Abdi Bozkurt

Intravenous leiomyomatosis extending into the right ventricle after subtotal hysterectomy

A case of intravenous leiomyomatosis with extension into the right ventricle is described. A tumor in the inferior vena cava was detected three years after a subtotal hysterectomy had been performed for a myomatous uterus but was misdiagnosed as a thrombus. The tumor enlarged and intruded into the right ventricle for which she underwent surgery. The correct diagnosis was made during the surgery, therefore a two-stage resection was planned. Surgical resection is the best treatment for intracardiac extension of intravenous leiomyoma. We recommend iliac venotomy to remove the ilio-caval portion of the tumor in both stages of operations.

Evaluation of arterial stiffness for predicting future cardiovascular events in patients with ST segment elevation and non-ST segment elevation myocardial infarction.

Background. Arterial stiffness parameters in patients who experienced MACE after acute MI have not been studied sufficiently. We investigated arterial stiffness parameters in patients with ST segment elevation (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI). Methods. Ninety-four patients with acute MI (45 STEMI and 49 NSTEMI) were included in the study. Arterial stiffness was assessed noninvasively by using TensioMed Arteriograph. Results. Arterial stiffness parameters were found to be higher in NSTEMI group but did not achieve statistical significance apart from pulse pressure (P = 0.007). There was no significant difference at MACE rates between two groups. Pulse pressure and heart rate were also significantly higher in MACE observed group. Aortic pulse wave velocity (PWV), aortic augmentation index (AI), systolic area index (SAI), heart rate, and pulse pressure were higher; ejection fraction, the return time (RT), diastolic reflex area (DRA), and diastolic area index (DAI) were significantly lower in patients with major cardiovascular events. However, PWV, heart rate, and ejection fraction were independent indicators at development of MACE. Conclusions. Parameters of arterial stiffness and MACE rates were similar in patients with STEMI and NSTEMI in one year followup. The independent prognostic indicator aortic PWV may be an easy and reliable method for determining the risk of future events in patients hospitalized with acute MI.

Right and left ventricular adaptation to training determined by conventional echocardiography and tissue Doppler imaging in young endurance athletes.

Objective — Some findings of left ventricular (LV) functions in athletes are controversial. On the other hand, studies concerning the right ventricle (RV) are limited. The aim of the study was to assess the effects of endurance training on LV and RV systolic and diastolic function. Methods — A total of 60 (54 male, 6 female) athletes (mean age 20.7 ± 2.5 years) and 60 (51 male, 9 female) healthy subjects (mean age 21.3 ± 2.6 years) were included in the study. Standard echocardiographic examination and pulsed wave Doppler and tissue Doppler imaging (TDI) were performed. Results — Except LV and RV ejection fraction, all M-mode echocardiographic parameters of the athletes were found to be significantly greater compared to untrained subjects. LV cavity dimension enlarged ( > 55 mm) in 23 (38.4%) athletes but none of the controls. Of 54 male and 6 female athletes 33 (61.1%) and 5 (83.3%) had left vantricular hypertrophy. Athletes also had a greater RV free-wall thickness and mass index. None of the control subjects had either LV or RV hypertrophy.The mean LVMI/RVMI ratio was 3.77 ± 1.59 and 3.40 ± 1.32 in athletes and controls, respectively (p = 0.5).The mean E/A and Em/Am ratios and Sm velocities of both ventricles were significantly higher in athletes compared to untrained subjects (p < 0.001). Conclusion — Our study shows that despite an increase in left and right ventricular mass indexes, the LVMI/RVMI ratio stays stable.Training results in a better systolic and diastolic function.

Usefulness of N-Terminal Pro-B-Type Natriuretic Peptide Increase With Exercise for Predicting Cardiovascular Mortality in Patients With Heart Failure

