Belma Kalaycı

Assessment of the severity of aortic regurgitation with pulsed wave Doppler velocity profile in the descending aorta

OBJECTIVE The quantitative parameters which are used to assess the severity of aortic regurgitation (AR) provide the most accurate information whereas these parameters are difficult and time-consuming. The aim of this study was to get a practical parameter to use in daily practice for assessing the severity of aortic regurgitation. METHODS The study was an observational cohort study on diagnostic accuracy of severity of aortic regurgitation. Thirty-seven patients with aortic regurgitation determined by quantitative parameters (18 patients with severe aortic regurgitation and 19 patients with moderate aortic regurgitation) were included in this study. Each patients diastolic flow pattern in the descending aorta was examined by pulsed wave Doppler. Systolic and diastolic flow time-velocity integral (TVI), TVI time, systolic and diastolic TVI ratio in the descending aorta were evaluated. In addition to these parameters, dP/dt, peak acceleration time and end-diastolic flow velocity in the diastolic flow were determined. We investigated whether there a significant difference between two groups or not. Receiver operating characteristic (ROC) analysis was used to determine the optimal cut-off values of echocardiographic parameters which were used to identify the severity of aortic regurgitation. RESULTS The study population was composed of 16 female and 21 male patients. Their mean age was 46.5 years. The mean diastolic flow TVI of patients who had moderate and severe aortic regurgitation was found 10.1 cm and 18.6 cm, respectively (p<0.001). In the ROC curve analysis, the values of diastolic flow TVI above 13.5 cm was found to have 83% sensitivity and 90% specifity to predict the severity of aortic regurgitation (AUC: 0.91, 95% CI 0.80-1.0, p<0.001). Also we investigated the other parameters like systolic flow TVI, the ratio of systolic and diastolic flow TVI, mean diastolic flow time, mean systolic flow time, the ratio of systolic and diastolic flow time, end-diastolic velocity, peak acceleration time, dP/dt values in evaluation of diastolic flow in the descending aorta. These parameters were found statistically significant in assessing the severity of aortic regurgitation but their statistical power was weak. CONCLUSION TVI of diastolic flow which is measured with pulsed wave Doppler in descending aorta could be a practical parameter in assessing the severity of aortic regurgitation.

Pacemaker lead endocarditis with hiccups (Kalayci)

Background: Lead-related infections that might develop after pacemaker implantation associated with high mortality and morbidity rates are challenging to manage and pose high-cost. Patients with lead-related infections usually present with fever, chills and fatigue and the treatment can be challenging unless the implant system is extracted. Case presentation: A 66-year old male patient who underwent dual chamber pacemaker and implantable cardioverter defibrillator was admitted to the emergency service with a six-week history of complaints of hiccups and fever. After a detailed investigation, lead-related infective endocarditis was the diagnosis. The patient was initiated on antibiotic therapy and lead extraction was performed. Conclusions: Patients with signs of infection who underwent pacemaker implantation may present with atypical symptoms such as hiccup. In these cases, imaging, particularly echocardiography, should be performed as soon as possible and the localization of the pacemaker leads and signs of infective endocarditis should be investigated.

The relationship of Charlson comorbidity index with stent restenosis and extent of coronary artery disease

Objectives The objective of this study is to investigate the effect of comorbid conditions [Charlson comorbidity index (CCI)] on stent restenosis who underwent coronary angioplasty earlier. Methods Patients were divided into two groups; patients with critical restenosis [recurrent diameter stenosis >50% at the stent segment or its edges (5-mm segments adjacent to the stent) (Group 1; n = 53, mean age: 63.8 ± 9.9 years)] and patients with no critical restenosis [<50% obstruction (Group 2; n = 94, mean age: 62.1 ± 9.1 years)]. The CCI and modified CCI were used for the presence of comorbid conditions. The Gensini scoring system was used to assess the extent of coronary artery disease (CAD). Results Group 1 had a significantly greater CCI and modified CCI score compared to Group 2 (7.1 ± 3.7 vs. 5.6 ± 1.6, p = 0.006; 6.9 ± 3.6 vs. 4.5 ± 1.5, p = 0.008, respectively). There was a weak correlation, albeit significant, between the modified CCI score and restenosis percentage (r = 0.29, p < 0.001; r = 0.25, p = 0.003, respectively). Conclusions In conclusion, the CCI score is greater among patients with stent restenosis than those without. CCI score is higher among patients with a more diffuse CAD than with a milder disease extent.

