Risk factors for left atrial appendage thrombus.

Background: Atrial fibrillation (AF) is the most common persistent rhythm disorder that has been shown to be associated with a significant increase in stroke risk. Left atrial appendage (LAA) thrombi are responsible for most of strokes of cardiac origin. CHA2DS2-VASc is a risk scoring system to identify patients' indications for anticoagulation in nonvalvular AF patients. The aim of our study was to investigate CHA2DS2-VASc score, the other risk factors, echocardiographic data and blood parameters for LAA thrombus.Methods: Two hundred and sixty-four patients who were admitted to our adult cardiology outpatient clinic and who underwent a transesophageal echocardiography procedure between June 2017 and June 2019 included in our study. Patient's demographic data, transthoracic echocardiographic examinations, and laboratory results were recorded retrospectively.Results: LAA thrombus was detected in 39 (14.7%) patients. The rates of coronary artery disease and systolic dysfunction were significantly higher in patients with LAA thrombus (p = .017, p = .016, respectively). When AF subtypes were examined in detail, thrombus rate was significantly higher in persistent AF (51 vs. 25.7%, p = .002). Although the CHA2DS2-VASc score was slightly higher in the thrombus group, there was no statistically significant difference between the two groups (3.0 ± 1.65 vs. 2.78 ± 1.66).Conclusions: In conclusion, CHA2DS2-VASc score system itself was not informative about LAA thrombus formation although some of its components were related with LAA thrombus formation. According to a multiple regression analysis, the independent determinants of LAA thrombus were the presence of AF and coronary artery disease.

Mitral Omnicarbon monoleaflet valve dehiscence mapped by 3D echocardiography.

A patient with a prosthetic mitral valve presented with dyspnea, a new murmur and anemia. Real time three-dimensional (3D) echocardiography revealed a large valvular dehiscence that spanned approximately 50% of the circumference of the valve ring. By transesophageal echocardiography the paravalvular leak was mapped between 60 and 180 degrees that exactly matched the 3D echocardiographic appearance.

Treatment-associated change in apelin concentration in patients with hypertension and its relationship with left ventricular diastolic function.

OBJECTIVE: We examined the change in apelin concentration and its relationship with left ventricular diastolic function in patients treated for hypertension. METHODS: Ninety treatment-naive patients with newly diagnosed hypertension and 33 age- and sex-matched control subjects were prospectively enrolled. Patients with hypertension were randomized to treatment either with telmisartan 80 mg or amlodipine 10 mg. Apelin concentration was measured and echocardiography was performed at baseline and after 1 month of treatment. RESULTS: The data of 77 patients and 33 controls were analyzed. Mean age, gender, baseline blood pressure, apelin levels, and echocardiographic measurements were similar between the treatment groups (p>0.05 for all). Apelin concentration was significantly lower in patients with hypertension than in controls. There was a significant increase in apelin level after 1 month of treatment in both groups (0.32±0.17 vs. 0.38±0.17 ng/dL in telmisartan group, p=0.009, and 0.27±0.13 vs. 0.34±0.18 ng/dL in amlodipine group, p=0.013). Diastolic function improved significantly in both groups (p<0.05) but was not significantly associated with change in apelin concentration. CONCLUSION: Apelin concentration increased significantly after 1 month of effective treatment with telmisartan or amlodipine to a similar extent. Change in apelin concentration was not associated with improvement in diastolic function.

Doppler tissue imaging of the heart in secondary amyloidosis.

Secondary amyloidosis (SA) affects cardiac texture and function by interstitial fibrosis. Doppler tissue imaging (DTI) may quantify heart function through the assessment of myocardial velocities. Echocardiographic findings of early cardiac amyloidosis (CA) without heart failure (HF) caused by SA were determined both by standard methods and DTI. It was then determined whether DTI is superior to conventional echocardiography in documenting early CA due to SA. Twenty-five patients with SA who had CA without HF (group 1) were compared with 25 healthy control subjects (group 2). After standard echocardiography, systolic (s), early (e) and late diastolic (a) velocities of interventricular septum, anterolateral, and anterior and inferior walls were measured from mitral annulus by DTI. The averages were called (s(mean)), (e(mean)), and (a(mean)), respectively. Fractional shortening (FS) and ejection fraction (EF) values of groups 1 and 2 were similar. Standard Doppler echocardiographic values were not typical for a specific diastolic abnormality. The (s(mean)) and (e(mean)) for group 1 were lower but (a(mean)) was higher compared with group 2 (all P < .05). The group 1 (e(mean)/a(mean)) was lower (P < .0001) and (E/e(mean)) was higher (P = .003) than in group 2 (both P < .05). (E/e(mean)) and (E/e(lateral wall)) ratios were positively correlated (r = 0.74, P < .05). In patients with early CA due to SA without HF, by DTI, (s(mean)) and (e(mean)) velocities decrease and (a(mean)) velocity increases. These may be markers of subclinical CA of SA when standard echocardiography is not informative. (E/e(mean)) ratio may be an alternative index to (E/e(lateral wall)).

