Aortic aneurysm mimicking a right atrial mass.

We present a case of a 54-year-old female who was initially thought to have a cystic mass in the right atrium on two-dimensional transthoracic echocardiography. Careful transducer angulation and off-axis imaging showed this mass-like effect was produced by an aortic root aneurysm impinging on the right atrium.

Usefulness of bubble study in echocardiographic diagnosis of contained rupture of hydatid cyst in the right ventricular outflow tract.

We describe an adult female presenting with dyspnea in whom both transthoracic and transesophageal echocardiography detected a mobile sac-like structure in the right ventricular outflow tract (RVOT) containing a heterogenous echogenic mass. This sac-like structure markedly changed its shape and size during the cardiac cycle. These findings and the fact that the patient lived in a rural area raised the possibility that this was a hydatid cyst. A bubble study using normal saline was useful in detecting a contained rupture of the cyst. Bubble echoes were noted within the sac-like structure but did not penetrate the inner wall of the cyst which contained echogenic material, indicating that the rupture was confined only to the outer layers. At surgery, a 0.5 cm communication was noted between the cyst and the RVOT and pathology confirmed the diagnosis of hydatid cyst.

Incremental value of live/real time three-dimensional transthoracic echocardiography over the two-dimensional technique in assessing carcinoid heart disease involving the aortic valve.

We present a case of an adult with metastatic carcinoid heart disease, in whom live/real time three-dimensional transthoracic echocardiography provided incremental value over two-dimensional transthoracic echocardiography in assessing involvement of the aortic valve.

Is Low Serum Klotho Level Associated with Alterations in Coronary Flow Reserve?

BACKGROUND: The Klotho gene, described as an "aging suppressor" gene, encodes a single-pass transmembrane protein. The extracellular part of Klotho is cleaved and released into the circulation where it may function as a vasculoprotective hormone. Coronary flow reserve (CFR) is accepted as a marker of coronary microvascular dysfunction when epicardial coronary stenosis is absent. There are no data regarding the relationship between serum Klotho levels and disorders in coronary microcirculation in healthy adults. We aimed to investigate the association between serum Klotho levels and alterations in coronary microcirculation in healthy adults using echocardiographic measurements of CFR. METHODS: Thirty-four healthy volunteers (median age: 34 [27-39], 14 males) were enrolled in this study. The study population was divided into two subgroups according to the median value of serum Klotho levels: a high Klotho (HK) group (n = 17, median age: 34 [30-38]; 6 males) and a low Klotho (LK) group (n = 17, median age: 32 [26-39]; 8 males). The analysis of coronary flow velocities was performed by transthoracic Doppler echocardiography. RESULTS: Hyperemic diastolic peak flow velocities and CFR were significantly higher in the HK group than in the LK group (70 [66-92] versus 61 [47-66], P = 0.003 and 3.0 [2.6-3.8] versus 2.2 [1.7-2.8], respectively, P = 0.001). Serum Klotho levels were positively correlated with CFR (P < 0.001). CONCLUSION: Serum Klotho levels correlate with CFR in a healthy population. Low serum Klotho levels may potentially identify patients with impaired CFR.

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of aortic atherosclerotic thrombi and ulcers.

We present two cases in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided incremental value in the assessment of atherosclerotic disease in the aorta. In one patient, it identified additional atherosclerotic ulcers as well as thrombi within them which were missed by two-dimensional (2D) TEE. In both cases, the size of the large mobile atherosclerotic plaque was underestimated by 2DTEE as compared with 3DTEE. Furthermore, 3DTEE provided volume quantification of the thrombi and ulcers which is not possible by 2DTEE. The echocardiographic findings of atherosclerotic plaques were confirmed by computed tomography in one patient and by surgery in the other.

Two- and live/real time three-dimensional transthoracic echocardiographic assessment of infective endocarditis of a valved pulmonary conduit.

