Does Employing a Flowchart Improve the Diagnostic Performance of Cardiac Magnetic Resonance Imaging in Left Ventricular Noncompaction?

BACKGROUND: To test the hypothesis that making a diagnosis of left ventricular noncompaction (LVNC) on cardiac magnetic resonance imaging (CMRI) using a noncompacted-to-compacted (NC/C) myocardium ratio > 2.3 would yield significant errors, and also to test a diagnostic flowchart in patients who undergo CMRI and have clinical and echocardiographic findings suggesting LVNC could improve the diagnosis of LVNC. METHODS: A total of 84 patients with LVNC and 162 controls consisting of patients with other diseases and healthy participants who had CMRI and echocardiograms were selected. The diagnostic flowchart of the study involved the use of CMRI with all available sequences for patients with a high pre-test probability of LVNC. Two blinded independent cardiologists evaluated echocardiograms, and patients with suggestive echocardiographic and clinical findings for LVNC were enrolled in the high pre-test probability of LVNC group. Two independent blinded radiologists established the diagnosis of LVNC based on NC/C ratio > 2.3 on CMRI, and they were allowed to re-assess the patients following the diagnostic flowchart. RESULTS: An NC/C ratio > 2.3 identified 83 of 84 LVNC patients, yet incorrectly classified 48 of the 162 controls as having LVNC. Radiologists changed their decision in 23 of 48 patients with incorrect diagnoses, resulted in improved specificity (70.4% to 84.6%). The use of the CMRI diagnostic flowchart in the high pre-test probability group yielded a high specificity (97.2%) and accuracy (95.9%). CONCLUSIONS: LVNC diagnosed by CMRI based on the NC/C criterion can lead to overdiagnosis, whereas only using CMRI in patients with a high pre-test probability of LVNC with all available sequences may improve the diagnostic performance.

Successful Treatment of Massive Pulmonary Embolism With Catheter-Directed Thrombolysis in a Patient With Lymphocele: A Rare Cause of Thromboembolism.

Pulmonary embolism is a frequent and mortal situation especially in high-risk patients. Although thrombolytics and anticoagulants are the main options in treatment, substantial portion of patients also have high bleeding risk. Therefore, new catheter-directed treatment strategies, such as ultrasound-assisted transcatheter thrombolysis, gain importance in treatment options for intermediate and high-risk patients. Here, we report a case of massive pulmonary embolism due to the iatrogenic lymphocele after a radical retropubic prostatectomy procedure. The usage of ultrasound-assisted transcatheter thrombolysis was successful in such a high-risk patient.

Effect of acute sleep deprivation on left atrial mechanics assessed by three-dimensional echocardiography.

BACKGROUND: Although sleep deprivation (SD) affects cardiovascular system in many ways, physio-pathological changes in cardiac chamber volume and function have not been described well. The aim of the present study was to investigate the effect of SD on left atrial (LA) and ventricular function with three-dimensional (3D) echocardiography. METHODS: Thirty-two healthy individuals (12 females, mean age 33.25 ± 8.18) were evaluated. Echocardiographic examination was performed once after a night of regular sleep and a night of sleep debt. Beside conventional parameters, 3D phasic volumes and function were measured using a commercially available 3D echocardiography system and offline analysis software. RESULTS: Mean sleep duration of the study group was 8.15 ± 2.19 h in the day of regular sleep and 2.56 ± 2.25 h in the day of sleep deprivation. There was a significant prolongation in deceleration time (180.83 ± 15.34 vs. 166.44 ± 26.12; p = 0.044) and increase in E/e' (6.95 ± 1.26 vs. 6.38 ± 0.85; p = 0.005). Among 3D measurements, the difference in left ventricular ejection fraction (EF), LA EF, LA reservoir function and LA active EF were not significant. Mean LA passive EF of the individuals was significantly lower after night shift (24.10 ± 7.66 vs. 31.49 ± 7.75; p = 0.006). CONCLUSION: Acute SD is associated with a reduction in LA passive emptying function in healthy adults. 3D-derived indices were sufficient to show subclinical diastolic dysfunction according to impairment in passive phase of LA ejection. Prospective large-scale studies are needed to enlighten this issue.

Screening Tests Predicting Cancer Metastasis in the Etiology of Pericardial Effusion: HALP Score and PNI. / Testes de Triagem Prevendo Metástase de Câncer na Etiologia do Derrame Pericárdico: HALP Score e PNI.

