION: Elevated risk of adverse events in comparison to metallic stents resulted in withdrawal of everolimus-eluting bioresorbable scaffolds (eBVS), known as the most intensively studied BVS. There is a paucity of data comparing the two different BVS. AIM: To evaluate the long-term clinical outcomes of the novolimus-eluting bioresorbable vascular scaffold (nBVS) compared with eBVS. MATERIAL AND METHODS: Consecutive patients treated with nBVS or eBVS in our center were screened. The primary outcome was the 3-year rate of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, target vessel myocardial infarction (TV-MI), and target-lesion revascularization (TLR). RESULTS: After matching, 98 patients treated with 135 eBVS were compared with 98 patients treated with 136 nBVS. Baseline characteristics, clinical presentation, and lesion characteristics were comparable in both groups. The 3-year MACE rate was higher in the eBVS group (17.3% vs. 6.1%; p log-rank = 0.02). The occurrence of TLR (16.3% vs. 5.1%; p log-rank = 0.02) and TV-MI (8.2% vs. 0 %; p log-rank = 0.004) was also higher in the eBVS group except for cardiac deaths (1% vs. 2%; p log-rank = 0.98, eBVS vs. nBVS, respectively). Of note, definite device thrombosis rate was markedly increased in the eBVS group (5.1% vs. 0%; p log-rank = 0.03). CONCLUSIONS: The present study revealed that the 3-year event risk was lower for nBVS compared to eBVS. More evidence is needed to evaluate long-term performance of novolimus-eluting biovascular platforms.

Musculoskeletal pain and related factors in coronary artery disease: An observational cross-sectional study.

BACKGROUND AND AIM: In patients diagnosed with coronary artery disease (CAD), we aimed to determine the characteristics and risk factors of co-occurring musculoskeletal pain and examine its effects on functional capacity, psychological status and health-related quality of life. PATIENTS AND METHODS: A total of 100 patients with (n= 50) and without (n= 50) musculoskeletal pain were enrolled. All patients were assessed on sociodemographic and clinical properties. The Duke Activity Status Index (DASI), the Hospital Anxiety and Depression Scale (HADS) and the Short Form-36 (SF-36) were applied as clinical assessment scales. RESULTS: Patients with musculoskeletal pain were mostly female, and had a lower education level and annual income. The pain was mostly nociceptive, intermittent, sharp/stabbing in character, and located in the chest and spine. Having musculoskeletal pain resulted in lower levels on the DASI and all subgroups of the SF-36, and higher levels on the HADS. Female gender, lower education level and severity of emotional distress proved to be independent risk factors for the development of musculoskeletal pain. CONCLUSIONS: In CAD, the co-occurrence of musculoskeletal pain leads to a further decrease in health-related quality of life and functional status, and increased severity of anxiety and depression. This stresses the importance of the detection and optimal treatment of musculoskeletal pain in patients diagnosed with CAD.

[Ultrasound-assisted, catheter-directed thrombolysis of acute pulmonary embolism via the subclavian vein: alternative access path]. / Akut pulmoner emboli ile basvuran orta riskli bir hastada, subklavyen veni yoluyla kateter aracili ultrason ile tromboliz: Alternatif girisim yeri.

Routinely, the femoral vein is used for access in ultrasound-assisted, catheter-directed thrombolysis (USAT). Presently described is a case of bilateral femoral venous occlusion caused by chronic thrombosis, successfully treated with USAT, using subclavian vein for access.

Usefulness of Neuron-Specific Enolase to Detect Silent Neuronal Ischemia After Percutaneous Coronary Intervention.