The Influence of Comorbid Conditions on Graft Stenosis in Patients with Coronary Artery Bypass Graft Operation

Mailing Address: Turgut Karabag Bulent Ecevit Universitesi İncivez Mahallesi, Üniversite Cd., Postal Code: 67100 Merkez/Zonguldak Merkez/Zonguldak Turkey E-mail: turgutkarabag@yahoo.com The Influence of Comorbid Conditions on Graft Stenosis in Patients with Coronary Artery Bypass Graft Operation Turgut Karabag, Belma Kalayci, Bahar Sahin, Elif Coskun, Mustafa Umut Somuncu, Mustafa Ozan Cakir Bulent Ecevit University, Kozlu/Zonguldak Turkey

Atrioventricular conduction defect associated with severe hyponatremia

Hyponatremia is the most common electrolyte disorder among hospitalized patients and in the clinical setting. Patients with hyponatremia may develop a variety of symptoms, primarily neurological and gastrointestinal. Hyponatremia is more frequently encountered in patients with an underlying heart disease, particularly in the elderly. We hereby present a case of complete atrioventricular block in an elderly patient who had undergone aortic valve replacement and had been using thiazide. Complete atrioventricular block improved after sodium replacement therapy and no other cause of electrolyte disorder was documented.

The relationship of age-adjusted Charlson comorbidity ındex and diurnal variation of blood pressure

ABSTRACT Backgrounds: Charlson Comorbidity index (CCI) is a scoring system to predict prognosis and mortality. It exhibits better utility when combined with age, age-adjusted Charlson Comorbidity Index (ACCI). The aim of this study was to evaluate the relationship between ACCI and diurnal variation of blood pressure parameters in hypertensive patients and normotensive patients. Methods: We enrolled 236 patients. All patients underwent a 24-h ambulatory blood pressure monitoring (ABPM) for evaluation of dipper or non-dipper pattern. We searched the correlation between ACCI and dipper or non-dipper pattern and other ABPM parameters. To further investigate the role of these parameters in predicting survival, a multivariate analysis using the Cox proportional hazard model was performed. Results: 167 patients were in the hypertensive group (87 patients in non-dipper status) and 69 patients were in the normotensive group (41 patients in non-dipper status) of all study patients. We found a significant difference and negative correlation between AACI and 24-h diastolic blood pressure (DBP), awake DBP, awake mean blood pressure (MBP) and 24-h MBP and awake systolic blood pressure(SBP). Night decrease ratio of blood pressure had also a negative correlation with ACCI (p = 0.003, r = −0.233). However, we found a relationship with non-dipper pattern and ACCI in the hypertensive patients (p = 0.050). In multivariate Cox analysis sleep MBP was found related to mortality like ACCI (p = 0.023, HR = 1.086, %95 CI 1.012–1.165) Conclusion: ACCI was statistically significantly higher in non-dipper hypertensive patients than dipper hypertensive patients while ACCI had a negative correlation with blood pressure. Sleep MBP may predict mortality.

The Relationship Between Aspirin Resistance and Carotid Imaging in Young Patients With ST-Segment Elevated Myocardial Infarction: A Cross-Sectional Study

The presence of carotid atherosclerosis accompanied by coronary artery disease is associated with poor prognosis. A subset of patients who take aspirin continue to have recurrent cardiovascular events, which may be due to aspirin resistance (AR). Also, carotid plaques may cause turbulent flow which in turn may lead to platelet activation and poor antiplatelet response. In our study, we aimed to show the prevalence of AR and its relationship between high-risk carotid images in young patients with ST-segment elevated myocardial infarction (STEMI). In our study, we included 112 patients younger than 45 years with STEMI. Aspirin response test was evaluated 1 hour after aspirin intake using multiplate platelet function analyzer, and carotid ultrasonography has been performed to determine carotid intima–media thickness (CIMT) and the presence of carotid plaque. We identified 30.3% AR in young patients with STEMI. Carotid intima–media thickness (P = .002), carotid plaque (P = .012), and high-risk carotid image (P = .015) values are significantly high in patients who have AR. Independent of other risk factors, the presence of carotid plaque and being in the high-risk carotid group were associated with 3.7 times and 3.2 times increased odds for AR, respectively. In young patients with STEMI, physicians should be careful about AR, especially in patients who have carotid plaque and thicker CIMT.