BACKGROUND: Cancer screening is absolutely necessary in patients with pericardial effusion, given that cancer is one of the most serious diseases in the etiology of pericardial effusion. In previous studies, it was stated that the systemic immune-inflammation index (SII); the prognostic nutrition index (PNI); and the hemoglobin, albumin, lymphocyte, platelet (HALP) score can produce scores related to cancer. OBJECTIVES: This study began considering that these scoring systems could predict cancer in the etiology of patients with pericardial effusion. METHODS: This study produced a retrospective analysis of patients who underwent pericardiocentesis between 2006 and 2022. Pericardiocentesis was performed in a total of 283 patients with moderate-to-large pericardial effusion or pericardial tamponade within the specified period. HALP, PNI, and SII scores were calculated according to the peripheral venous blood taken before the pericardiocentesis procedure. The statistical significance level was set at p<0.05. RESULTS: The HALP score proved to be 0.173 (0.125-0.175) in cancer patients and 0.32 (0.20-0.49) in non-cancer patients (p<0.001). The PNI score proved to be 33.1±5.6 in cancer patients and 39.8±4.8 in non-cancer patients (p<0.001). CONCLUSION: The HALP score and PNI proved to be easy and fast cancer screening tests that can predict cancer metastasis in the etiology of patients with pericardial effusion.

FUNDAMENTO: A triagem do câncer é absolutamente necessária em pacientes com derrame pericárdico, pois o câncer é uma das doenças mais graves em sua etiologia. Estudos anteriores indicaram que o índice de inflamação imunológica sistêmica (IIS), o índice prognóstico nutricional (PNI) e o escore de hemoglobina, albumina, linfócitos e plaquetas (HALP) podem ser escores relacionados ao câncer. OBJETIVOS: Este estudo foi iniciado considerando que esses sistemas de pontuação poderiam prever o câncer na etiologia de pacientes com derrame pericárdico. MÉTODOS: Os pacientes submetidos à pericardiocentese entre 2006 e 2022 foram analisados retrospectivamente. A pericardiocentese foi realizada em um total de 283 pacientes com derrame pericárdico ou tamponamento cardíaco de moderado a grande no período especificado. Os índices de HALP, PNI e IIS foram calculados do sangue venoso periférico retirado antes do procedimento de pericardiocentese. O nível de significância estatística foi aceito em p<0,05. RESULTADOS: O escore HALP foi de 0,173 (0,125-0,175) em pacientes com câncer. Detectou-se que em pacientes não oncológicos o escore foi de 0,32 (0,20-0,49; p<0,001). O escore de PNI foi de 33,1±5,6 em pacientes com câncer. Detectou-se que em pacientes não oncológicos o escore foi 39,8±4,8 (p<0,001). CONCLUSÃO: Os escores HALP e PNI são testes de triagem de câncer fáceis e rápidos que podem prever metástases de câncer na etiologia de pacientes com derrame pericárdico.

The relationship between prognostic nutritional index and long-term mortality in patients undergoing emergency coronary artery bypass graft surgery for acute-ST elevation myocardial infarction.

BACKGROUND: Malnutrition and the prognosis of coronary artery disease (CAD) are shown to be correlated. The significance of nutritional status has been evaluated in patients with ST elevation myocardial infarction (STEMI), stable CAD, and elective coronary artery bypass graft (CABG) surgery. However, the prognostic impact of poor nutritional status on STEMI patients who underwent emergent CABG is not known. In this study, we aimed to investigate the relationship between nutritional status assessed by the prognostic nutritional index (PNI) and long-term mortality in STEMI patients who underwent emergent CABG. To the best of our knowledge, our study is the first one to evaluate the PNI effect on this specific population. METHODS: 131 consecutive patients with STEMI who did not qualify for primary percutaneous coronary intervention and required emergent CABG between 2013 and 2018 were included in our study. The study population was divided into two groups: survivors and non-survivors. The PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3) for both groups, using the preoperative data. The optimal cut-off value was obtained by receiver operating characteristic (ROC) analysis. According to the cut-off value, we investigated the relationship between PNI and long-term mortality. RESULTS: The mean age of the study population was 57.0±10.6. During the median 92.7 (70.0-105.3)-month follow-up, 32 of the 131 patients (24.4%) died. Regression analysis showed a significant association between glucose levels (hazard ratio (HR), 1.007; 95% confidence interval (CI), 1.002-1.012; p=0.011) and PNI (HR, 0.850; 95% CI, 0.787-0.917; p<0.001) and long-term mortality. Accord-ing to the ROC analysis, the cut-off value for PNI to predict all-cause mortality was found to be 44.9, with a sensitivity of 81.3% and a specificity of 89.9%. In addition, age, ejection fraction, glomerular filtration rate, Killip classification, and left anterior descending-left internal mammary artery graft use are significantly associated with long-term all-cause mortality in STEMI patients undergoing emergency CABG. CONCLUSION: The PNI was significantly associated with long-term mortality in patients with STEMI who underwent emergent CABG. PNI can be used to improve the accuracy of the risk assessment of STEMI patients undergoing emergent CABG.

Exploring Regional Disparities in Heart Failure Epidemiology and Outcomes: A Comprehensive Study Across Geographical Regions in Türkiye.

