Alper Onbasili

Novel Approach to Measure Myocardial Performance Index: Pulsed-Wave Tissue Doppler Echocardiography

A simple, reproducible, noninvasive myocardial performance index (MPI) for the assessment of overall cardiac function has been described previously. The purpose of this study was to compare the MPI obtained by pulse Doppler method with the MPI obtained by tissue Doppler echocardiography (TDE) in normal subjects and patients with dilated cardiomyopathy (DCMP). Fifteen patients with DCMP and 15 healthy subjects were included. In order to calculate MPI by TDE, isovolumetric contraction (IVCT), relaxation time (IVRT), and ejection time (ET) were measured at two different sites of mitral annulus: septum and lateral. MPI was calculated by dividing the sum of IVCT and IVRT by ET at each site of measurement. The mean MPI value was found by dividing the sum of these MPI values into two. The same parameters were measured using the mitral inflow and left ventricular outflow velocity time intervals in pulsed Doppler method. At all sites measured, MPI by TDE correlated well with conventional MPI both in healthy subjects and patients with DCMP. The highest correlation was observed in mean values of MPI by TDE: r = 0.94, P < 0.0001 in healthy subjects; and r = 0.95, P < 0.0001 in patients with DCMP. In conclusion, this study clearly demonstrated that MPI could be measured by TDE and it correlated well with conventional MPI in normal and diseased heart. (ECHOCARDIOGRAPHY, Volume 20, August 2003)

Trimetazidine in the prevention of contrast-induced nephropathy after coronary procedures

Objective: To evaluate the efficacy of trimetazidine (TMZ) in the prevention of contrast-induced nephropathy (CIN) in patients with high serum creatinine levels undergoing coronary angiography/angioplasty. Methods: TMZ (20 mg thrice daily) was administered orally for 72 h starting 48 h before the procedure. All patients were given intravenous saline (0.9%) at a rate of 1 ml/kg of body weight per hour for 24 h starting 12 h beforehand. Serum creatinine levels were measured before the procedure, 48 h and 7 days after the procedure. Increase in serum creatinine level exceeding 0.5 mg/day or one quarter of the basal value is considered as CIN. Venous blood samples for serum total antioxidant capacity (TAC) measurement were drawn before and after coronary angiography. Results: Basal serum creatinine levels and TAC were similar in TMZ and control groups. Serum creatinine levels in the control group increased significantly 2 days after the procedure, and returned to the baseline values on the seventh day. However, it did not change significantly on the second day, and even significantly decreased on the seventh day in the TMZ group. CIN developed in 2.5% (1/40) of patients in the TMZ group and in 16.6% (7/42) of patients in the control group (p<0.05). TAC values were not different between treatment groups. Conclusion: TMZ along with isotonic saline infusion is more effective than isotonic saline alone in reducing the risk of CIN in patients with pre-existing renal dysfunction.

The Effects of Spinal Anesthesia on QT Interval in Preeclamptic Patients

In this study, we measured the effects of spinal anesthesia on the corrected QT (QTc) interval in women with severe preeclampsia. Twenty-five preeclamptic (preeclamptic group) and 25 healthy pregnant women with normal arterial blood pressure and QTc interval (control group) were enrolled in this prospective, case-controlled study. Arterial blood pressure, heart rate, and QTc interval values were obtained before (baseline value) and at 5, 10, 20, 30, 60, and 120 min after initiation of spinal anesthesia. Total ephedrine dose, time elapsed until sensory block, and Apgar scores were recorded. Prior to spinal anesthesia, QTc interval values were significantly higher in the preeclamptic group (452 ± 17.5 ms) when compared with that in controls (376 ± 21.4 ms). Although the QTc interval shortened during spinal anesthesia when compared with baseline value in the preeclamptic group (P < 0.05), it showed no significant change in the control group. In conclusion, the QTc interval may be prolonged in severe preeclamptic patients who have hypertension and hypocalcemia. Spinal anesthesia for cesarean delivery may normalize that prolonged QTc interval due to sympathetic blockade.

