Ayhan Cevik

Persistent left superior vena cava: Experience of a tertiary health-care center

Background:  The aim of this study was to assess the prevalence of persistent left superior vena cava (PLSVC) in patients with all types of congenital heart defects and to determine the congenital heart anomalies accompanying PLSVC.

The Effect of Fibrin Glue on the Intensity of Colonic Anastomosis in the Presence and Absence of Peritonitis: An Experimental Randomized Controlled Trial on Rats

Aim. Anastomotic leakage after colon anastomosis is the most frequent and most feared complication with its highest mortality rate. In this study, we aimed to expose the impact of performing fibrin glue on sutured colocolic anastomosis, in the presence of experimental peritonitis, on anastomosis safety. Method. In this experimental study, the rats were divided into two groups as control group (Groups 1 and 3) and experimental group (Groups 2 and 4). They were also divided as clean abdomen (Groups 1 and 2) and infected abdomen (3 and 4) groups. Full-thickness incisions were made on the proximal colon of both groups of rats. The control groups anastomoses were conducted only with sutures, whereas in experimental group, fibrin glue was applied over the sutures. The samples were taken on the 10th day. Results. Highest values for average levels of hydroxyproline in the tissues and anastomotic bursting pressures were detected when fibrin glue was applied on sutured anastomosis in clean abdomen. In the histopathological staging performed in line with Ehrlich-Hunt model, lowest values were detected during the presence of peritonitis. Conclusion. As a result, it has been established that the use of fibrin glue over sutured colocolic anastomosis, both in clean abdomen and in the presence of peritonitis, had increased anastomosis safety.

Serum Levels of Soluble ICAM-1 in Children with Pulmonary Artery Hypertension

This prospective cross-sectional study attempted to determine both the usefulness of the serum intercellular adhesion molecule-1 (ICAM-1) as a biomarker for pulmonary artery hypertension secondary to congenital heart disease and the nature of this markers association with catheter angiographic findings. Our study included a total of 70 male and female children, comprising 30 patients with both pulmonary artery hypertension and congenital heart disease, 20 patients with congenital heart disease alone, and 20 healthy control subjects. Levels of ICAM-1 in plasma samples from all groups were measured by the enzyme-linked immunosorbent assay method. Cardiac catheterization was also performed in all patients. The mean serum ICAM-1 levels in pediatric patients who had congenital heart disease with and without pulmonary artery hypertension were 349.6 ± 72.9 ng/mL and 312.3 ± 69.5 ng/mL, respectively (P=0.002). In healthy control subjects, the mean serum ICAM-1 level was 231.4 ± 60.4 ng/mL. According to the results of this study, the ICAM-1 level of the pulmonary artery hypertension group was significantly higher than those of the congenital heart disease group and the healthy control group. Correlation analysis showed that ICAM-1 level was correlated with systolic and mean pulmonary artery pressures (r=0.62, P=0.001; r=0.57, P=0.001)-which are 2 important values used in diagnosis of pulmonary artery hypertension. Moreover, receiver operating characteristic analysis yielded consistent results for the prediction of pulmonary artery hypertension. Therefore, we conclude that ICAM-1 has potential use as a biomarker for the diagnosis and follow-up of pulmonary artery hypertension.

Subclinical Cardiac Dysfunction in Children with Coeliac Disease: Is the Gluten-Free Diet Effective?

Objectives. The aim of this study is to investigate the effects of coeliac disease on cardiac function in children using conventional transthoracic echocardiography (TTE) and tissue Doppler echocardiography (TDE). Methods. Coeliac disease patients were evaluated in two different groups based on serum endomysial antibody (EmA) titers (EmA (+) and EmA (−)), and the data obtained by conventional and TDE studies were compared between the patient groups and healthy controls. Results. There was no significant difference between EmA (+) and EmA (−) groups in terms of the conventional TTE parameters, including ejection fraction (EF), fractional shortening (FS), and left ventricle end diastolic diameter (LVEDD), that show the left ventricular systolic function (P = 0.727, P = 0.317, P = 0.118). TDE showed a significant difference in left ventricle (LV) isovolumic relaxation time (LV IVRT) and LV myocardial performance index (LV MPI) parameters between EmA (+) and EmA (−) patient groups (P < 0.0001). Conclusion. The measurement of LV MPI and LV IVRT parameters by TDE would be beneficial in early determination of the cardiac involvement and establishing appropriate treatment and followup of patients with coeliac disease as well as in making distinction between EmA (+) and EmA (−) patients.