Background: Heart failure (HF) is a common condition that affects 1-3% of the general population. Its prevalence exhibits notable international and intranational disparities, partly explained by socioeconomic status, religion, ethnic diversity, and geographic factors. A comprehensive understanding of the epidemiological symptoms of HF in different regions of Türkiye has yet to be revealed. Aims: To examine epidemiological data from 2016 to 2022, focusing on crucial patient characteristics and geographical regions, to determine the incidence and prevalence of HF in Türkiye across seven diverse geographical regions. Study Design: A nationwide population-based retrospective cohort study. Methods: The comprehensive National Electronic Database of the Turkish Ministry of Health was used in this study to obtain data that covers the whole Turkish population from January 1, 2016, to December 31, 2022. The International Classification of Diseases-10 (ICD-10) codes were used to identify adults with HF (n = 2,701,099) and associated comorbidities. Türkiye is divided into seven geographically distinct regions. Epidemiological characteristics and survival data of these regions were analyzed separately. All-cause mortality was set as the primary outcome. Results: In , the total estimated prevalence of adult patients with HF is 2.939%, ranging from 2.442% in Southeastern Anatolia to 4.382% in the Black Sea Region. Except for the Eastern Anatolia Region, the three most often reported comorbidities were hypertension, dyslipidemia, and anxiety disorders. The rates of prescribing guideline-directed medical therapy (GDMT) for HF and other medications varied significantly. GDMT prescription rates were lowest in the Eastern Anatolia Region (82.6% for beta-blockers, 48.7% for RASi, 31.8% for mineralocorticoid receptor antagonists, and 9.4% for SGLT2i). The Mediterranean and Aegean regions had the highest median N-terminal brain natriuretic peptide (NT-proBNP) levels of 1,990,0 pg/ml (518.0-6,636,0) and 1,441,0 pg/ml (363.0-5,000,0), respectively. From 2016 to 2022, 915,897 (33.9%) of 2,701,099 patients died. The Eastern Anatolia Region had the lowest all-cause mortality rate of 26.5%, whereas the Black Sea Region had the highest all-cause mortality rate of 35.3%. Conclusion: Our real-world analysis revealed geographic disparities in HF characteristics, such as decreased mortality in socioeconomically challenged regions. Higher stress susceptibility in developed regions may increase the likelihood of adverse outcomes.

Navigating Heart Failure: Unveiling Sex Disparities in Guideline-Directed Medical Therapy Combinations.

Major heart failure (HF) trials remain insufficient in terms of assessing the differences in clinical characteristics, biomarkers, treatment efficacy, and safety because of the under-representation of women. The study aimed to present sex-related disparities in HF management, including differences in demographics, co-morbidities, cardiac biomarkers, prescribed medications, and treatment outcomes. The study utilized anonymized data from the Turkish Ministry of Health's National Electronic Database between January 1, 2016, and December 31, 2022. The cohort analysis included 2,501,231 adult patients with HF. Specific therapeutic combinations were analyzed using a Cox regression model to obtain relative risk reduction for all-cause death. The primary end point was all-cause mortality. In the cohort, 48.7% (n = 1,218,911) were male, whereas 51.3% (n = 1,282,320) were female. Female patients exhibited a higher median age (71 vs 68 years) and manifested higher prevalence of diabetes mellitus, anemia, atrial fibrillation, anxiety, and ischemic stroke. Male patients demonstrated higher rates of previous myocardial infarction, dyslipidemia, chronic obstructive pulmonary disease, and chronic kidney disease. Higher concentrations of natriuretic peptides were observed in female patients. Renin-angiotensin aldosterone inhibitor, ß blockers, mineralocorticoid receptor antagonists, sodium/glucose cotransporter 2 inhibitor (SGLT2i), and ivabradine were more commonly prescribed in male patients, whereas loop diuretics, digoxin, and ferric carboxymaltose were more frequent in female patients. Male patients had higher rates of cardiac resynchronization therapy and implantable cardioverter defibrillator implantation rates. All-cause mortality and hospitalization rates were higher in male patients. Compared with monotherapy, all combinations, including SGLT2i, showed a beneficial effect on all-cause mortality in both female and male patients with HF. In hospitalized patients with HF, the addition of digoxin to renin-angiotensin aldosterone inhibitor, mineralocorticoid receptor antagonists, and ß blockers was superior to monotherapy regarding all-cause mortality in female patients with HF compared with male patients with HF. In conclusion, this study highlights that sex-specific responses to HF medication combinations compared with monotherapy and differences in co-morbidities underscore the importance of tailored management strategies. Digoxin showed a contrasting effect on all-cause mortality between both sexes after hospitalization, whereas SGLT2i exhibited a consistent beneficial effect in both sexes when added to all combinations.

Deciphering mortality risk of diabetes medications in heart failure patients with diabetes mellitus under triple guideline-directed medical therapy.

