Ekrem Bilal Karaayvaz

Serum omentin 1 level is associated with coronary artery disease and its severity in postmenopausal women.

We evaluated whether serum omentin levels are associated with coronary artery disease (CAD) and its severity among postmenopausal women. We enrolled 193 consecutive postmenopausal women who had undergone coronary angiography for suspected stable CAD. The study population was divided into 2 groups based on the results of coronary angiography (CAD group, n = 110 and control group, n = 83). Omentin 1 levels were measured and disease severity was assessed using the SYNTAX score (SS) in the CAD group. Those patients with angiographic CAD had significantly decreased omentin 1 levels, compared to those without CAD (247.5 + 127.4 vs 506 + 246 ng/mL, P < .001). After adjusting for cardiovascular risk factors, a decreased omentin 1 level was found to be an independent predictor of both angiographic CAD and a high SS. Our data indicate that a decreased omentin 1 level is associated with CAD and its severity among postmenopausal women.

Impact of vitamin D insufficiency on the epicardial coronary flow velocity and endothelial function.

ObjectiveIncreasing evidence suggests a relationship between vitamin D (VD) insufficiency and cardiovascular disease. The present study evaluated the effect of VD insufficiency on epicardial coronary flow rate, subclinical atherosclerosis, and endothelial function. MethodsThe present study was cross-sectional and observational. We enrolled 222 consecutive patients who had undergone coronary angiography for suspected ischemic heart disease and were found to have normal or near-normal coronary arteries. Thereafter, 25(OH)D3 levels were measured and the coronary flow rate was assessed using the thrombolysis in myocardial infarction frame count. Slow coronary flow (SCF) was defined as a thrombolysis in myocardial infarction frame count greater than 27/frame. Endothelial function was assessed by brachial artery flow-mediated dilatation. Carotid intima-media thickness, an indicator of subclinical atherosclerosis, was measured using B-mode ultrasonography. ResultsThe mean level of 25(OH)D3 was 31.8 ng/ml, and 47% (n=106) of the patients had insufficient 25(OH)D levels (<30 ng/ml). Baseline characteristics were similar between VD-insufficient and VD-sufficient groups. The incidence of SCF was significantly higher in the VD-insufficient group than in patients with sufficient VD (relative risk=3.5, 95% confidence interval=1.1–10.5, P=0.01). After adjusting for cardiovascular disease risk factors, VD insufficiency was independently associated with SCF. The linear regression analysis showed that VD insufficiency was correlated independently with % flow-mediated dilatation (&bgr;=0.424, P<0.001) and carotid intima-media thickness (&bgr;=0.43, P<0.001). ConclusionA strong association was found between VD insufficiency and the SCF phenomenon. In addition, VD insufficiency was associated with endothelial dysfunction and subclinical atherosclerosis. We believe that further studies are required to clarify the role of VD in patients with SCF.

Fractional Exhaled Nitric Oxide Measurement in Pulmonary Hypertension: A Follow-Up Study

Pulmonary hypertension (PH) is a fatal disease although significant improvements in treatment are achieved. Easily implemented and noninvasive prognostic techniques are needed while following-up these patients. The aim was to investigate the role of fractional exhaled nitric oxide (FeNO) in follow-up for patients with PH. In this longitudinal study, patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH) who were seen in PH Outpatient Clinic, Istanbul Faculty of Medicine, Istanbul University, were enrolled in the study. Echocardiography, 6-minute walking test, brain natriuretic peptide, and FeNO measurements were performed, and World Health Organization functional class was evaluated to all patients at baseline, and third, and sixth months. Right-heart catheterization and pulmonary function tests at the time of diagnosis were recorded. The study comprised 31 patients (23 women, 8 men; mean age: 53.4 ± 17.1 years) with PAH (n = 19) and CTEPH (n = 12) and 80 healthy controls. Patients with PH had lower FeNO values than the control group (16.5 ppb vs 19.8 ppb; P < .05). Fractional exhaled nitric oxide values did not change during follow-up and did not correlate with other follow-up measures except tricuspid annular plane systolic excursion values. Fractional exhaled nitric oxide was higher in the idiopathic PAH subgroup at baseline and at third month than patients with PAH associated with other diseases. Fractional exhaled nitric oxide did not change in patients who had clinical deterioration. As a conclusion; Patients with PH had lower FeNO values than healthy controls, but FeNO did not change significantly during follow-up. Large-scale studies with prolonged follow-up periods are needed to understand the role of FeNO in the follow-up of the patients with PH.