Magnetic Resonance Imaging in Pediatric Pulmonary Hypertension

The present study aims to determine the efficacy and reliability of cardiovascular magnetic resonance imaging in establishing the diagnosis and prognosis of pulmonary hypertension in children. This is a retrospective comparison of 25 children with pulmonary hypertension and a control group comprising 19 healthy children. The diagnosis of pulmonary hypertension was made when the mean pulmonary artery pressure was ≥25 mmHg by catheter angiography. The children with pulmonary hypertension had significantly lower body mass indices than did the healthy children (P=0.048). In addition, the children with pulmonary hypertension had significantly larger main pulmonary artery diameters and ascending aortic diameters (both P=0.001) but statistically similar ratios of main pulmonary artery diameter-to-ascending aortic diameter. If the main pulmonary artery diameter was ≥25 mm, pediatric pulmonary hypertension was diagnosed with 72% sensitivity and 84% specificity. In the event that the ratio of main pulmonary artery diameter-to-ascending aorta diameter was ≥1, pediatric pulmonary hypertension was diagnosed with 60% sensitivity and 53% specificity. When compared with children who had New York Heart Association functional class II pulmonary hypertension, the children with functional class III pulmonary hypertension had significantly larger main (P=0.046), right (P=0.036), and left (P=0.003) pulmonary arteries. Cardiovascular magnetic resonance imaging is useful in the diagnosis of children with pulmonary hypertension. Pediatric pulmonary hypertension can be diagnosed with high sensitivity and specificity when the main pulmonary artery diameter measures ≥25 mm.

Evaluation of pulmonary vascular resistance and vasoreactivity testing with oxygen in children with congenital heart disease and pulmonary arterial hypertension.