Association between fractional flow reserve and Duke Treadmill Score in patients with single-vessel disease

BACKGROUND Duke treadmill score (DTS) is an index that provides prognostic information calculated at exercise stress test. Fractional flow reserve (FFR) is an invasive method used to evaluate intermediate coronary stenosis. The direct relation of DTS and FFR has not been studied to date. AIM The present study aims to investigate the relationship between the DTS and FFR. METHODS The study population consisted of a total of 106 patients with single-vessel disease, as confirmed by coronary angiography performed following EST, and whose FFRs were measured. The patients were separated into three groups according to the DTS values: low risk (DTS ≥ +5), intermediate risk (-10 ≤ DTS ≤ +4), and high risk (DTS ≤ -11). According to the FFR values, the patients were separated into two groups: FFR < 0.80 and FFR ≥ 0.80. RESULTS Angina symptoms and chronic heart failure were more frequent in the group with FFR < 0.80 than the group with FFR ≥ 0.80; respectively, 95% vs. 69.8%, p = 0.020 and 15% vs. 3.5%, p = 0.045. The mean DTS value was lower in the group with FFR < 0.80 than the group with FFR ≥ 0.80 (1.60 vs. 5.07; p = 0.011). However, there were no statistically significant differences in the DTS risk groups among the FFR groups (p = 0.070). A weak positive correlation was found between the numerical DTS and FFR values (r = 0.139; p = 0.156). When the patients with high-risk were excluded, a statistically significant relationship was determined between the FFR and in the groups with low- and intermediate-risk in terms of the DTS values (p = 0.029). CONCLUSION In conclusion, our study results showed an association with FFR and in the groups with low and intermediate risk in terms of the DTS values. DTS levels can be useful to determine patients who require invasive management.

A rare cardiovascular cause of fever of unknown origin: Infected thoracal aortic aneurysm

Aortitida může vyvolat horecku neznameho původu. Vysetřeni pacientů prokazuje přitomnost sepse. Pokud jsme nedokazali urcit jeji přicinu, zvažovali jsme použiti transthorakalni echokardiografie, ktera vsak obtižně prokazuje postiženi sestupne aorty. Proto je vhodne u pacientů s aortitidou mit na paměti možnost diagnostiky pomoci CT angiografie.Popisujeme připad pacienta, který byl dopraven do nasi nemocnice se sepsi. Vysetřeni odhalilo přitomnost sakularniho aneurysmatu, periaortalniho abscesu a nahromaděni vzduchu v oblasti hrudni aorty v důsledku infekce gram-pozitivni bakterii Staphylococcus aureus.

Case images: Absence of posterior mitral valve leaflet detected in late adulthood.

A 62-year-old woman suffering from dyspnea and palpitation was referred. Electrocardiography (ECG) revealed left bundle branch block and atrial fibrillation. Transthoracic echocardiography revealed absence of posterior mitral valve leaflet (PMVL) and mild mitral regurgitation (Figure A, Video 1*). Posterior myocardial wall replacement of the posterior leaflet had proceeded to coaptation line of the mitral valve (Figure B, Video 2*). Chordae tendineae and papillary muscles were attached to the tip of posterior myocardial wall. Coronary sinus was dilated. However, contrast echocardiography was normal during agitated saline injection into right and left upper extremity intravenous line. Ejection fraction was 40%, measured by Simpson’s rule. Subsequent transesophageal echocardiography (TEE) confirmed transthoracic echocardiography findings (Figure C; arrow: absent PMVL; Video 3*; all midesophageal views; 87°). Color Doppler examination revealed mild mitral regurgitation in TEE examination (Figure D). Coronary arteries were near normal on angiography. Medical follow-up was decided upon. Congenital malformations of the posterior mitral leaflet are extremely rare and present with a wide spectrum. Hypoplasia of the posterior mitral valve leaflet has been reported, and a few cases of absent PMVL have been described. Absence of the PMVL is usually symptomatic, due to severe mitral regurgitation and coexisting abnormalities such as intracardiac shunt. The present patient was asymptomatic until late adulthood, and no other cardiac anomaly was present. Absent PMVL may be more prevalent in asymptomatic adults than is known. 275