Alev Arat Ozkan

Clinical and Echocardiographic Risk Factors for Embolization in the Presence of Left Atrial Thrombus

Aims: The aim of our study was to evaluate the factors leading to embolization in patients with left atrial thrombi (LAT). With this purpose, we retrospectively analyzed clinical, transthoracic, transesophageal echocardiographic data of patients with LAT in the transesophageal echocardiographic evaluation. Methods and Results: One hundred ninety‐two patients with LAT not on anticoagulant therapy were divided into two groups according to the presence of prior ischemic stroke. The group with ischemic stroke included more patients with sinus rhythm and less patients with mitral stenosis. They had smaller left atrial diameter, more left atrial appendage spontaneous echo‐contrast, higher appendage ejection fraction, and emptying velocity. Conclusion: Once the thrombus has been formed, cerebral embolization seems to be higher in patients with relatively preserved appendage ejection fraction and emptying velocity. Presence of atrial appendage spontaneous echo‐contrast also favor embolization. Factors leading to embolization seem to differ in some respects from the causes of thrombus formation.

Impact of Rosuvastatin on Contrast-Induced Acute Kidney Injury in Patients at High Risk for Nephropathy Undergoing Elective Angiography

Although statins have been shown to prevent contrast-induced acute kidney injury in patients with acute coronary syndromes, the benefit of statins is not known for patients at high risk for nephropathy who undergo elective coronary angiography. Two hundred twenty consecutive statin-naive patients with chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73 m(2)) who underwent elective coronary or peripheral angiography were randomly assigned to receive rosuvastatin (40 mg on admission, followed by 20 mg/day; n = 110) or no statin treatment (control group, n = 110). Contrast-induced acute kidney injury was defined by an absolute increase in serum creatinine of ≥0.5 mg/dl or a relative increase of ≥25% measured 48 or 72 hours after the procedure. Contrast-induced acute kidney injury occurred in 15 patients (7.2%), 9 (8.5%) in the control group and 6 (5.8%) in the rosuvastatin group (p = 0.44). The incidences of adverse cardiovascular and renal events (death, dialysis, myocardial infarction, stroke, or persistent renal damage) were similar between the two groups at follow-up. In conclusion, rosuvastatin did not reduce the risk for contrast-induced acute kidney injury or other clinically relevant outcomes in at-risk patients who underwent coronary and peripheral vascular angiography.

Beneficial effects of rosuvastatin treatment in patients with metabolic syndrome.

We determined the effect of 6-month rosuvastatin treatment on blood lipids, oxidative parameters, apolipoproteins, high-sensitivity C-reactive protein, lipoprotein(a), homocysteine, and glycated hemoglobin (HbA1c) in patients with metabolic syndrome (MetS). Healthy individuals (men aged >40 years and postmenopausal women) with a body mass index ≥30 (n = 100) who fulfilled the National Cholesterol Education Program Adult Treatment Panel III diagnostic criteria for MetS were included. Total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels decreased (P < .0001). The change in LDL 1 to 3 subgroups was significant (P = .0007, P < .0001, and P = .006, respectively). Changes in LDL 4 to 7 subgroups were not significant. There was a beneficial effect on oxidized LDL, fibrinogen, homocysteine, and HbA1c. Rosuvastatin significantly increased high-density lipoprotein levels (P = .0003). The oxidant/antioxidant status and subclinical inflammatory state were also beneficially changed. Rosuvastatin had a significant beneficial effect on atherogenic dyslipidemia as well as on oxidative stress and inflammatory biomarkers in patients with MetS.

Oxidative status and lipid profile in metabolic syndrome: gender differences.