A new perspective on cardiotoxicity of 5-fluorouracil. A novel research tool 'cardiac ultrasonic integrated backscatter analysis' indicates transient, subclinical myocardial dysfunction due to high-dose leucovorin and infusional 5-fluorouracil regimen.

Background: The pathophysiology of 5-fluorouracil (5-FU) cardiotoxicity is still controversial. The objective of this study was to assess the influence of high-dose leucovorin and infusional 5-FU regimen (HDLV5FU) on cardiac tissues. Methods: We monitored 28 patients (median age 68 years) under HDLV5FU chemotherapy with complete blood counts, cardiac enzymes, C-reactive protein, coagulation tests, Holter electrocardiogram, and conventional echocardiography. Cardiac ultrasonic tissue characterization with integrated backscatter (IBS) analysis was performed in the 16 last enrolled patients. Results: The magnitude of both anterior and posterior cardiac IBS values significantly decreased at the 48th hour of treatment compared to both 0th hour and day 15 (p < 0.003). Cardiac IBS values on the 15th day were not different from the 0th hour. Clinical cardiotoxicity was not observed and other monitored parameters did not change significantly in any patient (p > 0.5 for all). Conclusion: Cardiac IBS analysis suggests that 5-FU might cause reversible subclinical myocardial dysfunction.

The effect of atorvastatin on platelet function in patients with coronary artery disease

Background — Lipid-lowering therapy was shown to have several beneficial effects in patients with coronary artery disease (CAD). Aim — The objective of this study was to investigate the effect of atorvastatin on platelet aggregation in patients with CAD. Methods — Twenty-five hypercholesterolaemic patients who had angiographically proven CAD and 16 normal subjects were enrolled. All patients received 10 mg/day atorvastatin for two months. Anti-platelet agents were discontinued 15 days prior to blood sampling at the beginning and at the end of the atorvastatin therapy. Aggregometric curves of the platelets in response to ADP, collagen and epinephrine were obtained using the aggregometry (turbidimetric) technique. Results — In patients with CAD, total cholesterol (TC) and LDL cholesterol (LDL-C) basal levels were measured (230 ± 49 mg/dl, 140 ± 41 mg/dl, respectively). Following lipid-lowering therapy, TC and LDL-C decreased significantly (p < 0.05). The activation measurements of aggregometric curves decreased significantly compared with basal parameters in response to ADP but not in response to collagen and epinephrine. Conclusion — Lipid-lowering therapy with the HMG-CoA reductase inhibitor, atorvastatin, had a marked reduction effect on platelet aggregation.

Influence of high-dose leucovorin and 5-fluorouracil chemotherapy regimen on P wave duration and dispersion

Background:  Although 5‐fluorouracil (5‐FU)‐related cardiotoxicity is well known, atrial arrhythmia, as a potentially serious complication has not been studied in detail. The aim of this study was to determine the P max and Pd in the electrocardiograms (ECG) of patients receiving 5‐FU treatment.

Primary percutaneous coronary intervention of anomalous origin of right coronary artery above the left sinus of valsalva in a case with acute myocardial infarction Coronary anomalies and myocardial infarction

Anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva is exceedingly rare. We presented a case with anomalous origin of the RCA above the left sinus of Valsalva with inferior wall myocardial infarction and successful primary percutaneous coronary intervention to this artery which is the first report in the literature.