Effects of a single, 24-hour, low-dose intravenous dobutamine infusion on left ventricular myocardial performance index in congestive heart failure: A prospective, nonrandomized study.

BACKGROUND: Dobutamine, a predominantly beta-adrenergic sympathomimeticagent, is used for improving left ventricular (LV) systolic performance with different dosing regimens in patients with congestive heart failure (CHF). Myocardial performance index (MPI) is an indicator of LV global function that is correlated with LV end-diastolic pressure, and it is increased in CHF. OBJECTIVE: The purpose of this study was to examine the effects of a single, 24-hour, low-dose, IV dobutamine infusion on LV systolic and diastolic function and on MPI in CHF as an indicator of LV global function, as well as the adverse effects (AEs) of the infusion. METHODS: This prospective, nonrandomized study was conducted at theDepartment of Cardiology, Baskent University Hospital, Ankara, Turkey. Adult patients with LV ejection fraction (EF) <35%, sinus rhythm, and symptomatic CHF were treated using a standard protocol for at least 4 weeks. At the end of this period, patients with symptomatic CHF and EF <35% underwent echocardiography that included measuring isovolumic relaxation and contraction times (IRT and ICT, respectively) and LV ejection time (ET), and calculating LV MPI using the formula MPI = (IRT + ICT)/ET Dobutamine 2.5 µg/kg · min was then infused intravenously for 24 hours. Echocardiography was repeated 24 hours later and values were compared with preinfusion data. Patients were observed and monitored for CHF symptoms and AEs for 24 hours. RESULTS: Forty-three patients were enrolled in the study, and 31 (22 men,9 women; mean [SD] age, 67.55 [11.78] years) continued after the 4-week standard-treatment period. Mean (SD) heart rate (74.93 [20.15] vs 80.23 [13.74] bpm, respectively), systolic blood pressure (129.00 [19.23] vs 126.67 [23.79] mm Hg), and diastolic blood pressure (75.80 [11.26] vs 74.96 [8.30] mm Hg) were statistically similar before and after the infusion. The mean (SD) end-diastolic volume was statistically similar to the preinfusion value (215.87 [76.74] vs 211.08 [65.51] mL); however, the mean (SD) end-systolic volume was significantly reduced (163.80 [63.86] vs 146.74 [53.12] mL; P = 0.01). Mean (SD) EF (25.33% [7.77%] vs 30.45% [7.63%]; P = 0.001) and stroke volume (SV) (54.92 [22.30] vs 63.59 [23.91] mL; P = 0.04) increased significantly. The mean (SD) early:late diastolic flow velocity (E/A ratio) (1.58 [1.36] vs 1.65 [1.27]), IRT (107.03 [35.37] vs 100.42 [34.32] ms), ICT (96.61 [34.27] vs 86.35 [44.80] ms), ET (240.65 [33.28] vs 243.48 [33.54] ms), and MPI (0.81% [0.28%] vs 0.78% [0.31%]) did not change significantly after dobutamine infusion. No AEs were observed. CONCLUSIONS: In this study of adult patients with symptomatic CHF, a single, 24-hour, low-dose, IV dobutamine infusion (2.5 µg/kg · min) was associated with decreased LV end-systolic volume and increased SV and EF However, LV diastolic function parameters, isovolumic time intervals, ET, and MPI were statistically similar to preinfusion values. The infusion was well tolerated.

Carbon coating of stents has no effect on inflammatory response to primary stent deployment.