BACKGROUND Metabolic syndrome is associated with cardiovascular disease and oxidative stress. The aim of this study was to investigate the differences of novel oxidative stress parameters and lipid profiles in men and women with metabolic syndrome. METHODS The study population included 88 patients with metabolic syndrome, consisting of 48 postmenauposal women (group I) and 40 men (group II). Premenauposal women were excluded. Plasma levels of total antioxidant status (TAS) and total oxidative status (TOS) were determined by using the Erel automated measurement method, and oxidative stress index (OSI) was calculated. To perform the calculation, the resulting unit of TAS, mmol Trolox equivalent/L, was converted to micromol equivalent/L and the OSI value was calculated as: OSI = [(TOS, micromol/L)/(TAS, mmol Trolox equivalent/L) x 100]. The Student t-test, Mann-Whitney-U test, and chi-squared test were used for statistical analysis; the Pearson correlation coefficient and Spearman rank test were used for correlation analysis. P < or = 0.05 was considered to be statistically significant. RESULTS Both women and men had similar properties regarding demographic characteristics and biochemical work up. Group II had significantly lower levels of antioxidant levels of TAS and lower levels of TOS and OSI compared with group I (P = 0.0001, P = 0.0035, and P = 0,0001). Apolipoprotein A (ApoA) levels were significantly higher in group I compared with group II. CONCLUSIONS Our findings indicate that women with metabolic syndrome have a better antioxidant status and higher ApoA levels compared with men. Our findings suggest the existence of a higher oxidative stress index in men with metabolic syndrome. Considering the higher risk of atherosclerosis associated with men, these novel oxidative stress parameters may be valuable in the evaluation of patients with metabolic sydrome.

Acute myocardial infarction in a young pregnant woman.

Myocardial infarction (MI) is very rare during pregnancy (1/10000), happens mostly during the third trimester and puerperium and mortality rates are high (19-21 %) (1). In most cases the diagnosis was made postmortem (2). Mostly, vasospasm with pregnancy induced hyperco-agulable state, which is potentiated by exogenous factors -like proges-togens and smoking.

Concurrent pulmonary embolism and acute coronary syndrome with dynamic electrocardiographic changes.

Concomitant occurrence of pulmonary embolism and acute coronary syndrome is rare. The early diagnosis and treatment of acute coronary syndrome with right ventricular myocardial ischemia during acute pulmonary embolism (APE) are crucial. The irreversible right ventricular myocardial dysfunction is a major risk factor for mortality from APE. In this case report, we present a 66-year-old female patient with APE who had a significant right coronary artery (RCA) lesion, which was successfully treated with angioplasty and stent implantation.

Successful repair of a large aortic abscess causing apical displacement of the anterior mitral valve

Anatomic continuity between the anterior mitral leaflet and the aortic root may predispose those patients with aortic root pathology to functional changes of the mitral valve without any involvement of this valve. A 34-year-old man presented with aortic valve endocarditis. Transthoracic echocardiograpy showed severe aortic regurgitation with a large aortic root abscess. The anterior leaflet of the mitral valve was displaced towards the apex of the heart causing moderate mitral regurgitation. The patient underwent aortic valve replacement with reconstruction of the aortic annulus and ventriculoaortic continuity. This procedure alone restored the mitral valve structure and function without any need for intervention on the mitral valve. Aortic abscess is a serious complication of aortic valve endocarditis and may alter the function of other structures of the heart, especially the mitral valve. Restoration of aortic wall integrity and left ventricular – aortic continuity usually restores the mitral valve structure and function if the valve is unaffected by the infection. A decision on the mitral valve should be made following correction of the aortic pathology.

GRACE score also predicts anatomic complexity of coronary artery disease patients presenting with non-STEMI

