Ayhan Olcay

Prevalence of Coronary Artery Anomalies in 12,457 Adult Patients Who Underwent Coronary Angiography

Coronary artery anomalies are found in 0.2% to 1.3% of patients undergoing coronary angiography and 0.3% of an autopsy series. We aimed to estimate the frequency of coronary artery anomalies in our patient population.

Negative association of endothelial nitric oxide gene polymorphism with hypertension in Turkish patients: effect of ecNOS polymorphism on left ventricular hypertrophy

BackgroundEndothelial nitric oxide synthase produces nitric oxide which is involved in many physiologic regulatory functions. Variable number of tandem repeats in intron 4 of endothelial nitric oxide synthase gene are reported to be associated with blood pressure regulation. Nitric oxide is involved in regulation of cardiomyocyte genes but it is not known If endothelial nitric oxide synthase 4 gene polymorphisms are related with left ventricular hypertrophy. We studied endothelial nitric oxide synthase 4a/b allele status in hypertensive and normotensive patients and echocardiographic parameters in a subgroup of hypertensive group.MethodsWe performed a case-control study involving 110 Turkish hypertensive patients and 87 controls. All subjects were genotyped for endothelial nitric oxide synthase 4a/b polymorphism. Echocardiographic measurements were obtained in 94 of the hypertensive patients.ResultsEndothelial nitric oxide synthase 4a/b genotype frequencies were 6.4%, 23.6%, 70% in hypertensives and 1.1%, 18.4%, 80.5% in controls for a/a, a/b, b/b, respectively. Left ventricular dimensions, mass and diastolic indices were not different across endothelial nitric oxide synthase 4 genotypes. Patients with 4a/a genotype had higher interventricular septal thickness than the other group; 14.83(1.6), 11.91(1.51), 12.21(1.56) for a/a, a/b, b/b, respectively and p = 0.0001.ConclusionEndothelial nitric oxide synthase 4a/b gene polymorphism is not associated with hypertension in Turkish patients. 4a/a genotype was associated with higher interventricular septal thickness in hypertensive patients.

Pressure-derived collateral flow index : a strong predictor of late left ventricular remodeling after thrombolysis for acute myocardial infarction

ObjectiveDespite proved efficacy of pressure-derived collateral flow index in determining microvascular dysfunction in patients with acute myocardial infarction, its role in prediction of left ventricular remodeling at long term has yet to be demonstrated. In this study, we investigated the relationship between quantitatively assessed microvascular dysfunction by using intracoronary pressure wire and late left ventricular remodeling. Patients and methodsThe study population consisted of 28 patients with first acute myocardial infarction. They were treated with fibrinolytic therapy. The inclusion criteria were thrombolysis in myocardial infarction grade II–III flow in infarct-related artery and all destined for stent implantation. Cardiac catheterization and stent implantation were performed in mean of 3.3 days after acute myocardial infarction. During the stent implantation procedure, the pressure-derived collateral flow index was measured by using intracoronary pressure wire. Control angiograms were performed at 6±2 months. Echocardiographic left ventricular volume indexes were measured at discharge, at 6 months and at 1 year. Changes in left ventricular volumes from baseline to 1 year were followed. ResultsLeft ventricular end-diastolic volume index at 1 year correlated significantly with the pressure-derived collateral flow index (r=0.69, P<0.01). A significant correlation was also observed between the change in left ventricular end-diastolic volume index from baseline to 1 year and the pressure-derived collateral flow index (r=0.65, P<0.01). The most important predictor of 1-year left ventricular remodeling was the pressure-derived collateral flow index (P<0.0001), and collateral circulation (P=0.03). ConclusionThe pressure-derived collateral flow index is a powerful independent predictor of 1-year left ventricular dilatation. Given its simplicity of measurement, and correlation with microvascular obstruction and left ventricular outcome at long term, the pressure-derived collateral flow index may provide useful and valuable estimates of clinical outcomes after acute myocardial infarction.

Myocardial infarction associated with thrombus formation in non-culprit coronary arteries

Acute coronary syndromes may be associated with a systemic acute pro-thrombotic condition, possibly involving inflammatory mechanisms as well, which are not confined to a single spot in the coronary circulation. Multivessel coronary thrombosis appears to be an exceptionally rare clinical finding. Here we present a case of anterior MI complicated by thrombi in circumflex and right coronary arteries.