The aim of this study was to investigate the effects of stent carbon coating on inflammatory response. The authors serially measured plasma concentrations of C-reactive protein (CRP), fibrinogen, and several cytokines (tumor necrosis factor, interleukin [IL]-1-beta, IL-6, and IL-8) in patients with single-vessel coronary stenosis who underwent primary stent implantation. None of the subjects had inflammatory or infectious disease at the time of the procedure. Forty-six patients (38 males; mean age 55 +/-9 years) were studied. Blood samples were collected before and at 2, 4, 6, 24, and 48 hours after stent implantation. Patients were randomly assigned 1 of 2 different stent types, an uncoated MAC (AMG Raesfeld-Erle, Germany) (UC-MAC) or a carbon-coated MAC (CC-MAC) stent. Implantations were performed without predilatation, and stents were deployed at a maximum pressure of 6 atmospheres for 90 seconds. Of the 46 patients, 14 had stable, 27 had unstable, and 5 had atypical angina. According to ACC/AHA classification, 35 lesions (76.1%) were type A, 10 (21.7%) were type B, and 1 (2.2%) was type C. Single stenosis of 28 left anterior descending, 12 circumflex, and 6 right coronary arteries were treated. Serum IL-6 increased in both the UC-MAC and CC-MAC groups, with concentrations significantly elevated above baseline at 6 hours, and then decreasing after 24 hours (baseline, 6-hour, and 24-hour values = 3.1 +/-2.3, 5.7 +/-3.8, and 6.3 +/-4.6 pg/mL, respectively, in UC-MAC; 3.7 +/-2.6, 6.2 +/-6.0, and 4.6 +/-3.7 pg/mL, respectively, in CC-MAC [p=0.002]). Plasma fibrinogen, CRP, and leukocyte concentrations also increased in both groups over the 24 hours (p < 0.05). The elevations of IL-6, CRP, and fibrinogen were similar in the 2 groups. The percent increases in IL-6, fibrinogen, and CRP were not associated with stent length, size, or clinical presentation (all p > 0.05). The results showed that stent implantation increases plasma IL-6, fibrinogen, and CRP concentrations, but carbon coating of the stent does not seem to affect this inflammatory response.

Effects of hemodialysis on myocardial performance index.

The myocardial performance index (MPI) reflects global ventricular function. Chronic hypervolemia and uremia may negatively affect the myocardium of both ventricles. The aims of this study were to investigate how chronic renal failure (CRF) affects biventricular MPI and to determine whether preload reduction by hemodialysis (HD) affects left ventricular MPI (LVMPI) and right ventricular MPI (RVMPI) in CRF. Twenty-one patients with CRF (group 1) were examined 1 hour before and 1 hour after an HD session and 17 healthy control patients (group 2) were examined once by echocardiography. The MPI for each ventricle was calculated as the sum of isovolumic time intervals divided by the ejection time. Before HD, the LVMPI of group 1 was similar to that in group 2 (P>.05), but the RVMPI of group 1 was significantly higher (P=.007). After the HD session, LVMPI and RVMPI remained unchanged (P>.05 for both). The LVMPI and RVMPI were not correlated either before or after HD in group 1 (P>.05 for both), whereas they were correlated in group 2 (r=0.671, P=.003). Chronic renal failure causes isolated RV dysfunction, as reflected by increased RVMPI values. Preload reduction by HD does not affect LVMPI or RVMPI. Patients with CRF also do not exhibit the correlation of LVMPI and RVMPI that is observed in healthy individuals.

Effects of enalaprilat infusion on hemodynamics and renal function in patients undergoing cardiac surgery.

OBJECTIVE: This study was undertaken to evaluate the effect of enalaprilat infusion on hemodynamics and renal function during cardiopulmonary bypass (CPB). METHODS: Thirty adults undergoing CPB were randomly allocated into 2 groups. All patients received the same anesthetic protocol and same dopamine infusion protocol (2 mg/kg(-1)/min(-1)) during the study. In addition to dopamine infusion 15 patients received enalaprilat infusion (0.06 mg/kg(-1)/hr(-1)) during CPB. Blood creatinine, urea levels, and creatinine clearance (CLcr) were measured and cardiac output (CO) was calculated by echocardiography preoperatively and on the 6th postoperative day. Mean arterial pressure (MAP), central venous pressure (CVP), systemic vascular resistance (SVR) measurements were recorded during the operation and during postoperative 24 hours. RESULTS: In the control group postoperative blood creatinine and urea levels were significantly higher and CLcr measurements were significantly lower than the preoperative values (p<0.05). These values did not change in the enalaprilat group. Mean arterial pressure was similar in both groups (p>0.05), but SVR was lower (p<0.05) and CVP was higher (p<0.05) in the enalaprilat group than in the control group. In the enalaprilat group postoperative CO measurements were higher than the preoperative values (p<0.05). CONCLUSION: Our results demonstrate that enalaprilat infusion during CPB improves renal function and CO measurements in the early postoperative period.

