Derviş Oral

Assessment of left ventricular diastolic function with Doppler tissue imaging: Effects of preload and place of measurements

Mitral inflow velocities are widely used for the evaluation of left ventricular (LV) diastolic function. However, they are closely affected by other factors such as preload. The purpose of this study was to evaluate the usefulness of tissue Doppler velocities obtained from the mitral annulus for the evaluation of ventricular relaxation in patients under different loading conditions. We also evaluated the effect of preload at different sides on the mitral annulus. The study population consisted of 62 consecutive patients (38 male, 24 female with a mean age of 42 ± 13 years) who have undergone hemodialysis. Both mitral inflow velocities (E wave, A wave, E wave deceleration time and isovolumetric relaxation time) and mitral annulus tissue Doppler velocities (E′, A′) from the septal, lateral, anterior, posterolateral and inferior sides of the mitral annulus were measured immediately before and after hemodialysis. Mitral inflow E and A wave velocities and E/A ratio decreased significantly (p < 0.001, p = 0.007, p < 0.001, respectively) after hemodialysis. Mitral annulus E′ wave velocities and E′/A′ ratios obtained from five different sides of the annulus also changed significantly (p < 0.001 for all); however, there was no change in the A′ wave velocity (p > 0.05 for all) after hemodialysis. The decrease in E wave and E/A ratio in mitral inflow measurements and E′ velocities and E′/A′ ratios in tissue Doppler measurements were correlated with the amount of fluid extracted (for mitral inflow E wave, r = 0.392, p = 0.002 and E/A ratio, r = 0.280 and p = 0.027; for lateral side E′, r = 0.329, p = 0.009 and E′/A′ ratio, r = 0.286, p = 0.04; for septal side E′, r = 0.376, p = 0.003 and E′/A′ ratio, r = 0.297, p = 0.019; for anterior side E′, r = 0.342, p = 0.007 and E′/A′ ratio, r = 0.268, p = 0.035; for posterolateral side E′, r = 0.423, p = 0.001 and E′/A′ ratio, r = 0.343, p = 0.007; and for inferior side E′, r = 0.326, p = 0.01 and E′/A′ ratio, r = 0.278, p = 0.029). We conclude that mitral annular velocities obtained by tissue Doppler are preload dependent parameters for the evaluation of LV diastolic function.

Elevated Whole-Blood Tissue Factor Procoagulant Activity as a Marker of Restenosis After Percutaneous Transluminal Coronary Angioplasty and Stent Implantation

Background—Experimental data suggest that tissue factor (TF) may induce neointimal hyperplasia after arterial injury. In this study, we investigated the hypothesis that elevated levels of TF in the circulation contribute to the development of restenosis after percutaneous transluminal coronary angioplasty (PTCA) or stent implantation. Methods and Results—Whole-blood TF procoagulant activity (TF-PCA) was measured using a previously described assay before, at 3 hours after, and at 24 hours after the intervention in 61 patients with stable angina undergoing PTCA (n=20) or stent implantation (n=41). Coronary angiography was performed 4 to 6 months after the intervention, and luminal narrowing ≥50% was defined as restenosis. Whole-blood TF-PCA levels did not correlate with intracellular monocyte tumor necrosis factor-&agr; expression, a marker of activation of these cells. Baseline levels and time course of whole-blood TF-PCA after the intervention were compared in patients who did or did not subsequently develop restenosis. Whole-blood TF-PCA levels did not change significantly in the 24 hours after either intervention. However, in both the PTCA and stent groups, initial TF-PCA was significantly higher in patients who subsequently developed restenosis (P =0.018 and 0.039 compared with those who did not develop restenosis for PTCA and stent groups, respectively). Conclusions—Higher baseline values of whole-blood TF-PCA may be a predictor of restenosis after PTCA and stent implantation.

Exercise-induced myocardial ischemia in patients with coronary artery ectasia without obstructive coronary artery disease

BACKGROUND Aetiology, clinical significance and treatment options for coronary artery ectasia/aneurysm is not clear. OBJECTIVE We sought to determine whether exercise can induce coronary ischemia in patients with coronary artery ectasia/aneurysm without significant coronary stenosis. METHODS Coronary artery ectasia was defined as 1.5-2-fold, aneurysm as >2-fold luminal dilatation of the adjacent normal segment. The study patients could have irregularities with ectatic coronaries but they did not have stenotic lesions >50% with visual assessment of two blinded observers. Patients having coronary artery ectasia or aneurysm with prior myocardial infarction, dilated cardiomyopathy, valvular heart disease, bundle branch block, significant ST-T changes were excluded. The control group was formed from a well matched population of 32 patients with normal coronary arteries who have not performed a treadmill test before coronary angiography. The study group underwent a symptom limited treadmill test if they did not have one before coronary angiogram, all control patients underwent treadmill test. RESULTS Thirty-three patients with coronary artery ectasia/aneurysm (ranging from one to three vessels) but without significant stenosis were derived from 4470 cardiac catheterization procedures between January 1998 and July 2000. In the study group, 17 of the patients had positive treadmill tests with respect to five patients in the control group (P = 0.004). In subgroup analysis, diffuse ectasia/aneurysm (involving 2-3 vessels) was found to be strongly related with ischemia (P = 0.005) with respect to local disease. CONCLUSION Coronary artery ectasia/aneurysm may lead to exercise induced ischemia, especially in the diffuse form.