BACKGROUND: Scientific evidence regarding the impact of different combinations of diabetes medications in heart failure patients with diabetes mellitus (HFwDM) remains limited. AIM: We aimed to investigate the effect of monotherapy and combination therapy for DM on all-cause mortality in HFwDM under triple guideline-directed medical therapy (GDMT). METHOD: This nationwide retrospective cohort study included adult HFwDM under triple GDMT between January 1, 2016 and December 31, 2022.We collected the data from the National Electronic Database of the Turkish Ministry of Health.We created various combination including different diabetes medications based on the current guidelines for DM.The primary endpoint was all-cause mortality. RESULTS: A total of 321,525 HFwDM under triple GDMT (female:49%, median age:68[61-75] years) were included. The highest rate of prescribed combination therapy was metformin and sulfonylureas (n = 55,266). In Cox regression analysis, insülin monotherapy had the highest risk for all-cause mortality (HR:2.25, 95CI%:2.06 - 2.45), whereas combination therapy including metformin, SGLT2i, and sulfonylureas provided the most beneficial effect on survival (HR:0.29, 95CI%:0.22-0.39) when compared to patients not receiving diabetes medication. Among patients taking diabetes medications, the inclusion of SGLT2i demonstrated a survival benefit (p < 0.05), despite concurrent use of volume-retaining medications such as insulin and thiazolidinediones. Conversely, combinations of diabetes medications without SGLT2i did not demonstrate any survival benefit compared to patients not taking diabetes medication (p > 0.05). CONCLUSION: This study underscored the use of SGLT2i as monotherapy or as a part of combination diabetes medications to improve survival among HFwDM, while also highlighting that combinations lacking SGLT2i did not confer any survival benefit.

Effect of Bendopnea on Achievement Medical Treatment Target Doses in Heart Failure.

BACKGROUND: The newly described bendopnea in heart failure (HF) is associated with increased cardiac filling pressures. The aim of the study was to show the effect of bendopnea follow-up on reaching optimal medical treatment doses in HF. METHODS: A total of 413 patients were screened, and we included 203 patients with HF who were previously evaluated for bendopnea. Demographic data, presence or absence of bendopnea, medical history, laboratory findings, and medical treatments were evaluated. Optimal medical therapy target doses at baseline and 3rd month were compared in groups with and without bendopnea. RESULTS: On admission, 64 patients (31.5%) had bendopnea. The rate of patients with bendopnea decreased in the 3rd month (n=42, 20.7%). The proportion of patients who used at least 50% of the recommended medical treatment dose on admission and in the 3rd month was compared; angiotensin-converting enzyme inhibitor /angiotensin receptor blockers use increased from 40.6% to 71.9% in those with bendopnea (P=0.013), from 56.1% to 81.3% in those without bendopnea (P<0.001) and beta-blockers use increased from 28.2% to 60.9% in those with bendopnea (P=0.042), from 31.6% to 69.8% in those without bendopnea (P<0.001). However, aldosterone antagonists use decreased from 70.3% to 67.2% in those with bendopnea (P=0.961), from 68.4 % to 64.1% in those without bendopnea (P=0.334). Bendopnea was independently effective in achieving ACE-I/ARB target doses (OR: 0.359, CI 95%: 0.151-0.854, P=0.020). CONCLUSION: Bendopnea follow-up in HF patients can provide a significant improvement in reaching the recommended treatment target doses.

Systemic Immune Inflammation Index is a Novel Marker in Predicting the Presence and Severity of Isolated Coronary Artery Ectasia. / O Índice de Inflamação Imune Sistêmica é um Novo Marcador na Previsão da Presença e Gravidade aa Ectasia Coronariana Isolada.

BACKGROUND: The underlying pathology of isolated coronary artery ectasia (CE) has not been fully elucidated. OBJECTIVE: We aimed to examine the relationship between the systemic immune inflammation index (Sii), which corresponds to the multiplying of the neutrophil-to-lymphocyte ratio (NLR) and the platelet counts, and isolated CE. METHOD: The retrospective study population included 200 patients with isolated CE, 200 consecutive with obstructive coronary artery disease, and 200 consecutive with a normal coronary artery angiogram. A 2-sided p-value of <0.05 was considered significant. RESULTS: Sii, NLR, platelet-to-lymphocyte ratio (PLR), and monocyte-to-high density lipoprotein cholesterol ratio (MHR) were significantly higher in the CE group compared with the other groups (all p<0.001). In multivariate analysis, Sii (p<0.001, OR = 1.005, 95% CI =1.004-1.005) was found to be an independent predictor of isolated CE. In Receiver Operating Characteristic curve analysis, Sii had a higher Area Under the Curve than NLR, PLR, and MHR. Sii value of >517.35 has 79% sensitivity, 76% specificity for the prediction of the CE [AUC: 0.832, (p<0.001)]. Sii had a significant correlation with the number of ectatic coronary arteries and Markis classification (r:0.214 p=0.002; r:-0.195, p=0.006, respectively). CONCLUSION: To the best of our knowledge, this is the first study that Sii was significantly associated with isolated CE presence and anatomical severity.