We describe the use of a nonstandard left infraclavicular approach in making the diagnosis of an infected valved conduit with two-dimensional transthoracic echocardiography. The patient was an adult with tetralogy of Fallot and pulmonary atresia who had undergone multiple surgical repair procedures. The initial diagnosis of infective endocarditis was made by transesophageal echocardiography. Both techniques demonstrated a single, large vegetation in the conduit. Live/real time three-dimensional transthoracic echocardiography, on the other hand, provided further information by demonstrating several additional vegetations in the conduit and more comprehensively assessed their size by enabling measurement of their azimuthal dimensions and volumes. The patient was treated with antibiotics with complete resolution of the vegetations.

Incremental value of live/real time three-dimensional transthoracic echocardiography over two-dimensional echocardiography in hypertrophic cardiomyopathy with mid-ventricular obstruction and apical aneurysm.

We describe a case of hypertrophic cardiomyopathy with mid-left ventricular obstruction and apical aneurysm containing thrombi where live/real time three-dimensional transthoracic echocardiography provided incremental value over two-dimensional echocardiography in assessing the findings.

Incremental Value of Live/Real Time Three-Dimensional over Two-Dimensional Transesophageal Echocardiography in the Assessment of Atrial Septal Pouch.

An atrial septal pouch (ASP) results from partial fusion of the septum primum and the septum secundum, and depending on the site of fusion, the pouch can be left-sided (LASP) or right-sided (RASP). LASPs have been described in association with thrombi found in patients admitted with acute strokes, raising awareness of its potential cardioembolic role, especially in those with no other clearly identifiable embolic source. We retrospectively studied 39 patients in whom the presence of an ASP had been identified by three-dimensional transesophageal echocardiography (3DTEE) and who had a two-dimensional transesophageal echocardiogram (2DTEE) performed during the same clinical encounter. The incremental value provided by 3DTEE over 2DTEE included the detection of six ASPs not found by 2DTEE; the detection of two ASPs in the same subject (in four patients) not identified by 2DTEE; larger ASP measurements of length and height in over 80% of the cases; and measurement of the ASP width (elevational axis) for the calculation of the area of the ASP opening, because of its unique capability to view the pouch en face. In addition, the volume of ASP and of the echogenic masses contained in the ASP (four of 39 patients) could be calculated by 3DTEE, which is a superior parameter of size characterization when compared to individual dimensions. One of these patients who presented with ischemic stroke diagnosed by magnetic resonance imaging had a large (>2 cm) mass in a LASP, with echolucencies similar to those seen in thrombi and associated with clot lysis and resolution. This mass completely disappeared on anticoagulant therapy lending credence that it was most likely a thrombus. There was no history of stroke or any other type of embolic event in the other three patients with masses in ASP. In conclusion, this retrospective study highlights the incremental value of 3DTEE over 2DTEE in the comprehensive assessment and characterization of ASPs, which can aid in the clarification of their role in cryptogenic stroke patients.

An epidemiological study to evaluate the use of vitamin K antagonists and new oral anticoagulants among non-valvular atrial fibrillation patients in Turkey- AFTER-2 study design.

OBJECTIVES: Atrial fibrillation (AF) is one of the most common causes of preventable ischemic stroke and is related to increased cardiovascular morbidity and mortality. There is a lack of data in Turkey on the use of new oral anticoagulants (NOACs), and time in therapeutic INR range (TTR) in vitamin K antagonist users and AF management modality. In this multi-center trial, we aimed to analyze, follow and evaluate the epidemiological data in non-valvular AF patients. STUDY DESIGN: Four thousand one hundred consecutive adult patients from 42 centers with at least one AF attack identified on electrocardiography will be included in the study. Patients with rheumatic mitral valve stenosis and prosthetic valve disease will be excluded from the study. At the end of one year, the patients will be evaluated in terms of major cardiac end points (death, transient ischemic attack, stroke, systemic thromboembolism, major bleeding and hospitalization). RESULTS: First results are expected in June 2015. Data about major cardiovascular end-points will be available in January 2016. CONCLUSION: The rates and kind of oral anticoagulant use, TTR in vitamin K antagonist users and main management modality applied in non-valvular AF patients will be determined by AFTER-2 study. In addition, the rate of major adverse events (MACEs) and the independent predictors of these MACEs will be detected (AFTER-2 Study ClinicalTrials.gov number, NCT02354456.).