Echocardiographic evaluation of left ventricular diastolic function in chronic cor pulmonale

In this study we hoped to understand the abnormalities of left ventricular filling dynamics in chronic cor pulmonale. Our findings showed a severe left ventricular diastolic impairment, directly related to a progressive increase in pulmonary hypertension itself, as expressed by correlation analysis between systolic pulmonary artery pressure and the following parameters: transmitral flow velocity in early/late diastole ratio (r = -0.69, p <0.001), isovolumic relaxation time (r = 0.54, p = 0.001), and transmitral flow velocity in early diastole (r = -0.59, p <0.01).

Effect of losartan on circulating Tnfα levels and left ventricular systolic performance in patients with heart failure

Background Tumor necrosis factor alpha (TNFα) plays an important role in the pathophysiology of heart failure. Recent studies have shown a beneficial effect of losartan in these patients. However, the effect of losartan on TNFα levels in heart failure has not yet been studied. We evaluated the effect of losartan on circulating TNFα levels and ejection fraction (EF) in patients with congestive heart failure. Methods Forty patients with heart failure and EF ≤ 40% were enrolled into the study. All of the patients have been given diuretic and digitalis therapy. Twenty patients were given losartan (50 mg/d) (Group I, 10 women, 10 men, 12 dilated cardiomyopathy, 8 ischemic heart disease, mean age 64.9 ± 8.9), and another 20 patients were not given losartan because of hypotension or renal dysfunction (Group II, 13 men, 7 women, 10 dilated cardiomyopathy, 10 ischemic heart disease, mean age 61.2 ±10.5). EF was measured at the initial evaluation and on the fifteenth day of the therapy by echocardiographic examination using an acoustic quantification method. Circulating TNFα levels were also measured at the initial evaluation and on the fifteenth day of therapy by the ELISA method. Results Losartan significantly increased EF and decreased TNFα (EF increased from 29.4 ± 7.3% to 36.0 ± 8.5%, P < 0.001, and TNFα decreased from 39.2 ± 37.4 pg/ml to 27.0 ± 30.0 pg/ml, P < 0.05). Changes in TNFα levels and EF were not found to be correlated (r=−0.28, P=0.24). However, in the control group, EF and TNFα levels were similar at baseline and at the fifteenth day (EF 31.4 ± 8.1% vs 31.7 ± 7.8%, P=0.1, and TNFα 91.5 ± 86.0 pg/ml vs 110.0 ± 80.7 pg/ml, P=0.1, respectively). Conclusions Losartan improves left ventricular systolic function and decreases TNFα level. The decreased TNFα level seems to be independent of EF.

Restenosis after Transluminal Coronary Angioplasty: A Risk Factor Analysis

Background: Restenosis after percutaneous transluminal coronary angioplasty (PTCA) is a major problem limiting the long-term efficacy of the procedure. The purpose of this study was to determine whether risk factors such as cigarette smoking, diabetes mellitus, hypertension or hypercholesterolaemia correlate with restenosis after PTCA. We also studied the relationship between a history of previous myocardial infarction and the extent of coronary artery disease (single-, two- or three-vessel) with restenosis after coronary angioplasty. Methods: A total of 360 patients underwent successful PTCA. Follow-up coronary angiograms were performed in 181 patients after a mean ± SD period of 6 ± 4 months. Results: The restenosis rate was 49%. We divided the patients into two groups: 89 patients with restenosis (8 women and 81 men) and 92 patients with no restenosis (14 women and 78 men). Age, sex, a history of cigarette smoking, diabetes mellitus and a history of previous myocardial infarction were not associated with restenosis. Serum levels of triglyceride were also unrelated to the restenosis rate. Restenosis was associated with hypertension, low levels of high-density-lipoprotein cholesterol, high levels of low-density-lipoprotein cholesterol and high total cholesterol levels (P < 0.001). Patients with two-vessel or multivessel disease had significantly higher restenosis rates than patients with single-vessel disease (P < 0.001). Conclusion: Patients with hyperlipidaemia, hypertension and multi-vessel disease appear to be at higher risk of recurrent restnosis.