FUNDAMENTO: A patologia subjacente da ectasia da artéria coronária (EC) isolada não foi totalmente elucidada. OBJETIVO: Nosso objetivo foi examinar a relação entre o índice de inflamação imune sistêmica (Sii), que corresponde à multiplicação da razão neutrófilos-linfócitos (RNL) e as contagens de plaquetas, e EC isolada. MÉTODO: A população do estudo retrospectivo incluiu 200 pacientes com EC isolada, 200 consecutivos com doença arterial coronariana obstrutiva e 200 consecutivos com angiografia coronária normal. Um valor de p bicaudal <0,05 foi considerado significativo. RESULTADOS: Sii, RNL, razão plaqueta-linfócito (RPL) e razão monócito-colesterol de lipoproteína de alta densidade (MHR) foram significativamente maiores no grupo EC em comparação com os outros grupos (todos p<0,001). Na análise multivariada, Sii (p<0,001, OR = 1,005, IC 95% =1,004-1,005) foi considerado um preditor independente de EC isolada. Na análise da curva Receiver Operating Characteristic (ROC), Sii teve uma área sob a curva maior em comparação com RNL, RPL e MHR. O valor de Sii >517,35 tem 79% de sensibilidade, 76% de especificidade para a predição do EC [AUC: 0,832, (p<0,001)]. Sii teve correlação significativa com o número de artérias coronárias ectásicas e classificação de Markis (r: 0,214 p=0,002; r:-0,195, p=0,006, respectivamente). CONCLUSÃO: Até onde sabemos, este é o primeiro estudo em que Sii foi significativamente associado à presença isolada de EC e gravidade anatômica.

Systemic Immune-Inflammatory Index Is Associated with Residual SYNTAX Score in Patients with ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Systemic immune-inflammatory index (platelet count × neutrophil-lymphocyte ratio) is a new marker that predicts adverse clinical outcomes in coronary artery diseases. Our aim was to investigate the relationship between the systemic immune-inflammatory index and residual SYNTAX score in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. METHODS: In this retrospective study, 518 consecutive patients who underwent primary percutaneous coronary intervention (PCI) with the diagnosis of ST-segment elevation myocardial infarction were analyzed. The severity of coronary artery diseases was determined by residual SYNTAX score. In the receiver operating characteristic curve analysis, systemic immune-inflammatory index with an optimal threshold value of 1025.1 could detect the presence of a high residual SYNTAX score; the patients were divided into 2 groups as low (326) and high (192) according to the threshold value. In addition, binary multiple logistic regression analysis methods were used to evaluate independent predictors of high residual SYNTAX score. RESULTS: In binary multiple logistic regression analysis, systemic immune-inflammatory index [odds ratio = 6.910; 95% CI = 4.203-11.360; P <.001] was an independent predictor of high residual SYNTAX score. In addition, there was a positive correlation between the systemic immune-inflammatory index and residual SYNTAX score (r = 0.350, P <.001). In the receiver operating characteristic curve analysis, the systemic immune-inflammatory index with an optimal threshold value of 1025.1 could detect the presence of a high residual SYNTAX score with 73.8% sensitivity and 72.3% specificity. CONCLUSION: Systemic immune-inflammatory index, an inexpensive and easily measurable laboratory variable, was an independent predictor of the increased residual SYNTAX score in patients with ST-segment elevation myocardial infarction.

Trends in heart failure between 2016 and 2022 in Türkiye (TRends-HF): a nationwide retrospective cohort study of 85 million individuals across entire population of all ages.

Background: Data on the burden of heart failure (HF) outside western countries are limited, but available data suggest it may present differently in other countries. The aim of this study was to examine the incidence, prevalence, and survival rates of HF in Türkiye, with a specific focus on how these rates vary according to age, sex, comorbidities, and socioeconomic status (SES). Methods: We harnessed the extensive National Electronic Database of the Turkish Ministry of Health, covering Turkey's entire population from January 1, 2016, to December 31, 2022, to identify 2,722,151 cases of HF and their associated comorbidities using ICD-10 codes. Analyzing the primary endpoint of all-cause mortality, our study utilized anonymized data to examine patient demographics, comorbidities, socioeconomic status, and survival patterns, employing statistical techniques to delve into relationships and trends. The data were segmented by gender, socioeconomic status, and age, involving cross-tabulations and statistical metrics to explore connections, odds ratios, and survival rates. Findings: The estimated prevalence of HF was 2.114% in Türkiye at the end of 2022, with an annual incidence ranging between 3.00 and 6.06 per 1000 person years. Females were older than males (69.8 ± 13.9 years vs. 66.8 ± 13.9 years, respectively). The most common comorbidities were congenital heart diseases and anemia under the age of 20, and hypertension and atherosclerotic cardiovascular disease in the adult population. Only 23.6% (643,159/2,722,151) of patients were treated with any triple guideline-directed medical therapy (GDMT) and 3.6% (96,751/2,722,151) of patients were on quadruple GDMT. The survival rates for patients with HF at 1, 5, and 7 years were 83.3% (95% CI: 83.2-83.3), 61.5% (95% CI: 61.4-61.6), and 57.7% (95% CI: 57.6-57.8) among females, and 82.1% (95% CI: 82.0-82.2), 58.2% (95% CI: 58.1-58.3), and 54.2% (95% CI: 54.0-54.3) among males. Despite a tendency for an increase from the highest to the lowest SES, the prevalence of HF and mortality were paradoxically lowest in the lowest SES region. Interpretation: The prevalence, incidence, and survival rates of HF in Türkiye were comparable to western countries, despite the notable difference of HF onset occurring 8-10 years earlier in the Turkish population. Drug usage statistics indicate there is a need for effective strategies to improve treatment with GDMT. Funding: None.