Aldosterone synthase -344c/t and angiotensin-converting enzyme I/D polymorphisms in turkish hypertensive patients with normal coronary arteries

Background — The renin-angiotensin-aldosterone system (RAAS) plays an important role in blood pressure regulation, left ventricular and vascular structure. Some hypertensive patients develop left ventricular dilatation and heart failure symptoms while others are relatively less affected.The purpose of our study was to determine whether two major polymorphisms of RAAS are associated with echocardiographic left ventricular mass, function and dilatation in hypertensive patients with normal coronary arteries. Methods — A Turkish population of 88 patients with hypertension and normal coronary arteries were studied by echocardiography for left ventricular dimension, mass and function. Genotyping was performed for aldosterone synthase (CYP11B2) -344C/T polymorphism in 85, angiotensin-converting enzyme (ACE) I/D polymorphism in 88 patients. Left ventricular dimensions, mass and function indices, after adjustment for clinical covariates, were analysed by multiple regression according to genotypes. Results — None of the two genotypes studied predicted left ventricular dilatation, mass or function in hypertensive patients with normal coronary arteries. Conclusion — Neither ACE I/D nor CYP11B2 -344C/T polymorphisms were useful to predict left ventricular mass, function or dilatation in our hypertensive patients with normal coronary arteries.

Admission Hyperglycemia and TIMI Frame Count in Primary Percutaneous Coronary Intervention

We evaluated the relationship between admission blood glucose levels and estimated coronary flow by the thrombolysis in myocardial infarction (TIMI) frame count (TFC) method in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). The TFC of 121 consecutive patients with STEMI were evaluated after pPCI. Patients with admission glucose levels >198 mg/dL (11 mmol/L) were defined as hyperglycemic. Hyperglycemia was observed in 36 (29.8%) patients. The TFC was significantly higher in patients with hyperglycemia (70.75 [10-96] vs 56.87 [8-100], P = .04). No-reflow frequency was higher in the hyperglycemia group (44.4% vs 23.5%, P = .02). In multivariate linear regression analysis admission glucose was an independent predictor of high TFC (B = 0.21, P = .02). Our findings suggest that admission blood glucose is a predictor of TFC which reflects coronary blood flow.

Iliac artery perforation and treatment during lumbar disc surgery by simple balloon tamponade

IntroductionAlthough vascular injury during lumbar disc surgery is quite rare, it may be life threatening if not recognized and treated immediately.Case We report the case of a woman who had a left common iliac artery laceration during spinal surgery and was treated by endovascular therapy. In the past, open surgery was the only way to repair a vascular injury, but thanks to the advance of new endovascular techniques and devices, endovascular therapy has become a strong alternative.ConclusionThis case differs from those published in the literature as we used a single balloon inflation and subtotal occlusion without the need for a covered stent.

Case images: successful catheter ablation of atrioventricular nodal reentrant tachycardia in a patient with congenital absence of inferior vena cava.

A 50-year-old woman admitted with recurrent palpitations due to supraventricular tachycardia previously documented by ECG. She was referred for electrophysiological study and catheter ablation initiated by introducing the venous sheath via the right femoral vein. However, the ablation catheter could not be advanced through the inferior vena cava (IVC) due to resistance. Contrast injection through the sheath showed that IVC was totally occluded along with weak collaterals arising from the hepatic vein (Figure A and Video 1*). Following insertion of the sheath through the left femoral vein, another venograms were obtained also showed total absence of the IVC along with a tortuous azygous connection (Figure B and Video 2*). Then two sheaths were introduced into the right subclavian vein for the insertion of coronary sinus (CS) and radiofrequency (RF) catheters. CS catheter was positioned properly and the RF catheter was located near the region of His. Following programmed atrial stimulation, atrio-ventricular nodal reentrant tachycardia (AVNRT) was induced. The region showing slow pathway potentials was ablated with the RF catheter but several attempts failed to induce junctional beats. Retrograde transaortic approach was used to localize the region of slow pathway from the left ventricle. Subsequent RF deliveries showed junctional beats provided that AVNRT could no longer be induced. Figure C shows the catheters used in the procedure. Computed tomography with reconstruction demonstrated the interruption of the inferior vena cava below the hepatic level (Figure D). 685