Estimating pulmonary vascular resistance index (PVRI) is of critical importance in determining the type of cardiac surgery, the decision to perform heart transplantation, the choice between surgery and drug treatment or combined modalities, even though it is not the only criterion for judgment (1, 2). A positive pulmonary vasoreactivity test (PVT) is accepted as an indicator of low perioperative risk and good prognosis. An acute positive response to PVT is reported in only 40% of patients (3). This test has been applied in many centers, following different protocols and different evaluation criteria. Most centers use nitric oxide (NO) or oxygen (O2) inhalation, iloprost nebulization, or a combination thereof. A reduction by 20% of mean pulmonary artery pressure (PAPmean) or in the ratio of pulmonary resistance to systemic vascular resistance index (PVRI/SVRI) will define the patient as being a “responder” (4, 5). Reports on PVT performed with different drugs have been published recently (5-8). The aim of this study was to define the hemodynamic parameters of patients undergoing cardiac catheterization in our center for congenital heart disease and pulmonary arterial hypertension (PAH), characterize the efficacy of O2 use in the PVT, and present the clinical findings in these patients with congenital intracardiac shunts. The present study was conducted on a cohort of 30 children diagnosed with PAH and congenital intracardiac shunts and placed under close surveillance at the pediatric cardiology department of the study center between October 2009 and November 2011 (Table 1). As described previously the criteria used for PAH definition and patient selection were considered as mean pulmonary arterial pressure (PAPmean) of ≥25 mm Hg, pulmonary capillary wedge pressure (PCWP) of ≤15 mm Hg, and PVR index (PVRI) of > 3 WU/m2 at rest (6). The PVRI was calculated conventionally as the ratio of the difference between PAP and left atrial pressure or the pulmonary capillary wedge pressure to mean pulmonary flow, and the values were expressed as units per square meter. These parameters were also obtained before and after pulmonary vasoreactivity testing using 100% O2 by simple face mask for 10 min when a high PAPmean was suspected. The PVT was considered positive if PAPmean or the PVRI/SVRI ratio exhibited a reduction by more than 20% (7, 8). Patients were evaluated in two groups according to PVT results, responders and non-responders (Table 2). The median age, height, weight, body surface area (BSA) and heart rate of the recruited patients were respectively 20.0 months, 76.5 cm, 9.2 kg, 0.41 m2 and 112.0 beats/min. No significant difference was found in systolic PAP (PAPsystolic), SVRI, systemic flow (Qs) before and after PVT (p>0.05). The values of the other parameters before and after PVT were significantly different, with p<0.05. Average diastolic pulmonary arterial pressure (PAPdiastolic), PAPmean and median PVRI, PVRI/SVRI showed a significant decrease following PVT. Pulmonary blood flow (Qp) and its ratio to systemic blood flow (Qp/Qs) underwent a significant increase. The fall by more than 20% of PVRI and PVRI/SVRI was especially significant with regard to their PVT positivity (Table 3). No complication occurred in any patient during PVT testing with oxygen. No statistically significant difference in PVT-related measurements before and after the test was apparent within the non-responder patient group. All values in the responders, except Qs and SVRI (p=0.541 and p=0.984, respectively) were significantly different before and after the test (p≤0.05). All of the significantly different parameters except the Qp/Qs ratio in the responders showed a reduction after the test, whereas Qp/Qs was increased (p=0.019). While 11 of 13 nonresponders received medical treatment and the other two underwent full surgical correction, 14 of 17 responders were subjected to full surgical correction. Three patients of the recruited 30 patients were lost. Two of the deceased three patients had undergone surgery and one had had medical treatEvaluation of pulmonary vascular resistance and vasoreactivity testing with oxygen in children with congenital heart disease and pulmonary arterial hypertension

Relationship between ventricular function assessed by tissue Doppler imaging and exercise capacity in patients after repair of tetralogy of Fallot: an observational study.

OBJECTIVE The present study aims to study the relationship between tissue Doppler echocardiography (TDE) indices of right ventricle and exercise capacity in patients after total correction for tetralogy of Fallot (ToF). METHODS This cross-sectional observational study included 20 patients, after undergoing total correction procedure for ToF diagnosed with mild/moderate pulmonary regurgitation and 30 age-matched healthy children. In the postoperative period, patients were invited to hospital for evaluation of the ventricular functions by 2D, M-mode, Doppler (DE) echocardiography and TDE and exercise testing to evaluate the effort capacity. Statistical analysis was performed using Mann-Whitney U and Chi-square tests, and Pearson correlation analysis. RESULTS Compared with the controls; the mitral annular peak systolic flow velocity (Sm) value was significantly lower, while isovolumic contraction time (IVCT), isovolumic relaxation time (IVRT) and myocardial performance index (MPI) values obtained at the tricuspid and mitral (MV) valves were significantly higher (p<0.05 for all) in patients after ToF repair. There was a negative correlation between the exercise period and the total correction age (r=-0.20, p=0.015) and the same negative correlation existed between the exercise period and METS (r=-0.25, p=0.010). MV IVCT with DE and TDE was found to be correlated with METS (r=-0.45, p=0.04). Left ventricular MPI was found to be correlated with maximum heart rate (r=-0.20, p=0.03). By DE, tricuspid valve deceleration time and Sm peak flow velocity with TDE were significantly correlated with METS (r=-0.30, p=0.04; r=-025, p=0.005, respectively). MPI calculated with TDE was correlated with maximum heart rate (r=-0.15, <0.01). CONCLUSION Even if patients, undergone total correction surgery for ToF were asymptomatic or had minimal clinical symptoms, MPI index assessed by pulse wave TDE and exercise testing may allow early diagnosis of right ventricle dysfunction.