The CHA2DS2-VASc Score as an Early Predictor of Graft Failure After Coronary Artery Bypass Surgery.

Background and objective Graft patency is one of the major concerns after coronary artery bypass graft (CABG) surgery. The CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus (DM), stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category] score is a tool that was developed to predict the risk of thrombotic events in patients with atrial fibrillation (AF). In this study, we evaluated the use of the CHA2DS2-VASc score as a simple tool for predicting graft failure (GF) among patients who underwent CABG surgery. Methods In this retrospective case-control study, a total of 280 patients were enrolled after applying the exclusion criteria. Angiograms were analyzed by using the QCA software system (Pie Medical Imaging, Maastricht, The Netherlands) for each patient. A graft was described as failed if it had 70% or more stenosis or was completely occluded. Patients were classified into two groups: group one included patients without GF (GF-N) and group two included patients with GF (GF-Y). Thereafter, the CHA2DS2-VASc risk score was calculated for each patient. Results In our cohort, 136 patients had GF (GF-Y group) and 144 patients did not have GF (GF-N group). GF-N and GF-Y patients had their angiography performed 100.31 ± 8.04 and 103.49 ± 8.41 months after CABG, respectively. GF-Y group had a significantly higher rate of DM, hypertension, and heart failure with reduced ejection fraction (HFrEF). GF-Y group had higher CHA2DS2 (GF-N group: 1.47 ± 0.91 vs. GF-Y group: 2.57 ± 1.17, p=0.0001) and CHA2DS2-VASc score (GF-N group: 2.80 ± 1.11 vs. GF-Y group: 4.15 ± 1.25, p=0.0001). Analyses showed that only CHA2DS2-VASc was an independent predictor of GF while other parameters including DM, hypertension, HFrEF, creatinine, and CHADS2 were not found to be independent predictors of GF. A CHA2DS2-VASc score of >3 predicted GF with a sensitivity of 65.44% and a specificity of 74.31%. Conclusions The CHA2DS2-VASc score might be used as a feasible and simple method to predict the risk of GF after CABG surgery.

New prognostic markers in pulmonary arterial hypertension: CRP to albumin ratio and uric acid.

INTRODUCTION: Idiopathic pulmonary hypertension(IPAH) is a rare disease that causes severe morbidity and mortality despite advances in treatment management. Evaluating the prognosis of the disease is critical in determining therapeutic approaches. We aimed to evaluate the prognostic significance of C-reactive protein/albumin ratio (CAR) and uric acid, which is an easily applicable and inexpensive parameter in patients with IPAH. METHODS: Seventy-two IPAH patients and 99 consecutive non-IPAH patients as a control group were enrolled in the study retrospectively. Right heart catheterization(RHC), echocardiography, and laboratory parameters of the two groups and those who died and survived among the IPAH patients were compared. RESULTS: IPAH and control group were compared at the first stage and CAR (1.98(0.28-10.74), 0.75(0.22-4.7),respectively;p < 0.01) and uric acid (0.33(0.19-0.87), 0.3(0.11-0.48) mmol/L, respectively; p = 0.03) values were significantly higher in the pulmonary hypertension group compared to the control group. Compared with the surviving IPAH patients, CAR (4.60(1.39-10.74),1.54(0.28-6.74),respectively;p < 0.001) and uric acid levels (0.458(0.26-0.87), 0.315(0.19-0.56) mmol/L, respectively; p < 0.001) were significantly higher in the group of patients who died. In the multivariate Cox regression models uric acid(p < 0.001) and CAR(p < 0.001) were found to be associated with survival time. Receiver operating characteristic curves (ROC) analyses showed that > 1.54 CAR value (AUC = 0.81,Sens:85.7%,Spec:56.9%,p < 0.001) and > 5.85 mg/dL (>0.348 mmol/L) uric acid value (AUC = 0.864, Sens:85.7%, Spec:78.4%, p < 0.001) are strong predictors for mortality. CONCLUSION: In this study, we showed that simple markers such as CAR, which augment the inflammation marker feature of CRP, and uric acid can give prognostic information in PAH patients.