Epidemiology of atrial fibrillation in Turkey: preliminary results of the multicenter AFTER study.

OBJECTIVES: Although atrial fibrillation (AF) is one of the most common rhythm disorders observed in clinical practice, a multicenter epidemiological study has not been conducted in our country. This study aimed to assess our clinical approach to AF based upon the records of the first multicenter prospective Atrial Fibrillation in Turkey: Epidemiologic Registry (AFTER) study. STUDY DESIGN: Taking into consideration the distribution of the population in our country, 2242 consecutive patients with at least one AF attack determined by electrocardiographic examination in 17 different tertiary health care centers were included in the study. Inpatients and patients that were admitted to emergency departments were excluded from the study. Epidemiological data of the patients and the treatment administered were assessed. RESULTS: The mean age of the patients was determined as 66.8 ± 12.3 years with female patients representing 60% of the study population. While the most common AF type in the Turkish population was non-valvular AF (78%), persistent/permanent AF was determined in 81% of all patients. Hypertension (%67) was the most common co-morbidity in patients with AF. While a stroke or transient ischemic attack or history of systemic thromboembolism was detected in 15.3% of the patients, bleeding history was recorded in 11.2%. Also, 50% of the patients were on warfarin treatment and 53% were on aspirin treatment at the time of the study. The effective INR level was detected in 41.3% of the patients. The most frequent cause of not receiving anticoagulant therapy was physician neglect. CONCLUSION: These results demonstrate the necessity for improved quality of physician care of patients with AF, especially with regards to antithrombotic therapy.

Impact of body mass index on left ventricular diastolic dysfunction.

BACKGROUND: The prevalence of obesity is increasing in the developed and developing world. It is an independent risk factor for heart failure. Left ventricular (LV) diastolic dysfunction has been demonstrated to be a strong predictor of heart failure. In the present study we aimed to assess the impact of body weight on LV diastolic function. METHODS: The study was conducted on 2,228 participants (1,424 women, 804 men with a mean age of 49). Traditional and tissue Doppler echocardiographic examination were performed in all of the participants. The demographic and echocardiographic data were compared. Multivariate logistic regression analysis was used to assess the independent predictors of association of LV diastolic function. The study sample was divided into four groups: group 1 (body mass index [BMI] < 25.0 kg/m(2) ), group 2 (BMI 25.0-29.9 kg/m(2)), group 3 (BMI ≥ 30-39.9 kg/m(2)), and group 4 (BMI ≥ 40 kg/m(2)). RESULTS: Septal E was significantly lower in groups 2 and 3 compared to group 1 (P = 0.003). Septal A and septal A' were significantly higher whereas septal E' and lateral E' were significantly lower in the groups 2, 3, and 4 compared to the normal weight group (P < 0.001). Lateral A', deceleration time, and ejection time were significantly higher in obese when compared to the normal weight (P = 0.025, P < 0.001, and P = 0.009, respectively). The E/E' ratio was significantly higher in groups 2, 3, and 4 compared to the group 1 (P < 0.001). Logistic regression analysis revealed that age, BMI (OR = 1.060 [95% CI = 1.040 and 1.080]; P < 0.001), hypertension, and diabetes mellitus were independent predictors of LV diastolic dysfunction. CONCLUSION: BMI is an independent predictor of LV diastolic dysfunction along with age, hypertension, and diabetes mellitus.

Heart rate recovery index in patients with psoriasis.

