Arif Suner

Effects of slow coronary artery flow on P-wave dispersion and atrial electromechanical coupling

AIM Slow coronary flow (SCF) is characterized by angiographically normal coronary arteries with delayed opacification of the distal vasculature. The purpose of this study was to evaluate atrial electromechanical couplings and P-wave dispersion (Pd) reflecting intraatrial and interatrial conduction delays in SCF patients and the relationship between these parameters and Thrombolysis in Myocardial Infarction (TIMI) frame count. METHODS Thirty-four patients with SCF and 40 controls were enrolled. From 12-lead surface electrocardiograms, Pd was calculated. Atrial electromechanical coupling (PA), intraatrial, and interatrial electromechanical delay were measured with tissue Doppler imaging. RESULTS Maximum P-wave duration (Pmax) and Pd were higher in SCF patients than those of controls (109.2 +/- 9.3 vs 92.3 +/- 13.5 milliseconds; P < .0001 and 50.4 +/- 9.4 vs 34.4 +/- 8.9 milliseconds; P < .0001). Atrial electromechanical coupling at the left lateral mitral annulus (lateral PA), septal mitral annulus (septal PA), and right ventricular tricuspid annulus (RV PA) were significantly higher in SCF patients than controls (68.1 +/- 8.1 vs 52.6 +/- 7.3 milliseconds; P < .0001; 49.3 +/- 9.8 vs 38.2 +/- 5.3 milliseconds; P < .0001; 47.5 +/- 9.0 vs 37.6 +/- 4.6 milliseconds, P < .0001, respectively). Interatrial electromechanical delay (lateral PA - RV PA) was significantly longer in SCF patients (20.6 +/- 9.1 vs 15.0 +/- 6.0 milliseconds; P = .0002). A positive correlation was detected between circumflex coronary artery TIMI frame count and interatrial electromechanical delay (r = 0.45; P < .01). CONCLUSIONS Prolongation of interatrial electromechanical delay, Pmax, and Pd suggest that SCF might contribute to development of adverse functional and electrophysiologic atrial characteristics in these patients.

A previously undescribed anomaly of left anterior descending artery: Type V dual left anterior descending artery

Dual left anterior descending coronary artery (LAD) is a group of rare congenital coronary artery anomalies and exhibits 4 different types. The goal of this article is to define a new, previously undescribed type of dual LAD anomaly.

The influence of ambulatory blood pressure profile on global and regional functions of the left and the right ventricles in orderly treated hypertensive patients.

Background: The association between nondipping profile and adverse cardiovascular outcome is still controversial. Tissue Doppler imaging (TDI), a new and useful addition to standard echocardiographic imaging techniques, permits a quantitative assessment of both global and regional function and timing of myocardial velocities. In this study, we aimed to assess whether a reduced nocturnal fall in blood pressure (BP) in orderly treated hypertensive patients with satisfactory BP control is related to more prominent structural and functional alterations of the ventricles. Method and Results: Sixty‐nine hypertensive patients with adequate BP control were divided into two groups with respect to ambulatory BP profiles as dippers and nondippers. In addition to conventional echocardiographic parameters, in septal and lateral segments of left ventricle and free wall of right ventricle, peak systolic velocity (Sm), early (Em), and late (Am) diastolic velocities, isovolumic contraction time (ICTm), isovolumic relaxation time (IRTm), and ejection times (ETm) were measured, and modified myocardial performance index (MPIm) was calculated. Left ventricular (LV) and atrial dimensions, ejection fraction, transmitral early to late diastolic flow ratio, LV mass index, and LV hypertrophy ratio did not differ between groups. Both regional and mean LV Sm, Em/Am, MPIm and right ventricular Sm and MPIm were similar in both groups. Conclusion: In treated hypertensive patients with satisfactory BP control, there was no significant difference in cardiac structural and functional abnormalities among dipper and nondipper subjects.