[The effects of simvastatin combined with different antioxidant vitamin regimens on serum lipid profile in patients with low HDL cholesterol levels]. / HDL kolesterol düzeyi düsük olan bireylerde statin tedavisine farkli antioksidan vitaminlerin eklenmesinin serum lipid profili üzerine etkisi.

OBJECTIVE: This study was designed to compare the effects of simvastatin versus a combination of simvastatin with vitamin C or E on serum lipid profile, particularly, high-density lipoprotein (HDL)-cholesterol (C) level, in patients with a low HDL-C level. METHODS: Fifty-nine women and 49 men, who had a baseline HDL-C level equal to or lower than 40 mg/dl were randomized to one of the following study treatment groups: Group S (n=39) simvastatin 20 mg/day, Group S+C (n=33) simvastatin 20 mg/day + vitamin C 500 mg/day, and Group S+E (n=36) simvastatin 20 mg/day + vitamin E 400 IU/day. The groups' lipid profiles were obtained at baseline, 3rd and 6th months. RESULTS: Comparing with baseline values, total-C and low-density cholesterol (LDL-C) values significantly reduced (p<0.001) and HDL-C values significantly increased (Group S--33.9+/-3.9 mg/dl vs. 39.8+/-6.9 mg/dl, Group S+C--34.2+/-3.5 mg/dl vs. 38.1+/-6.1 mg/dl, Group S+E--33.1+/-3.6 mg/dl vs. 34.8+/-5.9 mg/dl, p<0.001) on therapy within the groups; however, there were no significant differences among the groups with regards to these parameters. The HDL-C levels increased from baseline by 14.0%, 11.7% and 10.2% in Group S, S+C, and S+E, respectively (p>0.05). CONCLUSION: A combination of simvastatin with antioxidant vitamins does not offer any beneficial effect over simvastatin alone. Particularly vitamin E seems to blunt the simvastatin induced HDL-C increase.

An extremely rare combination: pneumopericardium, pneumoperitoneum, and subcutanous emphysema-a case report.

Pneumopericardium, an accumulation of air in the pericardial cavity, occurs very rarely as compared to pneumothorax and pneumomediastinum. Clinical presentation is variable, patients are frequently asymptomatic, and mild cases usually resolve spontaneously. However, it may lead to pericardial tamponade, which requires rapid diagnosis and treatment that can be lifesaving. The traditional diagnostic, simple method of diagnosis is via an upright chest X-ray. Typical findings can be detected and a differential diagnosis can be made between pneumomediastinum and pneumopericardium. Echocardiography and chest computed tomography scans can also support the diagnosis. Only one case of pneumopericardium after surgical pericardiotomy has been reported in the literature so far. In this case report, iatrogenic pneumopericardium, which resolved spontaneously after surgical pericardiotomy, was reported in a 19-year-old patient who had a rejected liver transplantation, and had liver and kidney failure with pericardial tamponade. In this case, pneumopericardium was accompanied by pneumoperitoneum and subcutaneous emphysema; an extremely rare combination.

[Diagnosis and treatment of prosthetic valve dysfunction]. / Protez kapak sorunlarinda tani ve tedavi.

Prosthetic valve replacement replaces a heart disease with another one. There is no ideal prosthetic valve. All prostheses need to be followed by caution and treatment depends on the type of the prosthesis. Mechanical prostheses add anticoagulant drugs to patient's life and degeneration of bioprostheses requires reoperation. Prosthesis dysfunction includes a group of pathological processes like thrombosis, thromboemboli, valvular or paravalvular regurgitation, patient-prosthesis mismatch, infective endocarditis and bioprosthesis degeneration. Correct diagnosis and treatment of these problems will decrease the mortality and morbidity due to prosthetic valve disease.

Right ventricular contractile reserve in mitral stenosis: implications on hemodynamic burden and clinical outcome.