OBJECTIVES: In clinical practice, autonomic functions are indirectly investigated with heart rate recovery (HRR) index measurements. Our aim was to evaluate the HRR index in patients with psoriasis, which is a systemic inflammatory disease. STUDY DESIGN: The study population included 39 psoriasis patients (18 female, mean age 48±15 years) and 40 control group (18 female, mean age 44±9 years) healthy individuals. The severity of psoriasis was calculated using the psoriasis area and severity index (PASI). None of the study patients had a PASI score >50. All of the participants underwent treadmill exercise testing using the Bruce protocol. RESULTS: According to basic clinical and demographic characteristics, both groups were similar with regard to age, body mass index, and fasting glucose and cholesterol levels. No significant differences were observed in the systolic or diastolic blood pressures or resting heart rates between the two groups. All patients and control-group participants had sinus rhythm and normal 12-lead ECG results at rest. All subjects completed the exercise tests to exhaustion without rhythm abnormalities, ischemic changes, or other complications. The maximal heart rate and metabolic equivalents achieved during the exercise stress test (EST) were similar in the psoriasis and control group (163±16 vs. 170±16, p=0.07; 9.8±0.9 vs. 10.1±1.0, p=0.24, respectively). The 1st, 3rd, and 5th minute HRR indices of patients with psoriasis were similar to those of the control group (HRR1: 30±12, 32±18, p=0.71; HRR3: 57±13, 64±17, p=0.10; HRR5: 64±15, 68±16, p=0.46, respectively). CONCLUSION: The HRR index, which is calculated by an EST and associated with autonomic nervous system function, is not effected in mild to moderate psoriasis patients.

Carotid intima media thickness and cardiometabolic risk associates in Turkish adults.

OBJECTIVE: Carotid intima media thickness (CIMT) is a strong predictor of future vascular events. However, data for Turkish individuals are limited and the association between cardiometabolic risk factors and CIMT has not been studied before.Therefore, we sought to investigate the CIMT and cardiometabolic risk associates in a large cohort of Turkish adults. METHODS AND RESULTS: The study was conducted on 2230 participants (1427 women, 803 men with a mean age of 49). The participants underwent a Doppler Ultrasound examination of CIMT. Mean CIMT was 0.61 +/- 0.19 mm. Age- and sex-adjusted partial correlation analysis revealed that only systolic blood pressure and smoking amount was significantly correlated with CIMT. Receiver operator characteristics (ROC) calculations showed that age had the best area under the curve (AUC = 0.84), smoking had the best sensitivity (86%) and diastolic blood pressure (> 88 mmHg) had the best specificity (74%) in predicting a person with thickened carotid intima media (> 0.8 mm). Independent predictors of thickened carotid intima media were hypertension [(odds ratio (OR) = 2.74; 95% confidence interval (CI) = 1.663-4.53; P value < or = 0.001)], systolic blood pressure [OR = 1.01; 95% CI = 1.002-1.022; P value = 0.022] and age [OR = 1.11; 95% CI = 1.079-1.136; P value < or = 0.001). CONCLUSION: Age, systolic blood pressure and smoking amount (pack/year) were the only age- and sex-adjusted associates of CIMT. Age had the best AUC in ROC analysis predicting thickened carotid artery intima media. Hypertension, systolic blood pressure and age were independent predictors of high CIMT in Turkish adults.

The platelet functions in patients with ankylosing spondylitis: anti-TNF-alpha therapy decreases the mean platelet volume and platelet mass.

The present study was designed to investigate the interaction between platelet indices (mean platelet volume (MPV), platelet count (PLC) and platelet mass (PLM)), inflammatory markers and disease activity in ankylosing spondylitis (AS) subjects. The effects of anti-TNF-alpha therapy and conventional treatment on platelet indices were also compared. We studied 68 patients with AS (group I, 46 men, age: 36.4 +/- 6.9 years) and as control group 34 age and sex-matched healty subjects. All patients received conventional therapy (CT) at the beginning (Group I). The patients were reevaluated after 3 months according to Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score. Group II consisted of 35 subjects who responded to the CT and continued to take the same therapy for 3 months additionally. Group III consisted of 33 subjects who had a high disease activity score (BASDAI > 4) after 3 months and were accepted refractory to the CT therapy. In Group III the treatment was switched to infliximab and continued for 3 months at the standard intravenous dose. Significantly higher baseline MPV, PLC and PLM was reported as compared to controls decreased by therapy (9.12 +/- 1.20 vs. 8.35 +/- 0.94 fl, p < 0.001, 340 +/- 69 vs. 251 +/- 56 (x 10(3)/ microL) p < 0.0001, 3096 +/- 736 vs. 2110 +/- 384; p < 0.0001, respectively). In the same way, they were substantially lowered by both treatments in group II and group III. PLC and PLM were positively correlated with WBC and ESR (r : 0.44; p < 0.0001, r : 0.41; p = 0.001, r : 0.52; p < 0.0001, r : 0.41; p = 0.001), respectively) in AS patients. Additionally, MPV and PLM were positively correlated with BASDAI score (r : 0.41; p < 0.001, r = 0.29; p < 0.001 respectively). We have found that increased platelet activity reduced by therapy in AS patients. Additionally, it was correlated with inflammatory markers and disease activity. According to these results, it can be suggested that both anti-TNF-alpha and conventional therapy might contribute to a decrease in the risk of cardiovascular morbidity and mortality in AS patients.