N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) level at rest is related to left ventricular (LV) function and cardiovascular mortality in patients with heart failure (HF). There are limited and controversial data regarding changes in NT-pro-BNP level during exercise in patients with HF. The aim of this study was to investigate the effects of exercise on NT-pro-BNP levels and the relation between increases in NT-pro-BNP and the LV ejection fraction and cardiovascular mortality in patients with HF. Seventy-five patients with HF (New York Heart Association classes I to III) and 20 healthy subjects were enrolled in the study. Echocardiographic examination was performed. The modified Bruce protocol was used for symptom-limited exercise testing. Levels of NT-pro-BNP were measured at rest and after peak exercise. The patients were followed up for 690 to 840 days for cardiovascular mortality. Exercise induced significant increases in NT-pro-BNP in patients and controls. Except for a relative increase in NT-pro-BNP during exercise (relative DeltaNT-pro-BNP), NT-pro-BNP concentrations at rest and during peak exercise and absolute increases in NT-pro-BNP during exercise (absolute DeltaNT-pro-BNP) were significantly higher in patients with HF (p <0.001). Absolute DeltaNT-pro-BNP was positively correlated with NT-pro-BNP at rest (p <0.001). The level of absolute DeltaNT-pro-BNP was the most important parameter in predicting a LV ejection fraction <30% (p <0.001). Absolute DeltaNT-pro-BNP and LV end-systolic volume were found to be independent predictors of mortality (p = 0.012 and p = 0.015, respectively). In conclusion, exercise induced increases in NT-pro-BNP in patients and healthy subjects. Absolute increase in NT-pro-BNP is a reliable parameter in predicting a low LV ejection fraction and may help in the identification of patients at high risk for mortality.

Mitral annular calcification and aortic valve calcification may help in predicting significant coronary artery disease.

Mitral annular calcification (MAC) and aortic valve calcification (AVC) are manifestations of atherosclerosis. To determine whether mitral annular calcification and aortic valve calcification detected by transthoracic echocardiography (TTE) might help in predicting significant coronary artery disease (CAD), 123 patients with significant CAD and 93 patients without CAD detected by coronary angiography were investigated. MAC and AVC identified CAD with a sensitivity and specificity of 60.2%, 55.9% and 74.8%, 52.7%, respectively, and with a negative and a positive predictive values of 51.5%, 64.3% and 61.3% and 67.6%, respectively. The positive predictive value of MAC was greater than gender, hypertension, and hypercholesterolemia. AVC showed a positive predictive value greater than gender, hypertension, family history, and hypercho lesterolemia. The negative predictive values of MAC and AVC for CAD were greater than those of all risk factors except diabetes mellitus. In conclusion, presence of MAC and AVC on TTE may help in predicting CAD and should be added to conventional risk factors. Absence of MVC and AVC is a stronger predictor for absence of CAD than all conventional risk factors, except diabetes mellitus. Patients with MAC and AVC should be taken into consideration for the presence of significant CAD and thereby for diagnostic and therapeutic interventions in order to improve the prognosis.

Comparison of single-dose and repeated levosimendan infusion in patients with acute exacerbation of advanced heart failure

Background Levosimendan (LS) is a novel inodilator that improves cardiac performance, central hemodynamics, and symptoms of patients with decompensated chronic heart failure. The aim of this study was to compare the effects of single and repeated LS infusion on left ventricular performance, biomarkers, and neurohormonal activation in patients with acute heart failure. Material/Methods Twenty-nine consecutive patients with acute exacerbation of advanced heart failure were included in this study. LS was initiated as a bolus of 6 μg/kg followed by a continuous infusion of 0.1 μg/kg/min for 24 hours in both groups who received intravenous single and repeated (baseline and at 1 and 3 months) treatment. Physical examination, echocardiography, and biochemical tests (brain natriuretic peptide, tumour necrosis factor-α, interleukin-1β, 2, and 6) were performed before treatment and on 3 day of the treatment. The last evaluation was performed at 6 month after the baseline treatment. Results Twenty male and 9 female patients with mean age of 60.2±7.4 years were included in this study. A significant improvement in New York Heart Association functional status and myocardial performance index was detected only in the repeated LS treated patients at 6 month compared to the pretreatment status (p=0.03 and p<0.001; respectively). In addition, a significant decrease in brain natriuretic peptide (p<0.01) and plasma interleukin-6 (p=0.05) levels were also achieved only in patients who were given repeated LS. Conclusions Our study showed that repeated LS treatment is more effective compared to the single dose LS treatment in improving clinical status, hemodynamic and laboratory parameters in patients with acute exacerbation of advanced heart failure.

