Alparslan Birdane

Levosimendan is not effective in reducing pulmonary pressures in patients with idiopathic pulmonary arterial hypertension: report of two cases.

Currently, prostacyclin, endothelin receptor antagonists and phosphodiesterase inhibitors are recommended therapy in idiopathic pulmonary arterial hypertension. However, each of these drugs has limited efficacy in the improvement of clinical symptoms, pulmonary hemodynamics and long-term survival. Levosimendan, a novel calcium-sensitizing inodilator agent, has been shown to have pulmonary vasodilatory action. However, the potential pulmonary vasodilating effect of levosimendan in patients with idiopathic pulmonary arterial hypertension remains unclear. Levosimendan administered in two patients with nonvasoreactive idiopathic pulmonary arterial hypertension exhibited deterioration in clinical status, and, contrary to what was expected, levosimendan was found to increase pulmonary pressures and did not lead to a substantial improvement of the patients condition.

Importance of Initiation Pattern of Polymorphic Ventricular Tachycardia in Patients with Implantable Cardioverter Defibrillators

Background: Stored intracardiac electrograms (ICEGs) are helpful in understanding the initiation mechanisms of sustained ventricular arrhythmias and in determining the appropriateness of the therapy delivered by implantable cardioverter defibrillators (ICDs).

Mode of onset of polymorphic ventricular tachycardia in acute myocardial infarction

BACKGROUND Polymorphic ventricular tachycardia (PVT) can occur during acute myocardial infarction (MI). In the past, studies investigated the initiation pattern of ventricular tachycardias in different patient populations; however, the mode of onset of PVT in acute MI patients has not been investigated previously. OBJECTIVE To retrospectively investigate the electrophysiological features of PVT with different initiation patterns in acute MI patients to assess whether there is a relationship of the initiation patterns of PVT with clinical and electrophysiological characteristics. METHODS Sixty-two rhythm strips defined as PVT from 53 patients (mean [± SD] age 63±8 years) with acute ST elevation MI were analyzed. All patients were monitored while they were hospitalized in the coronary care unit, and the electrocardiogram strips were obtained from continuous monitoring. PVT was defined as sudden-onset tachycardia if it was not preceded by ventricular ectopic beats. PVT that was preceded by single or multiple ectopic beats was defined as nonsudden-onset tachycardia. RESULTS Nonsudden-onset episodes were more common than suddenonset episodes (40 episodes [64.5%] versus 22 episodes [35.5%]). In the nonsudden-onset group, 25 episodes (62.5%) were initiated after a single ectopic beat, while 15 episodes (37.5%) were initiated after multiple complexes. The mean (± SD) left ventricular ejection fraction of patients with nonsudden-onset PVT was decreased (53±6% versus 65±7%, P<0.01). Nonsudden-onset tachycardias had lower coupling intervals than suddenonset tachycardias. Similarly, the PVT cycle length was shorter in the presence of nonsudden-onset initiation. When nonsudden-onset PVT episodes were further subclassified based on the morphology of the first beat of tachycardia, 26 PVTs (65%) had a first beat of tachycardia similar to the subsequent PVT beats and 14 (35%) did not. CONCLUSIONS These results demonstrate that PVT is often preceded by ventricular ectopy in acute MI patients. Nonsudden-onset PVT is usually characterized by a lower coupling interval, shorter PVT cycle length and an associated lower ejection fraction.

Atrial Fibrillation after Percutaneous Coronary Intervention: Predictive Importance of Clinical, Angiographic Features and P-Wave Dispersion