[Age at death in the Turkish Adult Risk Factor Study: temporal trend and regional distribution at 56,700 person-years' follow-up]. / TEKHARF Taramasinda ölüm yasi: 56700 Kisi-yillik izlemede dönemsel egilim ve bölgesel dagilim.

OBJECTIVES: We analyzed the temporal trend and regional distribution of age at all-cause death and the sex-specific and age-bracket defined coronary mortality in the 18-year follow-up of the Turkish Adult Risk Factor Study. STUDY DESIGN: The participants of the Turkish Adult Risk Factor Study who have been examined in even years were last surveyed in August 2008. A total of 1,582 individuals were surveyed, which constituted half of the alive participants of the overall cohort. Information on death was obtained from first-degree relatives and/or health personnel of local heath offices. Survivors were evaluated by history, physical examination, and 12-lead electrocardiography. The cumulative follow-up was 56,700 person-years. RESULTS: Of 1,582 participants, 868 (431 men, 437 women) were examined, in 604 subjects information was gathered, and 47 participants (26 men, 21 women) were ascertained to have died. Twenty-two deaths were classified as of coronary origin. Cumulative assessment of the entire cohort in the age bracket of 45-74 years disclosed coronary mortality to be 7.64 per 1000 person-years in men and 3.84 in women and persisted to be the highest among 30 European countries, whereas overall mortality declined at a greater proportion. Overall mean ages at death were deferred within a 12-year period by 7.4 years in men and 6 years in women, to 71.9 and 74.8 years, respectively. The extension of this mean survival was similar among urban-rural areas and geographic regions. CONCLUSION: Coronary mortality declined modestly, but life expectancy of Turkish adults rose by a mean of nearly seven years in the 12 years to 2003-08, without showing major differences in sex, urban-rural dwelling, or geographic regions.

Predictive value of prehypertension for metabolic syndrome, diabetes, and coronary heart disease among Turks.

BACKGROUND: Predictors of prehypertension and the latter's significance in predicting metabolic syndrome (MetS), type 2 diabetes (DM), and incident coronary heart disease (CHD) need further exploration. METHODS: Individuals with or without prehypertension (blood pressure (BP) 120-139 systolic or 80-89 mm Hg diastolic) were studied prospectively in a representative sample of Turkish adults. RESULTS: Mean age of 1,501 men and 1,533 women was 48 +/- 12 years at baseline. Prehypertension, identified in 32.8% of the sample, differed from the normotensive group mainly by age-adjusted obesity measures and C-reactive protein (CRP) and progressed to hypertension at more than twofold annual incidence as normotension did. In logistic regression analysis, adjusted for sex, age, heart rate, and smoking status, prehypertension was predictive for risk of MetS in both genders (relative risk (RR) 1.55 (95% confidence interval (CI) 1.21; 1.99)) compared with normotensives. However, DM and CHD were significantly predicted by prehypertension only in women (RR 2.06 and 1.98, respectively, for outcomes). Cardiometabolic risks in women were largely independent of obesity. Body mass index (BMI) at baseline predicted significantly subsequent development of new prehypertension in both genders (hazard ratio 1.39 (95% CI 1.17; 1.65)) and CRP tended to contribute to this risk. CONCLUSIONS: Prehypertension, compared with normotension, approximately doubles the risk for DM, MetS, and CHD in women without conferring substantial risk in Turkish men, except toward MetS. Excess cardiometabolic risk of prehypertension in women is independent of obesity. BMI is a determinant of prehypertension.