Industry compliant health care provider: accepting defeat

Physicians, especially specialists, have always served in the positions of leadership at hospitals and the decision making tree of government management. There are no professionals more highly educated and trained in the field of medicine than doctors and surgeons. In the noble profession of medicine, physicians and surgeons are the gold standard, not providers. Providers operate under the control of their employer and they do not have autonomy.Recent trends in our country have taken autonomy of the physicians, forced them to work for a performance system and manage (not treat !!!) patients with limited reimbursements which is disrupting the basic tenet of physician-patient relationship, which is “serve the best interest of the patient”. The new system creates demand by creating more health buyers, more disease and health anxiety in society, thus creating more diagnostic work-up and much greater profit, which contradicts the basic tenet of medicine. Independent private office based practice, which is thousands of years old, is discouraged and physicians are forced to enter into either profit based large hospital groups or politically slanted, and sometimes a nonphysician managed state hospital system. Meanwhile, real patients not fitting into the criteria of the new generation health service buying customers always know subconsciously that they need real physicians and thus prefer university hospitals. However, university hospitals and their physicians are continuously portrayed by the new political and economic elite as expensive, sluggish, independant, rebellious, narrow-minded, nonobedient consumers of the system who should be tamed. During this “taming process” the foundations of art are threatened by ignorance of education of new doctors, and decreasing scientific productivity. Their autonomy, wisdom and centuries old traditions are seen as a threat to the new economic and political coalition. Loss of autonomy, exhaustion due to excessive -working hours, heavier malpractice penalties, physical threat and violence directed toward the doctors, which is not punished but, on the contrary, forgiven by the local justice institutions, are overwhelming problems at all levels of the health system. Currently, the joint commercialization of the health system is replacing and contradicting thousands of years of physician practice. Obviously, this new trend will destroy medicine and will ultimately disrupt individuals’ healthcare, and the economy of the country.Physicians on whose shoulders the whole system rests have no political or economic power and are forced to be a standardized obedient apparatus of the new system. Private hospital associations which have close ties and profit interests with hospital owners and politicians obtained far more political power and influence on state bureaucrasy and politics than most professional physician organizations. Physicians are often reluctant to become politically involved, but politicians need to hear the doctors’ voices. The remaining independent doctors are required to participate in politics in order to correct this ongoing misfit health system.There is great envy by politicians and corporations for physician autonomy, economic well being, instant social credibility and their publicly accepted esteem. Sadly, this coalition misses one crucial point which is that displacement of independent physicians and surgeons from their professional roles in medicine will result in the sacrifice of human lives. The profession of medicine is degenerating and the first step is to accept realistically that we have lost our dominant position and should return to our thousand year old position. Demands of accountability, pressure on physicians by government programs, shared control, greater efficiency are realities of modern medicine but those should not damage the basic role and position of the physician. Between large private hospital groups and politically constraining state hospitals, private offices will normalize the system and keep the inde-pendance of the physician. Political pressure to satisfy new health care consumers in state hospitals should be resisted.Interventional cardiology, together with cardiovascular surgery, is one of the most profitable and attractive targets of the new system. Drug companies, device companies, private hospitals and “pay for performance” system in state hospitals are making interventional car-diology more and more difficult to practice. System rewards only those performing more procedures, diagnostic work-ups and who are indus-try compliant. The issue of physician independance and ethical compli-ance is becoming of serious concern and should be discussed in sci-entific journals, cardiology meeting sessions and speciality training of fellows.Ayhan OlcayIstanbul-

Two-year results of primary coronary intervention performed in a medium-scale primary percutaneous coronary intervention center by two cardiologists who are not formally trained in interventional cardiology.

Electrocardiography was normal. A live healthy baby was delivered by caesarean section at 39 weeks of gestation without any complications during the labor and postpartum period. During pregnancy, echocardiographic cardiac chamber dimensions increase by 2 to 5 mm (4). Cardiac output increase 50% mainly due to an increase in stroke volume. Systemic vascular resistance decreases due to the low resistance in the uterine vessels and elevated levels of vasodilators (2). However, we observed a decrease in cardiac output and an increase in TPR in our patient. Mechanical mitral valve replacement behaves like mild mitral stenosis. Therefore, with increased volume load and tachycardia together may cause the patients to deteriorate and advance from one NYHA class to another. The increased heart rate of pregnancy may limit the time available for left ventricular filling, resulting in increased left atrial and pulmonary pressures and an increased likelihood of pulmonary edema. However, we could not conclude accurate results with only one patient. Therefore, we planned to make a study about this subject with more patients.