Cancer antigen-125 is a predictor of mortality in patients with pulmonary arterial hypertension.

BACKGROUND: Carbohydrate antigen 125 (CA 125), known as a tumor marker for ovarian cancer, has been reported to increase and be associated with severity in heart failure and chronic obstructive pulmonary disease. Patients with pulmonary arterial hypertension may also die due to developing right heart failure. The aim of this study is to evaluate the prognostic role of CA-125 in PAH patients. METHODS: A total of 40 consecutive patients with PAH were evaluated prospectively. The mean age of patients was 52 ± 11 years (12% males, 88% females) with a median follow-up period of 16 months. RESULTS: After follow-up period, 12 out of 40 patients (30%) died. CA-125 levels were higher among those who died compared to those who survived [78.5 (11.0-292) vs. 27.5 (2.10-138) U/ml, p = 0.001]. The optimal cut-off value of CA-125 to predict mortality was found as 35.29 U/ml, with 85.7% specificity and 75% sensitivity. In multivariable Cox proportional-hazards model with forward stepwise method; CA-125 > 35.32 U/ml on admission (HR = 7.645, 95% CI: 1.356-43.121, p = 0.021), age (HR = 1.132, 95% CI: 1.040-1.233, p = 0.004), TAPSE (HR = 0.740, 95% CI: 0.549-0.998, p = 0.048) and uric acid (HR = 1.444, 95% CI: 1.022-2.042, p = 0.037) remained associated with an increased risk of death. CONCLUSION: In this study, we showed for the first time that serum CA-125 values were an independent predictor for the long-term mortality in PAH patients.

Association Between Nutritional Indices and Long-Term Outcomes in Patients Undergoing Isolated Coronary Artery Bypass Grafting.

Background It is well known that approximately 20% of patients who undergo cardiac surgery experience weight loss in postoperative period. However, there is a lack of data on postoperative consequences of malnutrition. This study aimed to investigate the relationship between nutritional status and long-term outcomes in patients undergoing isolated coronary artery bypass grafting (CABG). Material and methods A total of 586 patients who underwent isolated CABG in our center between January 2015 and March 2016 were included in this study. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of all-cause death, non-fatal myocardial infarction (MI), and stroke. Patients were divided into two groups based on their MACCE outcomes. Prognostic nutritional index (PNI), geriatric nutritional risk index (GNRI), and controlling nutritional status (CONUT) scores were used to show the nutritional status. Results The mean follow-up time of the whole study group was 38.08 ± 13.4 months. The follow-up time was 39 ± 13 months in patients with mortality, while it was 20 ± 15 months in those without mortality. The PNI and GNRI values were lower in patients with major adverse cardiac and cerebrovascular events (MACCE) compared to patients without MACCE. The median CONUT score was higher in patients with MACCE. Conclusion Our study showed that nutritional indices including PNI, CONUT, and GNRI were associated with long-term MACCE and mortality in patients who underwent isolated CABG. The use of these scores in order to predict prognosis in patients treated with CABG seems to be an applicable method in clinical practice.

Predictors of long-term mortality in acute ST-elevation myocardial infarction patients undergoing emergent coronary artery bypass graft surgery.

OBJECTIVE: Coronary artery bypass graft (CABG) surgery as a primary treatment for acute ST-elevation myocardial infarction (STEMI) is still debated. This study aimed to evaluate the predictors of long-term mortality in STEMI patients undergoing emergent CABG. To the best of our knowledge, this is the first study to evaluate the long-term mortality predictors in patients with STEMI revascularized by primary CABG. METHODS: This retrospective study included 88 consecutive patients with STEMI, who did not qualify for primary percutaneous intervention and required emergent CABG between 2010 and 2017. The study population was divided into the following 2 groups: survivors and nonsurvivors. The 2 groups were compared in terms of demographics, preoperative, intraoperative, and postoperative characteristics. RESULTS: 23 of the 88 patients, died during the median 92.8 (69.0-105.1) months of follow-up. Data were evaluated with univariate and multivariate analyses. Killip class (p<0.001) was found to be an independent predictor of long-term all-cause mortality in patients with STEMI revascularized by CABG, and mortality rates increased significantly as Killip class increased (log-rank test, p<0.001). Moreover, age (p=0.044) was found to be an independent predictor of long-term mortality. Left ventricular ejection fraction, glomerular filtration rate, glucose levels, and left anterior descending artery to the left internal mammary artery graft usage (p=0.001, p=0.009, p<0.001, and p=0.039, respectively) were significantly associated with long-term all-cause mortality for our study population. CONCLUSION: Killip class was found to be an independent predictor of long-term all-cause mortality in patients with STEMI who underwent emergent CABG. The patients' admission status may give valuable information about long-term mortality.

Bleeding risk with concomitant use of tirofiban and third-generation P2Y12 receptor antagonists in patients with acute myocardial infarction: A real-life data.