Neutrophil to lymphocyte ratio predicts poor functional capacity in patients with heart failure.

OBJECTIVES We aimed to assess the relationship between neutrophil to lymphocyte ratio (N/L ratio) and functional capacity (FC) of patients with compensated heart failure (CHF). STUDY DESIGN A total of 94 consecutive CHF patients and age-gender matched 70 subjects with normal echocardiographic examination were enrolled. Peripheral venous blood samples were drawn before echocardiography examination and treadmill test in all study population. The treadmill test based on modified Bruce protocol was used to determine the functional status of CHF patients. Poor FC was defined as <5 metabolic equivalant (MET) in the exercise test. Afterwards, patients with CHF were divided into two groups with respect to the top and bottom 3 of the N/L ratio. RESULTS FC (3.2 ± 2.05 MET vs. 6.1 ± 2.04 MET, p<0.001), ejection fraction (%31.5 ± 7.64 vs. %34.8 ± 6.82, p=0.028) were found to be lower and N-terminal pro-brain natriuretic peptide (NT-proBNP) level (3360 ± 2742 pg/dl vs. 1613 ± 1334 pg/dl, p<0.001) pulmonary artery pressure (46.3 ± 11.50 mmHg vs. 41.5 ± 9.45 mmHg, p=0.049), left atrial diameters (4.6 ± 0.52 cm vs. 4.3 ± 0.43 cm, p=0.005), E/Ea ratio (12.2 ± 4.37 vs. 9.2 ± 3.20, p<0.001) were found to be higher in CHF patients with an N/L ratio >3 than with an N/L ratio <3. The N/L ratio, and log-NT-proBNP level were determined to be a predictive factor of poor FC (odds ratio [OR]=3.085, 95% confidence interval [CI]= 1.520-6.260, p=0.002 and OR=1.585, 95% CI=1.201-2.091, p=0.001, respectively). A cut-off point of 2.74 for the N/L ratio had 79.4% sensitivity and 80% specificity in predicting poor FC. CONCLUSION N/L ratio can be used to predict poor FC in patients with CHF.

The effect of trimetazidine on ventricular repolarization indexes and left ventricular diastolic function in patients with coronary slow flow.

ObjectivesCoronary slow flow (CSF) is associated with an increased incidence of adverse cardiovascular events. Previous studies have shown increases in P wave dispersion, QT dispersion, and the Tp-e/QT ratio, and a prolonged Tp-e interval, as well as left ventricular diastolic dysfunction in patients with CSF. We aimed to examine the effect of trimetazidine (TMZ) on these arrhythmia predictors and diastolic function of the left ventricle. MethodsOur study included 30 patients with CSF and 30 individuals with normal coronary arteries. Twelve-lead ECG and echocardiography were used to evaluate patients before and 4 weeks after treatment with TMZ. ResultsCompared with the control group, corrected Pd (29.3±9.1 vs. 22.9±11.6, P=0.022), corrected QT dispersion (32.3±11.1 vs. 27.4±6.8, P=0.032), corrected Tp-e interval (103.1±18.6 vs. 93.4±11.5, P=0.017), and Tp-e/QT ratio (0.236±0.03 vs. 0.210±0.02, P=0.001) were significantly longer, and the E/A ratio (0.905±0.16 vs. 0.986±0.12, P=0.037) and the mean Em/Am ratio (0.918±0.19 vs. 1.095±0.20, P=0.006) were lower in patients with CSF. Corrected Pd, corrected Tp-e interval, and the Tp-e/QT ratio were significantly decreased (29.3±9.12 vs. 22.5±9.20, P=0.022; 97.3±16.6 vs. 88.2±16.4, P=0.031; 0.22±0.03 vs. 0.20±0.31, P=0.042 respectively), and left ventricle mitral annular mean Em/Am velocity was significantly increased (0.918±0.19 vs. 1.095±0.20, P=0.017) after treatment with TMZ. ConclusionCSF may be related to increased P wave and QT dispersion, a prolonged Tp-e interval, and Tp-e/QT ratio, in addition to impaired diastolic filling. TMZ may be useful in restoring these findings.