BACKGROUND: We investigated whether isovolumic acceleration (IVA) under inotropic stimulation as a means of right ventricular (RV) contractile reserve, is a surrogate for hemodynamic burden and has prognostic value in patients with mitral stenosis (MS). METHODS: Thirty-one pure MS patients and 20 controls underwent cardiac catheterization, exercise test, and dobutamine stress echocardiography. RV fractional area change (FAC), +dP/dt/P(max), RV tissue Doppler indices (isovolumic contraction [IVC] and systolic [S] velocity, and IVA) were measured. Patients were followed-up for the occurrence of cardiac adverse events. RESULTS: Inotropic modulation unmasked statistically significant differences regarding magnitude of changes in IVA, IVC, S, and +dP/dt/P(max), but not RV FAC. Inability to increase IVA more than 6.5 m/s(2) was the only independent determinant of pulmonary capillary wedge pressure >or=18 mm Hg (P=.004). Although MS severity did not predict the RV contractile reserve and pulmonary artery pressure (PAP) behavior during inotropic stimulation, the RV contractile reserve was related to the degree of systolic PAP. IVA increases of <3.4 m/s(2) had 86% sensitivity and 75% specificity to predict unfavorable outcomes during long-term follow-up (20+/-8 months). CONCLUSION: RV contractile reserve provides complementary data to the hemodynamic significance of MS severity, may contribute to clinical decision making, and be of prognostic value in these patients.

Comparison of the non-invasive methods estimating dry weight in hemodialysis patients.

BACKGROUND: The treatment of deranged water homeostasis of hemodialysis (HD) patients needs focusing on an accurate assessment of dry weight (DW). However, the correct estimation of post-dialysis DW is still a problem. Echocardiography of inferior caval vein diameter (ICVD) was recently considered as a reliable technique to estimate DWs of HD patients, whereas conductivity measurements and biochemical parameters remain controversial. In this study, we aimed to compare the noninvasive methods estimating DW in HD patients. METHODS: We enrolled 60 patients: 30 hypervolemic (HV) (12 M, 18 F, with a mean age of 41.9 +/- 13.6 years, mean HD duration of 38 +/- 45 months) and 30 normovolemic (NV) patients (19 M, 11 F, with a mean age of 42.2 +/- 14 years, mean HD duration of 62 +/- 51.5 months) according to clinical sign and symptoms as well as the findings on chest x-ray. Furthermore, the DWs of patients were evaluated in post-HD period in terms of echocardiography parameters [ICVD and collapse index (CI) determined by Cheriex], plasma ANP (pANP) levels (RIA), and total body water (TBW) by bioelectrical impedance (BEI). RESULTS: Forty-one of 60 patients had hypervolemic findings (68%) and 19 patients had normovolemia (32%) according to echocardiography parameters. Determination of "hypervolemia" by clinical acumen and pANP levels were not reliable, especially negative predictive values were lower as follows: sensitivity, specificity, positive predictive value, negative predictive values of clinical acumen and pANP levels: 63%, 69%, 87%, 50%, and 67%, 59%, 79%, 43%, respectively. TBW established by BEI did not correlate with ICVD and CI after HD (p > 0.05). The TBW of HV group according to echocardiography parameters was greater than NV group, but the difference was not statistically significant (27.4 +/- 6.6 kg versus 26.4 +/- 5.8 kg, respectively, p > 0.05). However, there was not any difference in the divided BSA values (1.58 +/- 0.2 kg/m2 versus 1.60 +/- 0.2 kg/m2, respectively, p > 0.05). Hypertension was seen in 37 (90%) of the echocardiographically hypervolemic patients, and the blood pressure was kept under control by previously given medication in only 7 (19%) patients. After the dry weight of the patients was corrected echocardiographically to normal limits, the blood pressure of 31 patients (86%) was normalized without antihypertensive treatment, but only in 6 patients remained the necessity of antihypertensive treatment. In addition, in 8 of 11 normotensive patients using antihypertensive drugs, assessment of their clinical and radiological findings showed normovolemia but ICVD > 11.5 mm/m2; however, the need for antihypertensive drugs disappeared when the ICVD reduced to 8-11.5/m2. CONCLUSIONS: Clinical and radiological assessment, pANP levels, and TBW established by BEI appeared to be less valuable in interpreting DW's of HD patients. In accordance with the literature, echocardiography findings have proven to be reliable, and they are important noninvasive tools that can establish an effective and rational antihypertensive treatment.

Giant left atrial appendage aneurysm: the third ventricle!

The giant congenital intrapericardial aneurysmal dilatation of the left atrial appendage without mitral valve disease is a very rare condition that is generally diagnosed in older patients. The problem is usually accompanied with supraventricular rhythm disorders and life-threatening systemic thromboembolism. Complete surgical correction is possible, and it should be performed immediately after the diagnosis. We are going to describe a patient with a history of cerebral thromboembolism and palpitation who was diagnosed with congenital intrapericardial aneurysmal dilatation of the left atrial appendage. The condition was identified by means of echocardiography and was surgically treated by resection of the appendage containing the aneurysm.