OBJECTIVE: Combination of dual antiplatelet therapy (DAPT) with glycoprotein (GP) IIb/IIIa inhibitors can increase bleeding risk. In this study, we aimed to investigate bleeding complications of different DAPTs with concomitant tirofiban use in patients with acute coronary syndrome (ACS). METHODS: This retrospective study included 224 consecutive ACS patients (mean age 56.6±11.1 years, 193 men) who were given conventional dose of tirofiban (25 µg/kg per 3 minutes followed by an infusion of 0.15 µg/kg/min for 24 hours) in addition to DAPT (300 mg aspirin followed by 100 mg/day + 600 mg clopidogrel followed by 75 mg/day or 180 mg ticagrelor followed by 90 mg twice daily or 60 mg prasugrel followed by 10 mg/day). Any intra-hospital bleeding complications were noted. RESULTS: Of the 224 patients, 115 were given ticagrelor and 32 were given prasugrel. Mean hemoglobin fall was similar between the patients taking ticagrelor/prasugrel and those taking clopidogrel. Ten patients taking ticagrelor and one patient taking prasugrel had hemoglobin fall ≥3 g/dL versus two patients in clopidogrel group (p=0.228). Gastrointestinal bleeding (two patients taking ticagrelor), hematoma at access site (three patients taking ticagrelor), and cardiac tamponade (two patients taking ticagrelor) rates were also similar. Creatinine levels were associated with hemoglobin fall ≥3 g/dL (p=0.032, Odds ratio 2.189, 95% confidence interval 1.070-4.479). There was no relation between hemoglobin fall ≥3 g/dL and antiplatelet agent, age, sex, hypertension, or diabetes. CONCLUSION: Tirofiban may be given to patients receiving ticagrelor or prasugrel with a bleeding rate similar to clopidogrel. Close monitoring for bleeding risk is recommended, especially in patients with higher creatinine levels.

Increased frequency of occurrence of bendopnea is associated with poor outcomes in heart failure outpatients.

BACKGROUND: Relationship between the frequency of occurrence of bendopnea during the daily life of heart failure (HF) outpatients and clinical outcomes has never been evaluated before. METHODS: Turkish Research Team-Heart Failure (TREAT-HF) is a network between HF centres, which undertakes multicentric observational studies in HF. Herein, the data including stable 573 HF patients with reduced ejection fraction out of seven HF centres were presented. A questionnaire was filled by the patients, with the question 'Do you experience shortness of breath while tying your shoelace?', assessing the presence and frequency of bendopnea. RESULTS: To the question related to bendopnea, 48% of the patients answered 'yes, every time', 31% answered 'yes, sometimes', and 21% answered 'No'. Patients were followed for an average of 24 ± 14 months, and the patients who answered 'yes, every time' and 'yes, sometimes' to the bendopnea question were found having increased risk for both HF-related hospitalisations (HR:3.2, p < .001- HR:2.8, p = .005) and composite outcome consisting of 'HF-related hospitalisations and all-cause death in the multi-variate analysis (HR:3.1, p < .001- HR:3.0, p < .001). Kaplan Meier analysis for HF-related hospitalisation, all-cause death, and the composite of these were provided for these three groups, yielding significant and graded divergence curves with the best prognosis in 'no' group, with the moderate prognosis in 'sometimes' group, and with the worst prognosis in the 'every time' group. CONCLUSION: For the first time in the literature, our study shows that the increased frequency of bendopnea occurrence in daily life is associated with poor outcomes in HF outpatients.

Late gadolinium enhancement on CMRI in patients with LV noncompaction: An overestimated phenomenon?

BACKGROUND AND PURPOSE: Subendocardial fibrosis is recognized finding in left ventricular noncompaction (LVNC); however, the evidence regarding the patterns and the frequency of late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMRI) is controversial. The present study sought to assess the frequency and patterns of LGE in LVNC. MATERIALS AND METHODS: Patients with a diagnosis of LVNC based on the echocardiographic CMRI criteria were enrolled in this retrospective study. The myocardial noncompacted-to-compacted ratio (NC/C) was perpendicularly measured on short-axis cine images. Two observers jointly assessed the presence of LGE on short-axis LGE images. The long-axis four-chamber and long-axis two-chamber images were used to confirm the presence of LGE if needed. RESULTS: A total of 42 patients, 20 females (47.7%) and 22 were males (52.3%), were included in the study. The median age of the patients was 32.4 years (range 18-63). LGE was identified in 2 out of 42 patients (4.7%) with LVNC. LGE was identified in the interventricular septum involving the subendocardial layer and noncompacted lateral myocardial wall involving the trabeculae at mid-ventricular and basal levels. CONCLUSION: LGE is uncommon in patients with LVNC. We highlight that the diagnosis of LVNC in patients with atypical LGE patterns, such as epicardial or transmural enhancement, should be reappraised and the other cardiac diseases should be discarded before establishing the final diagnosis.