Coronary sinus dilatation is a sign of impaired right ventricular function in patients with heart failure.

Objective: The coronary sinus (CS) has been largely ignored by physicians due to a lack of adequate data about the importance of CS enlargement in patients with heart failure (HF). We aimed to assess whether CS dilatation develops in patients with HF and to demonstrate its relation with global myocardial function of the right ventricle (RV). Methods: In this cross-sectional study, 45 healthy subjects and 95 HF patients exhibiting left ventricular systolic dysfunction on echocardiographic examination (EF <45%) secondary to ischemic (n=56) or idiopathic dilated cardiomyopathy (DCM) (n=39) were enrolled. Patients with severe renal dysfunction and/or valve disease were excluded. CS was measured by echocardiography from the posterior atrioventricular groove in the apical four-chamber view. The RV myocardial performance index (MPI), which reflects both systolic and diastolic function of the ventricle, was detected using tissue Doppler imaging, and patients with an RV MPI >0.55 were defined as having impaired RV myocardial function. ANOVA, Kruskal-Wallis, Pearson’s correlation, and multivariate logistic regression analyses were used for the statistical analysis. Results: The CS and RV MPI values were significantly greater both in patients with ischemic and idiopathic DCM than in controls (8.79±1.7 mm and 8.33±2.1 mm vs. 5.74±0.6 mm, and 0.64±0.07 and 0.62±0.08 vs. 0.43±0.02; p<0.001 for both, respectively). For the prediction of HF patients with impaired RV function, the cut-off value for the diameter of the CS was 7.35 mm, with a sensitivity of 83% and a specificity of 79%. Conclusion: The CS diameter can be used as a novel echocardiographic marker that provides information about impaired RV function in patients with HF.

Evaluation of serum prolidase activity in patients with slow coronary flow

Introduction Slow coronary flow (SCF) is described as the slow passage of contrast to distal coronaries despite anatomically normal coronary arteries. It has been shown that increased serum prolidase activity (SPA) correlates with collagen turnover. Increased collagen turnover might be associated with the development of atherosclerotic plaques. Aim To investigate the relationship between serum prolidase activity and slow coronary flow. Material and methods This cross-sectional study included 40 SCF patients (mean age: 55.0 ±9.5 years, 20 females) and 40 controls (mean age: 53.9 ±8.2 years, 21 females) with normal coronary anatomy and normal coronary flow. The Thrombolysis in Myocardial Infarction (TIMI) frame-count (TFC) method was used for SCF diagnosis. Serum prolidase activity was measured spectrophotometrically, and the relevant parameters were compared between the groups. Results There were no statistically significant differences between the SCF and control groups in terms of basic demographic, clinical, and laboratory data. However, the SPA was significantly higher in the SCF group compared to the control (702.7 ±13.8 and 683.9 ±13.2 respectively, p<0.001). Serum prolidase activity was significantly correlated with the mean TFC (r=0.463, p<0.001). The overall findings of this study support the predictive accuracy of the serum prolidase activity in our cohort, with a statistically significant ROC value of 681.3. Conclusions Our study showed that SPA was increased in SCF patients. The activity of this enzyme was significantly correlated with the mean TFC.