Atrial fibrillation (AF) may occur during or after percutaneous coronary interventions (PCI). The purpose of the study was to determine the clinical, angiographic and electrophysiological predictors of AF after PCI. 225 patients undergoing PCI (mean age of 65 ± 11 years) who had sinus rhythm (SR) before balloon inflation were taken to study. Of these 22 developed AF in catheterization laboratory after balloon inflation or in 24 h following PCI (AF group), 203 did not (SR group). The patients in AF group were older (67 ± 9 vs. 63 ± 8 years, p < 0.05) and their ventricular ejection fraction was lower than SR group (56 ± 5 vs. 45 ± 7%, p < 0.05). The P-wave dispersion was significantly higher in AF group than SR group (53 ± 8 vs. 29 ± 10 ms, p < 0.001). For the patients with ST elevation myocardial infarction, the time from the onset of symptoms to balloon inflation was 3.7 ± 1.7 h in SR group. It was longer in AF group (4.1 ± 1.8 h, p < 0.05). TIMI perfusion grades 2 and 3 were achieved in 23 of 27 patients in SR group, and 5 of 8 patients in AF group. Multivessel disease was documented in 93 of the patients in SR group, and 12 in AF group. Clinical reperfusion was thought to be established in 20 in SR group, and 4 in AF group. In conclusion, our results show the importance of clinical factors, angiographic results and P-wave analysis in prediction of AF following PCI.

Plasminogen Activator Inhibitor Type-1 Gene 4G/5G Polymorphism Is Associated with Hypertensive Patients in the Turkish Population

This study has been performed on hypertensive patients in the Turkish population to determine the frequency of 4G/5G polymorphism genotypes of plasminogen activator inhibitor type-1 gene and with the aim of examining the role of this polymorphism in hypertension development. Genomic DNA obtained from 284 persons (176 patients with hypertension and 108 healthy controls) was used in the study. DNA was multiplied by polymerase chain reaction using 4G and 5G allele-specific primers. Polymerase chain reaction products were assessed by being exposed to 2% agarose gel electrophoresis. Results were evaluated with the chi-square test. The 4G allele frequency was 31.25% and the 5G allele frequency was 68.75% in patients, whereas it was 49/51% in a control group. 5G5G genotype was found statistically high (p < 0.001) in patients relative to controls. This study showed that the plasminogen activator inhibitor type-1 gene 4G/5G polymorphism and the 5G5G genotype appear to be associated with an elevated risk of developing hypertension in a representative sample of Turkish population.

Our initial experience with stent implantation for aortic coarctation in adults

OBJECTIVES We evaluated the procedural success and short-mid term results of stent implantation for aortic coarctation in adults. STUDY DESIGN The study included 15 consecutive patients (9 women, 6 men; mean age 27±7 years; range 17 to 45 years) treated with stent implantation for aortic coarctation. Fourteen patients had native, one patient had recurrent coarctation. Nine patients received bare metal and six patients received covered Cheatham-Platinum stents. Covered stents were used in patients with accompanying patent ductus arteriosus (n=2), severe coarctation (n=3), and recurrent coarctation (n=1). Procedural success was defined as the reduction in the pressure gradient across the coarctation site to less than 20 mmHg. The mean follow-up period was 10.4±4.6 months (range 3 to 18 months). RESULTS Stent implantation was successful in all the patients. Compared to the preprocedure figures, systolic gradient across the aortic coarctation decreased from 37.2±11.3 mmHg to 3.5±2.9 mmHg, the diameter of the coarcted aortic segment increased from 5.4±1.5 mm to 17.2±1.4 mm, and systolic blood pressure declined from 154±9.7 mmHg to 130±7.3 mmHg following stenting (for all, p<0.001). There were no procedure-related major complications. CONCLUSION Stent implantation for aortic coarctation in adults is a safe and effective alternative to surgical correction.

Association of paraoxonase 1 (PON1) gene polymorphisms and concentration with essential hypertension

ABSTRACT Human serum paraoxonase 1 (PON1) is carried by high-density lipoprotein in blood circulation and is shown to be effective in preventing oxidized phospholipids carried by low-density lipoprotein particles, thus it acts as an antioxidant. Polymorphism in this gene has been investigated for many metabolic diseases, but it is not thought to be a genetic risk factor for essential hypertension. The aim of this study was to determine whether there was an association between PON1 gene polymorphisms and concentration with essential hypertension. The study population was comprised of 100 patients with essential hypertension and 100 healthy controls. One promoter region [C(-108)T] and two coding region (Q192R and L55M) polymorphisms in the PON1 gene were genotyped in individuals by using the TaqMan assay. Plasma PON1 concentration in all volunteers was also measured spectrophotometrically by the enzyme-linked immunosorbent assay method. The genotype and allele frequencies of the PON1 C(-108)T polymorphism showed significant differences between the essential hypertensive and control groups (CT vs. CC: p<0.001; T allele vs. C allele: p<0.001). There was no significant difference for the PON1 L55M polymorphism between the groups, while the heterozygote genotype of the PON1 Q192R polymorphism showed significant difference (p = 0.03). The PON1 concentration was also found to be significantly lower in hypertensive patients (p < 0.001). Decline in the level of PON1 gene may be one of the main factors in the development of essential hypertension, and the PON1 C(-108)T polymorphism may have a prognostic value in the patients with essential hypertension.