Lipoprotein(a) is associated with coronary heart disease independent of metabolic syndrome.

AIM: To assess (i) the association between lipoprotein(a) [Lp(a)] with the likelihood of coronary heart disease and metabolic syndrome (MS) and (ii) its covariates in Turkish adults. METHODS: Cross-sectional evaluation of 1309 adults, who had serum Lp(a) determinations by Behring nephelometry, and followed for a mean 1.0 year. MS was defined by ATPIII criteria modified for male abdominal obesity. RESULTS: Mean age of the sample was 56.8+/-11.3 years. After adjustment for sex, age, and smoking status, log-transformed Lp(a) levels were associated significantly with coronary heart disease likelihood in both sexes combined [odds ratio: 1.53 (95% confidence interval: 1.06; 2.20)]. This association persisted after additional adjustment for MS [odds ratio: 1.57 (95% confidence interval: 1.09; 2.26)]. The Lp(a) mid-tertile (5-17 mg/dl), accompanied by significantly lower serum triglycerides than the two remaining tertiles, was inversely associated significantly with MS in either sex; in women, this association was independent of waist circumference. In a linear regression comprising seven variables, excepting total cholesterol, only gamma-glutamyltransferase in women (P=0.002) and waist circumference (P=0.057) in men were inverse covariates of modest magnitude of Lp(a). CONCLUSION: Coronary heart disease likelihood, significantly associated with Lp(a) concentrations, is independent of MS and insulin resistance. Suggestive evidence was provided that intermediary Lp(a) concentrations, when accompanied by the presence of MS, could accelerate progression of vascular disease, especially in women.

Acute coronary stenosis in a young man with Behçet's syndrome.

OBJECTIVE: To present a case of myocardial infarction due to Behçet's syndrome. CLINICAL PRESENTATION AND INTERVENTION: A 27-year-old man who was known to have Behçet's syndrome for 1 year presented with retrosternal fluctuating chest pain, which radiated to the epigastrium 5 h prior to admission. Coronary angiography showed total occlusion of the left anterior descending coronary artery, which was successfully treated with coronary stent implantation. CONCLUSION: This case shows that patients with Behçet's syndrome who had acute chest pain should be thoroughly examined for any signs of acute myocardial infarction.

[Turkish Adult Risk Factor Survey 2007: decline in all-cause and coronary mortality continues]. / TEKHARF çalismasi 2007 taramasi: mortalite ve koroner mortalitede azalma egilimi sürüyor.

OBJECTIVES: We analyzed all-cause and coronary mortality as well as incident coronary heart disease (CHD) among the participants of the Turkish Adult Risk Factor Study, who resided essentially in the Marmara and Central Anatolia regions and were surveyed in the summer of 2007. STUDY DESIGN: Information on the mode of death was obtained from first-degree relatives and/or health personnel of the local health office. Most of the participants who were alive underwent physical examination and 12-lead electrocardiography. Incident CHD was defined as fatal or nonfatal myocardial infarction that occurred after the previous survey or incident stable angina and/or myocardial ischemia. RESULTS: Of 1,618 participants to be surveyed, 961 were examined, 501 subjects were assessed based on information obtained, 18 men and 12 women were dead, and 52 subjects were lost to follow-up. The number of newly recruited subjects was 138. Addition of 3,010 person-years of follow-up raised the total follow-up of the survey to 48,500 person-years. Eight deaths were attributed to CHD; new coronary events were identified in 16 subjects. Annual mortality was estimated as 10.0 and coronary mortality as 2.7 per 1,000 adults. Overall mortality which was 11.2 per 1,000 person-years in the original cohort declined to 9.1 and 5.9 in more recently recruited 1997/98 and 2002/03 cohorts, respectively. In the age bracket of 45 to 74 years, all-cause mortality which was 15.2 in 2004 decreased to 10.2 per 1,000 person-years in the past three years (p=0.003), with a corresponding decrease in coronary mortality from 6.0 to 5.1 (p<0.18), indicating that the decreasing trend in overall mortality and coronary deaths observed in this age group in the previous years did not level off. CONCLUSION: Our data show that the incidences of overall and coronary mortality continue to decline.