PP-295 HEART RATE VARIABILITY IN FAMILIAL MEDITERRANEAN FEVER PATIENTS

OBJECTIVE Familial Mediterranean fever (FMF) is an autosomal recessive autoimmune disease, presenting with the attacks of fever and inflammation of serous membranes. One of the leading causes of death in autoimmune rheumatologic diseases is cardiovascular events. The purpose of this study is to evaluate the effects of FMF on the autonomic nerve and cardiovascular systems by measuring the indices of heart rate variability (HRV). MATERIAL AND METHODS Thirty FMF patients and the same number of healthy volunteers were enrolled to the study. Standard deviation of all R-R intervals (SDNN), the square root of the sum of the square of the differences between successive R-R intervals (RMSSD), standard deviation of 5-minute mean values of R-R interval (SDANN), low frequency (LF), and high frequency (HF) were measured. RESULTS Time domain indices (SDNN, SDANN, and RMSSD) were: 124.67±40.79, 129.87±36.43 (p=0.605); 11.43±38.41, 11.23±38.98 (p=0.984); and 33.43±17.39, 38.17±12.8 (p=0.235) for FMF patients and controls, respectively, and similar in both groups. Frequency domain indices (HF, LF, and LF/HF) were: 290.41±290.25, 322.20±222.54 (p=0.639); 596.16±334.07, 805.80±471.00 (p=0.051); and 3.57±2.57, 3.05±1.40 (p=0.338) for FMF patients and controls, respectively, and similar in both groups. CONCLUSION The HRV parameters were similar in both groups. However, studies including larger populations and using different methods are required to clarify if autonomic dysfunction exists in patients with FMF.

Is Transesophageal Echocardiography May Be Useful Diagnosis of LeftVentricular Noncompaction: A Case Report

The left ventricular non-compaction (LVNC) is a primary cardiomyopathy and is characteriezed by prominent trabeculations on the luminal surface of the ventricle and deep inter-trabecular recesses (DITR) communicating whith ventricular lumen and regional wall motion abnormalities. The diagnosis of LVNC is generally made whith transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMRI). The spectrums of clinic are highly variables, ranging from no symptoms to progressive deterioration in cardiac function which results in congestive heart failure, systemic thromboembolism, life threatening ventricular arrhythmias, and sudden cardiac death (SCD). A case of LVNC with sustained ventricular tachycardia (VT) was presented. An implantable cardiac defibrillator (ICD) was implanted because of the individual’s high SCD risk.

The Relationship between Ventricular Repolarization Indexes and Neutrophil to Lymphocyte Ratio in Patients with Slow Coronary Flow

Objective: Slow coronary flow (SCF) is characterized by angiographically normal coronary arteries with delayed opacification of the distal vasculature. The peak to the end of the electrocardiographic T wave (Tp-e) may correspond to the transmural dispersion of repolarization and that increased Tp-e interval and Tp-e/QT ratio are associated with ventricular arrhythmias. Neutrophil to lymphocyte ratio (NLR) is a new inflammatory marker using for cardiovascular risk prediction. The aim of this study was to evaluate the relationship between ventricular repolarization and inflammation in patients with SCF. Methods: Forty-six SCF patients and 44 controls were enrolled to the study. Coronary flow rates were measured by Thrombolysis in Myocardial Infarction frame count (TFC). Tp-e interval and Tp-e/QT ratio were measured from a 12-lead electrocardiogram, and Tp-e interval was corrected for heart rate (cTp-e). NLR was calculated as the ratio of neutrophil to lymphocyte count. These parameters were compared between groups. Results: Corrected Tp-e interval and Tp-e/QT ratio were significantly higher in SCF patients (94.5 ± 14.9 vs 88.1 ± 6.3 ms, 0.23 ± 0.03 vs 0.21 ± 0.02; P=0.009, and P=0.002, respectively). Also, NLR was increased in SCF patients (2.40 ± 0.9 vs 1.67 ± 0.5, P<0.001). The cTp-e was significantly correlated with mean TFC and NLR (r=0.50, p<0.001 and, r=0.37, p<0.001, respectively). Tp-e/QT ratio was significantly correlated with mean TFC and NLR (r=0.48, P<0.001 and r=0.28, P=0.006, respectively). Conclusion: Our study revealed that cTp-e interval and Tp-e/QT ratio were increased in SCF patients. These new electrocardiographic ventricular repolarization indexes were significantly correlated with the mean TFC and NLR.