Asymptomatic course of a metastatic mass completely filling the right atrium in a patient with hepatocellular carcinoma.

Intracardiac involvement rarely develops in patients with hepatocellular carcinoma (HCC) and its prognosis is poor. Patients generally have symptoms of sudden dyspnea or massive lower extremity edema and the clinical course may be further complicated by many fatal cardiovascular complications. Absence of cardiac symptoms or findings, however, is an unusual condition. We present a 61-year-old man with HCC who was incidentally found to have an intracavitary mass completely occupying the right atrium. He had no cardiac complaints, nor any signs of cardiac involvement. The mass was first detected by computed tomography and then confirmed by transthoracic echocardiography. The patient underwent a successful surgical resection and the histopathologic diagnosis was HCC. Unfortunately, the postoperative course was complicated by the development of acute kidney failure and, despite hemodialysis treatment, the patient died of kidney failure eight days after the operation.

Levosimendan and pulmonary hypertension.

Levosimendan, a novel calcium-sensitizing positive inotropic agent with vasodilatory effect, is increasingly used in the treatment of decompensated heart failure. It has been proven to enhance myocardial contractility by sensitizing troponin C to calcium within the cardiomyocyte, and hence to increase cardiac output and stroke volume with a simultaneous decrease in pulmonary capillary wedge pressure (PCWP), thereby leading to significant symptomatic, hemodynamic, and neurohormonal improvements in patients with advanced heart failure [1–4]. Levosimendan has also been shown to have vasodilating properties in the systemic and pulmonary vasculature, mediated by the activation of ATP-sensitive potassium channels and phosphodiesterase-III inhibition in vascular smooth muscle. As an inodilator drug, levosimendan has proved effective in treating acutely decompensated heart failure with systolic dysfunction.

Visualization of the site of the onset of ventricular depolarization by acceleration mode “Tissue Doppler Imaging” technique

Tissue Doppler imaging (TDI) is a relatively new echocardiographic technique that shows regional myocardial wall velocities. The aim of this study was to evaluate the potential value of acceleration mode TDI technique for the visualization of the origin of ventricular activation site using the model of right ventricular pacing. Twenty-seven patients with implanted permanent pacemakers were studied by acceleration mode TDI, 4 of these patients were pacemaker dependent. Parasternal and apical chamber views were recorded on video tape by using acceleration mode TDI technique during sinus rhythm with preserved atrioventricular conduction in 23 subjects who were not pacemaker-dependent, and also during right ventricular apical pacing in VVI mode in 27 subjects in whom pacing lower rate was increased if necessary. Fifty images recorded during sinus and pacing rhythm in cineloop were examined by two independent observers who were unaware of the rhythm patterns and by the same observer on two different occasions for localizing the site of onset of ventricular acceleration. The origin of ventricular activation during sinus rhythm started at basal septal part of the ventricle and during pacing started at apical part of the ventricle was considered as correct localizations. The origin of ventricular depolarization was correctly localized for 46 of 50 images (92%) and 44 of 50 images (88%) by the first and the second observers, respectively. Concordant results between observers appeared in 48 of 50 (96%) of images. The diagnostic accuracy of the concordant results was 44 of 48 (91.6%) images. The kappa for interobserver variability was 0.77 (p<0.001), and for intraobserver variability was 0.64 (p<0.001) and 0.63 (p<0.001) for the first and the second observers, respectively. These results suggest that acceleration mode TDI can be used to detect the initial ventricular excited position and seems to have a potential value for localizing of the origin of normal or abnormal myocardial depolarization.