Atila Bitigen

Relation of the severity of contrast induced nephropathy to SYNTAX score and long term prognosis in patients treated with primary percutaneous coronary intervention

BACKGROUND SYNTAX score (SXscore) has been developed to assess the severity and complexity of coronary artery disease. The aim of this study was to evaluate whether baseline SXscore was associated with contrast induced nephropathy (CIN) after primary percutaneous coronary intervention (p-PCI) in patients with ST-elevation myocardial infarction (STEMI). Secondarily we aimed to investigate the relation of the severity of CIN to long term prognosis. METHODS We retrospectively enrolled 1893 patients with STEMI treated by p-PCI. We prospectively followed up the patients for a mean duration of 45 months. The patients were grouped according to the development of no nephropathy (grade 0, n: 1634), mild nephropathy (grade 1, n: 153) or severe nephropathy (grade 2, n: 106). RESULTS SXscore was significantly higher (19.4±5.9 vs 15.6±4.8, p<0.001) in patients with CIN (grades 1 and 2) compared to those without CIN. SXscore was higher in patients with grade 2 CIN compared to those with grade 1 CIN (18.5±5.7 vs 20.7±5.9, p<0.001). In the multivariate analysis, SXscore was identified as an independent predictor of CIN (for one unit increment, OR: 1.06, 95% CI: 1.01-1.14, p=0.006). At long-term follow-up, death (p<0.001), stroke (p=0.006), reinfarction (p=0.024) and permanent HD requirement (p<0.001) were most frequent in grade 2 nephropathy group. HD was associated with very high in-hospital (60%) and long-term (83.3%) mortality rates. CONCLUSIONS SXscore is an independent predictor of development and severity of CIN after p-PCI. CIN is associated with poor prognosis during both early and late postinfarction period.

The role of tissue Doppler study in the assessment of left ventricular dysfunction in obesity.

Purpose — The purpose of this study was to investigate the potential utility of tissue Doppler echocardiography in the assessment of left ventricular systolic and diastolic function in the obese population. Method — 96 obese (48 male, 48 female) patients and 50 normoweight (25 male, 25 female) control subjects were enrolled. Obese patients were subgrouped into mild (25-29.9 kg/m2), moderate (30-34.9 kg/m2) and significant (≥ 35 kg/m2) according to their body mass index (BMI). Left ventricular systolic and diastolic functions were evaluated by tissue Doppler imaging with conventional transthoracic echocardiography. Peak systolic velocity (Sm) of the lateral mitral annulus, the duration from electrocardiographic Q wave to Sm and early and late diastolic velocities (Em, Am) were recorded with tissue Doppler imaging. Results — The ejection fraction and fractional shortening values were found to be increased in the mildly and moderately obese subjects. Left ventricular diameters were increased in all of the patients in the obesity group; however, relative wall thicknesses were similar to control subjects. The peak systolic velocities of the mitral lateral annular area (Sm) were lower in moderately and significantly obese subjects compared to the control subjects. None of the study patients had systolic dysfunction by conventional echocardiographic assessment while prevalence of diastolic dysfunction was significantly higher in the obese group of which the prevalence proportionally increased with BMI. Diastolic dysfunction was also more prevalent in the subjects with abdominal obesity which was determined by waist circumference (WC). Conclusion — The ejection phase indices were increased in mildly and moderately obese subjects. However, in significantly obese subjects they were similar to control subjects by conventional echocardiographic methods. Sm values of the moderately and significantly obese patients were significantly lower when measured by tissue Doppler imaging. Diastolic function was also shown to be impaired in the moderately and significantly obese subjects when measured by tissue Doppler imaging.

Extended Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy with Anomalous Insertion of Chordae Tendineae

We present a case of hypertrophic cardiomyopathy with anomalous insertion of mitral valve chordae tendineae diagnosed with two-dimensional echocardiogram. A high gradient was found in left ventricular outflow tract (LVOT) obstruction, which was attributed to the fixed gradient caused by anomalous insertion of chordae tendineae in addition to the gradient of dynamic LVOT obstruction. The misinserted chordae tendineae were resected, and an extended septal myectomy was performed. Follow-up echocardiography showed reduction of the pressure gradient to less than 40 mm Hg in the LVOT, and the patient had no symptoms during the 1-year follow-up period.

Large mural vegetation attached to the left ventricular outflow tract: a case report.

We describe an unusual case of staphylococcal endocarditis with vegetation attached to the left ventricular outflow endocardium in a patient with chronic severe aortic regurgitation that was diagnosed by transthoracic echocardiography. There was no involvement of aortic valve endocardium confirmed by transthoracic echocardiography, transesophageal echocardiography, and macroscopically in the operation. This report confirms that chronic endocardial trauma may provide a fertile nidus for the development of bacterial vegetation.

Atherosclerosis in type IV dual left anterior descending artery and anomalous aortic origin of the left circumflex artery in association with rheumatic valve disease: a case report.