Apical Hypertrophic Cardiomyopathy: Diagnosis with Contrast-Enhanced Echocardiography A Case Report

Apical hypertrophic cardiomyopathy is a rare form of hypertrophic cardiomyopathy (HCM) recognized by a unique spadelike configuration on the left ventriculogram. Two-dimensional echocardiography is another useful tool in the diagnosis of this condition. The diagnosis may be difficult and may mimic akinesia or apical thrombus in some patients with poor acoustic windows. A 50-year-old woman with typical angina and left ventricular hypertrophy with T wave inversion in leads V3-V6, II, III and aVF is presented. Apical HCM was diagnosed with contrast-enhanced echocardiography and confirmed by finding a spadelike configuration on the left ventriculogram. Apical HCM should be considered in patients in whom symptoms and ECG findings mimic ischemic heart disease. Contrast-enhanced echocardiography is a reliable and simple method in the diagnosis of apical HCM.

The relation between serum erythropoietin level and severity of disease and mortality in patients with chronic heart failure

Objective — We evaluated the relation between serum erithropoietin level and the severity of disease and mortality in patients with chronic heart failure (CHF). Methods — We enrolled 96 CHF patients and 50 age- and sex-matched control subjects. Haemoglobin, haemotocrit, N terminal pro-B type natriuretic peptide (NT-proBNP) and erythropoietin levels and echocardiographic parameters were measured. The patients were contacted 1 year after the evaluations to determine survival. Results — The patients had lower haemoglobin and haematocrit but higher serum erythropoietin and NT-proBNP levels than the control subjects. Serum erythropoietin and NT-proBNP levels increased with worsening functional class.The serum erythropoietin level correlated negatively with left ventricular ejection fraction (r = –0.404, P < 0.001), haemoglobin (r = –0.530, P < 0.001) and haematocrit (r = –0.496, P < 0.001) levels. The patients who died (n = 17) had lower haemoglobin and haematocrit levels and significantly higher erythropoietin and NT-proBNP levels. However, multivariate logistic regression analysis showed that only NT-proBNP level was an independent predictor of mortality (P = 0.002). Conclusion — Anaemia and resistance to erythropoietin develop proportionately to disease severity and left ventricular systolic dysfunction in patients with CHF.Although serum erythropoietin level seems related with mortality, this observation needs to be confirmed by studies with more patients and longer follow-up.

Reliability of Doppler Methods in the Evaluation of the Left Ventricular Systolic Function in Patients with Idiopathic Dilated Cardiomyopathy

Background: There are many new methods for evaluating the left ventricle (LV) systolic function. The aim of this study was to compare the methods, which evaluate the systolic function such as Simpsons method, myocardial performance index (MPI), systolic Sm wave, and dp/dt value of the mitral regurgitation. Methods: Forty patients (27 male, 13 female, mean age 52.5 ± 18.2 years) with idiopathic dilated cardiomyopathy and 40 healthy subjects (27 male, 13 female, mean age 49.3 ± 10.8 years) were included in the study. All patients and controls underwent echocardiographic examination by M‐mode, two‐dimensional, pulsed‐wave (PW) and continuous wave Doppler and tissue Doppler imaging (TDI). The MPI were measured by the summation of the isovolumetric contraction and relaxation times division of the LV ejection time, with both PW and TDI methods. Results: The cardiac chamber dimensions, MPI, and modified MPI were greater, LV ejection fraction and TDI Sm wave were lower in the patients compared to the controls (P < 0.001). The LV ejection fraction of patients calculated by Simpsons method compared with novel methods. Value of dp/dt (P = 0.010, r = 0.546), MPI (P = 0.002, r =−0.470) and modified MPI (P = 0.038, r =−0.330) were related to the LV ejection fraction. Tissue Doppler Systolic Sm wave had a modest correlation with LV ejection fraction (P < 0.001, r = 0.604). Conclusion: Doppler and tissue Doppler imaging methods correlate with traditional echocardiographic methods and can be used reliably and safely for left ventricular performance regardless of the patients echogenity.

Intimal Intussusception in Aortic Dissection and Coexisting Coronary Artery Disease

Intimal tear is rarely circumferential in aortic dissection. In such an instance, intimal intussusception may occur. This exposes the patient to the additional risk of severe aortic regurgitation, blockage of the left main coronary artery ostium, or both in proximal intimal intussusception in ascending aortic dissection. Here we present a 61-year-old patient with ascending aortic dissection, aortic regurgitation caused by an intussuscepted proximal intimal flap, and coexisting coronary artery disease. The presenting symptoms and electrocardiographic findings simulated an acute coronary syndrome. Among other diagnostic measures, only transesophageal echocardiography clearly defined the pathologic condition. The patient underwent a successful aortic root replacement and coronary artery bypass grafting.