The effects of L-carnitine treatment on left ventricular function and erythrocyte superoxide dismutase activity in patients with ischemic cardiomyopathy

We studied the effects of l‐carnitine on left ventricular systolic function and the erythrocyte superoxide dismutase activity in 51 patients with ischemic cardiomyopathy. They all previously were under the treatment of angiotensin‐converting enzyme inhibitor, digitalis and diuretics. Patients were randomized into two groups. In group I (n = 31), 2 g/day l‐carnitine was added to therapy. l‐Carnitine was not given to the other 20 patients (Group II). In group I (mean age 64.3 ± 7.8 years), 27 of the patients were men, and four were women. In group II (mean age 66.2 ± 8.7 years), 17 of the patients were men, and three were women. Twenty age‐matched healthy subjects (mean age: 60.1 ± 5.3 years) constituted the control group. In each group, left ventricular ejection fraction (LVEF) by echocardiography and red cell superoxide dismutase activity by spectrophotometric method were measured initially and after 1 month of randomisation. Compared with normal healthy subjects (n = 20), patients (n = 51) had significantly higher red cell SOD activity (5633 ± 1225 vs. 3202 ± 373 U/g Hb, P < 0.001). At the end of 1 month of l‐carnitine therapy, red cell SOD activity showed an increase in group I (5918 ± 1448 to 7218 ± 1917 U/g Hb, P < 0.05). In group II, red cell SOD activity showed no significant change after 1 month of randomisation (5190 ± 545 to 5234 ± 487 U/g Hb, P = 0.256). One month after randomisation there was a significant increase in LVEF in both groups I and II (37.8–42.3%, P < 0.001 in group I; 41.5–43.8%, P < 0.001 in group II). The improvement in LVEF was more significant in the l‐carnitine group (4.5% vs. 2.3%, P < 0.01). We conclude that, as a sign of increased free radical production, superoxide dismutase activity was further increased in patients with l‐carnitine treatment. l‐Carnitine treatment in combination with other traditional pharmacological therapy might have an additive effect for the improvement of left ventricular function in ischemic cardiomyopathy.

A Recurrent Right Heart Thrombus in a Patient with Behçet's Disease

We report the case of a patient who was admitted to the immunology unit of our medical facility. The patient had a history of recurrent oral ulcers, low‐grade fever, weight loss, and fatigue. Echocardiographic examination revealed a right ventricular mass that was initially thought to be a myxoma in an unusual location, and the patient was sent to surgery. Surgery revealed the mass to be a thrombus. After 5 months of anticoagulation therapy, the patient was readmitted to our institution with the same complaints, and a right atrial thrombus was found on echocardiographic examination. After a careful reevaluation of the patients history and episodes of recurrent oral and genital ulcers, as well as the papulopustular lesions found on his first admission to hospital, Behçets disease was diagnosed. The patient received thrombolytic therapy with a regression of thrombus, and continued with immunosuppressive and anticoagulation therapy. Five months later, echocardiographic examination showed complete disappearance of thrombus.

Coronary Artery Aneurysms Report of Two Cases and Review of the Literature

Two patients who had angiographically proven coronary artery aneurysms are presented. The clinical pictures of these patients were similar to that of patients with atherosclerotic coronary artery disease. Both had severe angina pectoris, and the second patient (case 2) had had myocardial infarction. Their coronary artery aneurysms were single, fusiform (case 1) and saccular (case 2) in shape and not associated with extensive coronary atherosclerosis. They were treated medically and did well.

Hyperhomocysteinemia and Restenosis

Objective This study was undertaken to assess the effect of plasma homocysteine level on angiographic restenosis 6 months after coronary angioplasty. Methods The plasma homocysteine level was measured in 100 consecutive patients at the time of coronary angioplasty, 56 patients who attended a 6-month follow-up angiogram being enrolled to the study; the 44 patients without a control coronary angiogram were not enrolled. Patients with and without angiographic restenosis were designated as groups A (n = 34) and B (n = 22) respectively. Results The baseline demographic (groups A and B), angiographic (groups A and B) and procedural characteristics were similar in both groups. The mean plasma homocysteine level (SD) was 15.2 (7.7) and 11.1 (2.5) μmol/l in groups A and B respectively (P = 0.007; 95% CI −6.9 to −1.1). With respect to the plasma homocysteine level, the upper and the lower thirds were compared by binary logistic regression (the lower third homocysteine level being < 10.6 μmol/l and the upper third homocysteine level > 14.1 μmol/l). The angiographic restenosis rate for the lower and upper tertiles was 47.4% and 89.5% respectively (P = 0.01; OR = 9.4; 95% CI 1.6−52.7). After adjustment for age and sex, the statistical significance did not change (P = 0.013; OR = 9.43; 95% CI 1.6-54.9). Even after adjustment for age, sex, smoking, hypertension, hypercholesterolemia, and diabetes mellitus, there was a statistically significant difference between the upper and lower tertiles (P = 0.008; OR = 41.3; 95% CI 2.6-635). Conclusion Increased plasma homocysteine level and diabetes mellitus were independent risk factors for angiographic restenosis after percutaneous transluminal coronary angioplasty and coronary stenting.