Unusual presentation of acute rheumatic fever: Complete atrioventricular block

Acute rheumatic fever (ARF) is a well-known disease that is still widely observed in developing countries, including our country. It is known that the majority of patients diagnosed with ARF display abnormalities of the conduction system, such as PR prolongation within the heart. However, there are only a few case reports that describe severe impairment in the electrical conduction system of the heart. Here we describe a male child who was diagnosed with ARF with complete atrioventricular block while he was under follow up with penicillin prophylaxis. A 14-year-old boy was admitted to the emergency room with the complaint of chest pain. He had had tonsillitis 2 weeks earlier. His vital signs were as follows: body temperature, 36.7°C; respiration rate, 18 breaths/min; pulse, 58 b.p.m.; and systolic/ diastolic blood pressure, 90/60 mmHg. Physical examination was regarded as normal except a grade 2/6 systolic murmur at the left upper parasternal area. The laboratory findings of the patient were reported as follows: hemoglobin, 12.3 g/dL; leukocyte count, 8100/mm; high sensitive C-reactive protein, 8.97 mg/dL; erythrocyte sedimentation rate, 82 mm/h; anti-streptolysin O, 761 U/mL; troponin, 0.046 ng/mL; and brain natriuretic peptide, 1200 picog/mL. As for the microbiological evaluation, throat cultures and Widal test were negative as well as serology for Borrelia burgdorferi, Clostridium diphtheria, Coxsackie, echoviruses, enteroviruses and adenoviruses. The electrocardiogram of the patient showed bradycardia with complete atrioventricular block (heart rate: 51 b.p.m., a QRS complex of 0.08 s, and a corrected QT interval of 0.44 s). Echocardiographic examination indicated first-degree mitral regurgitation with shortening fraction of 32% and ejection fraction of 66%. As the bradycardia of the patient deepened and clinical findings related with pre-shock appeared, the patient was hospitalized. Although continuous ECG monitoring of the patient showed complete heart block with a ventricular rate of 38–44 and second-degree atrioventricular block (Mobitz Tip II) (Fig. 1), pacemaker implantation was not performed due to the absence of symptoms and normal ventricular function. Therefore, penicillin prophylaxis was made and salicylate treatment in anti-inflammatory dose was initiated. The electrocardiographic abnormalities of the patient disappeared after 3 days and the patient was discharged from the hospital 1 week later. The clinical follow-up visits demonstrated nothing in particular except first-degree atrioventricular block. It is unknown how ARF leads to impairment in the cardiac conduction system. On the contrary, only a few patients with ARF experience secondand third-degree atrioventricular block requiring the temporary implantation of a pacemaker. When advanced heart block occurs with ARF, it appears to be a transient event, resolving over a period of days with anti-inflammatory treatment. As for the presented case, despite the lack of other major diagnostic criteria, such as arthritis and chorea, the detection of mild mitral regurgitation by echocardiography has

Sequential Transcatheter Closure of a Patent Ductus Arteriosus and a Muscular Ventriculer Septal Defect in a Child

Due to the developing technology in pediatric catheterization and increasing experience of pediatric cardiologists, currently transcatheter closure of multiple cardiac defects has become available. The present case report describes a patient who successfully underwent sequential transcatheter closure of patent ductus arteriosus (PDA) and muscular ventricular septal defect (VSD). Transcatheter closure of multiple defects is regarded as a reliable and efficient therapeutic option which can be an alternative to surgical treatment in appropriate cases.

Baş Ağrısıyla Başvuran Doğumsal Siyanotik Kalp Hastalığı Olgusunda Beyin Apsesi

Cocuklarda nadiren gorulen beyin apsesinin en sik nedeni, dogumsal siyanotik kalp hastaligidir. Dogumsal siyanotik kalp hastaligi tanisiyla takip edilen ve bas agrisi yakinmasiyla klinigimize basvuran 11 yasindaki bir erkek cocukta beyin apsesi saptanmistir. Dogumsal siyanotik kalp hastaligi olan bir cocukta inatci bas agrisi ortaya ciktiginda norolojik degerlendirme yapilmali ve gerekirse ileri goruntuleme tekniklerinden yararlanilmalidir.