Double left anterior descending coronary artery arising from the left and right coronary arteries is a very rare congenital coronary artery anomaly. In this case, there was also a circumflex artery arising from the right sinus Valsalva and in association with severe rheumatic valve disease. Subsequently, the patient underwent mechanical aortic valve replacement with a 21-mm bileaflet mechanical aortic valve and coronary artery bypass grafting. We performed coronary artery bypass grafting of 3 vessels, including the left internal mammary artery to the large diagonal branch and the saphenous vein graft to the circumflex artery and the right coronary artery, under cardiopulmonary bypass. In this report, we describe an unusual case of this combination in association with both atherosclerosis and rheumatic aortic and mitral valve disease.

Influence of diurnal blood pressure rhythm on aortic elastic properties in hypertensive subjects.

Objective — The aim of this study was to evaluate whether there is a relationship between aortic elastic properties and diurnal blood pressure rhythm in hypertensive subjects. Methods and results — This study included 41 hypertensive patients who were taking medical treatment and had undergone ambulatory blood pressure monitoring (ABPM). The patients were classified according to their night mean systolic blood pressure (Nm-SBP) fall. On the basis of Nm-SBP fall: 10 (24.4%) patients were dippers (with 10% but < 20% fall), 19 (46.3%) patients were nondippers (with 0% but<10% fall) and 12 (29.3%) patients were reverse dippers (with<0%). All subjects underwent echocardiographic examination. Internal aortic root diameters were measured at 3cm above the aortic valve by the use of two-dimensional guided M-mode transthoracic echocardiography, and arterial blood pressure was measured simultaneously from the brachial artery by sphygmomanometry.Two indexes of the aortic elastic properties were measured which are aortic distensibility and aortic stiffness index.After subgroup analysis of the hypertensive patients, the highest aortic stiffness index value was found in reverse dipper patients (5.8±3.4) followed by nondipper patients (4.87±3.5) and the lowest in dipper patients (3.5±1.3) although clinical blood pressure values of hypertensive patients were similar.The aortic stiffness index value of reverse dippers and nondippers (5.6±3.4) was higher than in the (3.5±1.3) dippers group. Conclusion — In this study, we found a relation between diurnal blood pressure patterns and aortic elastic properties.

Anticoagulant Therapy in Patients with Atrial Fibrillation and Coronary Artery Disease

Atherosclerotic cardiovascular disease and atrial fibrillation (AF) are causes of increased mortality and morbidity all over the world. Coexistence of both leads to even higher rates of mortality and morbidity. In AF, the main reason responsible for increased mortality and morbidity is thromboembolisation and consequently the development of a stroke [1]. Among patients with atrial fibrillation, the incidence of atherosclerotic cardiovascular dis‐ ease has been reported to be 20-30% [2]. Thus, development of an acute coronary syndrome (ACS) requiring percutaneous coronary intervention is very probable in patients with atrial fibrillation. Despite a 17% reduction in the incidence of stroke with aspirin compared to pla‐ cebo, vitamin K antagonist (VKA) warfarin is superior to both aspirin and aspirin plus clopi‐ dogrel combinations due to its preventing AF patients from thromboemboli [3]. While triple antithrombotic therapy (VKA+aspirin+clopidogrel) lowers the risk of stroke in stent im‐ planted patients with AF, it increases the risk of bleeding at longterm. Thus careful judge‐ ment of the risk of emboli and bleeding, the stent type (drug eluted or bare metal) to be implanted and the duration of appropriate treatment regimen is important.

Reshaping Left Judkins Catheter for Right Coronary Angiogram in Anomalous Aortic Origin of Right Coronary: Killing Two Birds with One Judkins Left

OBJECTIVES Selective cannulation of the right coronary artery (RCA) in the anomalous aortic origin of the RCA is technically difficult and challenging. In this study, we tested the success of RCA cannulation with a reshaped left Judkins catheter in cases of difficult selective cannulation. STUDY DESIGN The study population consisted of 837 consecutive patients (456 male, 381 female) that were admitted to our hospital with stable angina pectoris and acute coronary syndrome between October 1 and December 31, 2011. In cases where RCA cannulation was difficult, the 10 centimeter section of the left Judkins proximal to the secondary curve was reshaped by hand to form an inward slope. The secondary curve angle was increased to approximately 100 degrees and the primary curve angle was adjusted to 120 degrees. Then, we attempted to perform selective RCA cannulation. RESULTS In 49 of the 837 patients, selective RCA cannulation was unsuccessful with the right Judkins catheter. In 42 of these 49 (86%) cases, the RCA was cannulated with the reshaped left Judkins. We failed to cannulate the right coronary in two cases with downward angulation, one with upward angulation, one with high take-off origin, and one with anterior origin. A multipurpose, internal mammary artery, left Amplatz 1, and right Amplatz 1 catheter were used for cannulation in these cases, respectively. There was no angina, nor were there electrocardiographic or hemodynamic changes during the procedure. CONCLUSION In cases where the selective cannulation of the RCA is difficult, using a reshaped left Judkins may be a successful and cost-effective method of selective cannulation.