Increased plasma levels of neuron-specific enolase (NSE) are related to damage of neurons and neuroendocrine cells. We aimed to investigate elevation of NSE after elective percutaneous coronary intervention (PCI) on the prediction of silent cerebral infarct (SCI). Study population consisted of 2 groups of patients. Group 1 included 92 consecutive patients with normal coronary angiograms, whereas group 2 consisted of 89 patients who underwent elective coronary stenting. NSE levels were studied before and 12 hours after the procedure. Elevation of >0.12 µg/L was considered as SCI. Forty-seven of 181 study patients (26%) had SCI after the procedure. NSE elevation was significantly more prevalent in patients with PCI than that of controls. Elevation of NSE was observed in 42% of patients who underwent elective PCI (n = 37) and 11% of the normal coronary artery group (n = 10) (p <0.001). The incidence of SCI was higher in active smokers and patients who had history of myocardial infarction (MI) (55% vs 10%, p <0.001 for active smokers and 40% vs 8%, p <0.001 for history of MI, respectively). Multivariate analysis demonstrated history of smoking (odds ratio [OR] 9.9; 95% confidence interval [CI] 3.7 to 26.9; p <0.001) and previous MI (OR 4.4; 95% CI 1.7 to 11.4; p = 0.01) as independent predictors of SCI. For patients who underwent elective PCI, NSE levels after procedure increases. Invasive coronary procedures have risk of SCIs, even in patients with normal coronary arteries. In conclusion, increased diagnosis of SCIs might improve understanding of their relation with invasive cardiac procedures, facilitate to prevent occurrence of silent microemboli and decrease the risk of adverse neurologic events.

[Interventional challenges due to venous occlusion during cardiac resynchronization therapy in patients with prior cardioverter-defibrillator implantation: Case report]. / Önceden ICD yerlestirilmis hastalarda kardiyak resenkronizasyon tedavisine geçiste venöz tikanikliga bagli girisimsel zorluklar: Olgu sunumu.

Cardiac resynchronization therapy has become a mainstay of treatment for advanced systolic heart failure refractory to medical management. However, several limitations may affect this therapy, including a non-response rate of nearly 30%, failure to implant the leads via conventional transvenous route in an optimal location, and inability to cannulate the coronary sinus branches due to difficult anatomy or presence of venous valves. Venous occlusion may also present as a potential obstacle in patients with prior implantation of cardioverter-defibrillator. Presently described are cases of 2 patients with venous occlusion.

Serum nitric oxide levels in patients with coronary artery ectasia.

OBJECTIVE: Serum levels of nitric oxide (NO) are decreased in patients with atherosclerosis and also are a risk factor for the development of atherosclerosis. Endothelial dysfunction and diffuse atherosclerosis have been proposed for the etiology of coronary artery ectasia (CAE). The purpose of this clinical trial was to determine the relationship between CAE and serum NO levels. METHODS: This prospective controlled study was conducted between January 2008 and March 2012. Serum levels of NO were compared in 40 patients with CAE (mean age 60.1±7.3 years) and 40 patients with normal coronary arteries (mean age 57.6±5 years) as a control group. CAE was diagnosed when a segment of coronary artery was more than 1.5 times the diameter of the adjacent healthy segment. Patients with stenotic atherosclerotic plaques, slow coronary flow, previous history of revascularization, acute coronary syndromes, left ventricular dysfunction, valvular heart disease, and systemic diseases were not included in the study. The effect of NO on the outcome was studied by constructing a receiver operating characteristic (ROC) curve with CAE as the primary variable. Effects of different variables on CAE were calculated using binary logistics regression analysis. RESULTS: Serum NO concentrations were significantly lower in patients with CAE than in the control group (42.1±20.1 µmol/L vs. 77.3±15.7 µmol/L, p<0.001). According to the results of the multivariate regression analysis, LDL and NO levels were identified as independent factors associated with CAE (OR=1.02, 95% CI 1-1.04, p=0.02 and OR=0.88, 95% CI 0.83-0.93, p=0.001, respectively). ROC analysis revealed that using a cut-off point of 63.3, NO level predicts CAE with a sensitivity of 87.5% and specificity of 90%. CONCLUSION: Our study indicates that decreased levels of NO are present in patients with CAE compared to patients with normal coronary arteries, supporting the hypothesis that decreased levels of NO might be associated with CAE development.