Acute Coronary Syndromes (ACS) represent the most common cause of death in the western world. We retrospectively screened data of non-STEMI patients admitted to the coronary care unit of a tertiary center between March 2015 and March 2016. GRACE score was calculated and patients were classified into low (1 to 108), intermediate (109 to 140) and high risk (>40) groups according to GRACE categories. SYNTAX scores were also calculated. 201 patients (mean age: 63 ± 12 years, 53.7% female) were admitted with a diagnosis of non-STEMI. The mean GRACE score and SYNTAX score of study population were 105 ± 34.1 and 16.9 ± 12. Based on the GRACE score for in-hospital deaths, the SYNTAX score was 14.2 ± 10.1 in the low-risk group, 16.0 ± 13.4 in the intermediators group, and 24 ± 12.2 in high-risk group (ANOVA p<0.0001). Post-hoc Tukey analysis showed that the high-risk group had a significantly higher SYNTAX score than the low-risk and intermediate risk groups (p<0.0001 vs p=0.003 respectively). There were significant positive correlations between the SYNTAX score and GRACE scores of the study population calculated at admission for in-hospital deaths (r=0.363, p<0.0001). GRACE score can predict complexity of CAD (high risk coronary anatomy). As we can decide to perform early invasive strategy according to GRACE score, we may consider detecting high risk complex coronary anatomy during coronary angiography. So, we may be ready to discuss with heart team about treatment strategy (ad hoc-PCI, multi-vessel PCI or CABG) in patients with high GRACE score. Before giving ADP receptor antagonist, we may consider CABG requirement in these patient population.

Zotarolimus-eluting stent fracture at initial implantation diagnosed with StentBoost

Stent fracture is a rare complication of drug-eluting stent implantation with a reported rate of 0.84%–3.2% in various clinical studies with first-generation drug-eluting stents and 29% in autopsy studies. Sirolimus-eluting stents with their closed cell design were reported to be more prone to fracture compared to paclitaxel-eluting stents. Other risk factors for stent fracture are multiple stenting, longer stent length, chronic renal failure, right coronary artery intervention, and a higher maximal inflation pressure. The role of angiography in diagnosing stent fracture is limited, a fact also questioning the reliability of angiographic data. Image enhancement techniques like StentBoost are widely available in new-generation angiography systems and are used to assess stent expansion, overlap size, or to localize the postdilation balloon. Here, we report a case of zotarolimus-eluting stent fracture at initial implantation diagnosed with StentBoost.

ASSOCIATION OF PREPROCEDURAL LEVELS OF MATRIX METALLOPROINASE-9, HIGH SENSITIVE C-REACTIVE PROTEIN, SERUM AMYLOID A, AND NEOPTERIN WITH ANGIOGRAPHIC IN STENT RESTENOSIS

Objective: Vascular inflammation induced by percutaneous coronary intervention (PCI) has an important role in the pathogenesis of in-stent restenosis (ISR). Previous studies have addressed that serum amyloid A (SAA), high sensitive C-reactive protein (hs-CRP), neopterin, and matrix metalloproteinase-9 (MMP-9) play an important role in inflammatory process of development of ISR. Aim: We aimed to investigate the relationship of preprocedural levels of these inflammatory markers and the development of ISR. Methods and Materials: This was a prospective-case controlled study. 76 of 123 screened consecutive patients with stable angina who underwent coronary angiography, were scheduled for bare metal stent (BMS) placement. Control angiography was performed 6-12 months after the index intervention. Results: ISR was documented in the of 23 patients (30%), it was not documented in the remaining 53 patients (70%). The basal serum neopterin level was 2.32 ± 1.27 ng/ml and 1.67 ± 0.89 ng/ml, hs-CRP level was 9.16 ± 8.73 mg/L and 5.85±5.59 mg/L, the serum basal SAA level was 18.28 ±39.84 ng/ml and 12.77±23.67 ng/ml, the serum basal MMP-9 level was 75.06 ±35.05 ng/ml and 66.78±38.32 ng/ml, in patients with and without restenosis, respectively. Neopterine and hs-CRP levels exhibited a significant association with the ISR (p:0.01, p:0.04, respectively), SAA and MMP-9 levels did not (p:0.46, p:0.36, respectively). Conclusions: In present study, serum baseline neopterin and hs-CRP concentrations were predictive for the development of ISR. We also observed a significant correlation between the neopterin and hs- CRP in restenosis group.