Diastolic dysfunction in rheumatoid arthritis and duration of disease

Dear Editor, The article entitled “Diastolic heart function in RA patients” written by Wislowska et al. and published in one of the recent issues of your journal was quite interesting [1]. There is no good deWnition for early Rheumatoid arthritis (RA). Early disease has been taken as a symptom with duration of less than 2 year (more conventionally, a time point of 5 year) [2, 3]. Our study included 82 patients (67 females and 15 males) diagnosed as RA according to criteria of ARA and 47 healthy control subjects (31 females and 16 males). In our study, duration of disease was ranging from 1 to 30 years in the patients with RA and mean duration of the disease was 4.8 § 5.2 years. All the patients and control subjects were evaluated prior to the initiation of the study for previous cardiac disease as exclusion criteria. Thus, our study used tissue Doppler and Vp (velocity of Xow propagation) methods in addition to conventional pulse wave Doppler method in order to detect diastolic dysfunction. We categorized the patients into two groups as those with disease duration of less and more than 5 years (early and late RA), there were a signiWcant diVerence between two groups in mitral E/A ratio, tissue Doppler mitral annulus E /A ratio and Vp values (Table 1) [4]. The other study conWrms a high frequency of left ventricular diastolic dysfunction characterised by impaired E/A ratio, prolonged Isovolemic relaxation time (IVRT) and increased late diastole Xow velocity in patients with RA without evident cardiovascular disease. The correlation between transmitral Xow alteration and disease duration suggests a subclinical myocardial involvement with disease progression [5].

Effects of Sevoflurane on QT Dispersion and Heart Rate Variability

The purpose of this study was to use estimates of corrected QT dispersion (QTcd) and heart rate variability (HRV) to assess the effects of sevoflurane, an inhalation agent used frequently in clinical practice, on autonomic cardiac function. This study was conducted prospectively and in a blind manner on 20 women between 38 and 51 y of age who were classified as American Society of Anesthesiologists stage I–II and whose treatment required total abdominal hysterectomy. Electrocardiograms were recorded by 12-lead Holter monitor for 5 min before sevoflurane induction and again for 5 min at 10 min after tracheal intubation. Data on the first recording were considered as baseline; those on the second recording were viewed as final data. The study was terminated at this point, and surgery was allowed to proceed. QTcd and HRV values were assessed by a cardiologist, who was blinded to all data. All parameters were expressed as a mean value ± standard deviation. Wilcoxon’s test was used to compare baseline and final data. Statistical significance was considered asP< .05. No significant changes were observed between baseline and final QTcd values and between low and high-frequency components (LF and HF) of HRV; nor were changes seen in the LF/HF ratio. With the patient under sevoflurane/nitrous oxide anesthesia, no significant changes were detected in QTcd, LF, and HF values, and in the LF/HF ratio, whereas a significant increase (P=.001) was seen in standard deviation of the R-R interval, which was used as a measure of cardiac autonomic tone.

Cyclic Variation of Myocardial Integrated Backscatter and Myocardial Wall Thickness During Percutaneous Coronary Angioplasty

Cyclic variation of myocardial integrated backscatter (CVIBS) and change in myocardial wall thickness (WT%) were evaluated during percutaneous transluminal coronary angioplasty (PTCA). Fourteen patients who underwent PTCA of the proximal left anterior descending (LAD) coronary artery were included in the study. PTCA was performed by inflating the balloon at the site of the LAD lesion for 1 minute. CVIBS was measured at three episodes during PTCA in the parasternal short‐axis view: before the inflation, at the end of 1‐minute inflation, and at the fifth‐minute after deflation of the balloon. Three regions of interest were used to evaluate the three‐vessel territories: mid‐anteroseptal area for LAD, mid‐posterolateral area for circumflex artery, and mid‐inferior area for right coronary artery. The WT% was calculated in each area. In the LAD territory, CVIBS measured at the end of 1‐minute inflation was lower than the values obtained before PTCA, 5.2 ± 1.0 decibel (dB) versus 3.7 ± 0.7 dB (P < 0.01) . CVIBS magnitudes increased at the fifth‐minute after the deflation back up even to higher levels than pre‐PTCA values, 6.1 ± 1.0 dB versus 5.2 ± 1.0 dB (P < 0.01) . The WT% values decreased during balloon inflation but did not recover to the pre‐inflation values measured at fifth‐minute after deflation. In other sites, there was no change in either CVIBS or WT% values at any time studied. The observed increase in CVIBS may be an indicator of restoration of blood flow to ischemic myocardium. (ECHOCARDIOGRAPHY, Volume 20, July 2003)