TCTAP C-120 Management of a Type 3 Perforation of Ostial LAD When Surgery or Graft Stenting Is Not Available

### Patient Initials or Identifier Number YK ### Relevant Clinical History and Physical Exam A 77-year-old male patient had coronary angiography 10 years ago. There was no history of previous coronary intervention. He has recently complained of NYHA III and CCS III angina despite optimal medical

Postpacing Interval During Right Ventricular Overdrive Pacing to Discriminate Supraventricular from Ventricular tachycardia

Introduction Failure to differentiate supraventricular from ventricular arrhythmias is the most frequent cause of inappropriate implantable cardioverter-defibrillator (ICD) therapies. We hypothesized that the postpacing interval (PPI) after overdrive right ventricular pacing may differentiate ventricular (VT) from supraventricular tachycardia (SVT) such as sinus tachycardia, atrial flutter and atrial tachycardia. This hypothesis is based on the entrainment maneuver. Reentrant tachycardia circuit for VTs would haveshorter distance to RV apex than SVTs have, and the conduction time between a ventricular pacing site and the tachycardia origin is expected to be shorter in VTs than in SVTs. Methods 220episodes from 38 patients with single chamber ICDs that RV overdrive pacing could not terminate or change the tachycardia cycle length (TCL) were retrospectively reviewed. Episodes were classified as VTs (n=115) and SVTs (n=105). TCLs, PPIs and PPI-TCL were compared between groups. Results The cycle length of VTs was shorter than SVTs (320.6±30.3 vs 366.5±40 ms, p=0.001). PPI and PPI-TCL of VTs were shorter than SVTs (504.7±128.3 vs 689.2±121.8 ms, p=0.001, 184±103 vs 322.6±106.6 ms, p=0.001; respectively). ROC curve analysis demonstrated a 525 ms cut-off value for PPI has 89% sensitivity and 57.4% specificity to predict inappropriate ICD therapies due to SVTs (AUC:0.852). Similarly, A PPI-TCL <195 ms favored VT as a diagnosis rather than SVT with a 90% sensitivity, and 51% specificity (AUC:0.838). Conclusion Analyzing of PPI during overdrive pacing from RV apex may discriminate supraventricular from ventricular tachycardia. This criterion may have a potential role in implantable devices that use a single ventricular lead.

A rare cardiac manifestation of Wegener's granulomatosis.

The correct answer is C. The perioperative view and after excisional view of cardiac mass was shown in Figure 4-5. This is a case of myocarditis related to WG. As the ECGs and high level of cardiac markers with echocardiographic findings clearly showed us typical myocarditis case related to Wegener. ECGs indicate not only conduction abnormalities but also cardiac injury caused by myocarditis. And in the end, systolic dysfunction facilitate the development of cardiac thrombus. Spontan echo contrast described in text is also the precursor formation of cardiac thrombus. Transthoracic echocardiography displayed severe left ventricular systolic dysfunction with ejection fraction 25-30% and very large cardiac thrombus (4x4 cm) in the left ventricule apex (Video 1-2). One of treatment choice in such a cardiac thrombus is thrombectomy by surgery but there is a myocarditis process and patient is still on therapy for active inflammation. Timing of surgery is very important because of mortality on going myocarditis process. And another choice described in most of the cardiac thrombus cases is thrombolytic therapy (1). But this is a left ventricule cardiac thrombus and there is a risk of embolization. We opted for a treatment based on intravenous heparin dose adjustment by aPTT, intravenous furosemide, spiranolactone, carvedilol, ramipril and prednisolone. Two weeks later, thrombus size has mildy decreased (3 x 3 cm) and thrombus was more mobile (Video 3-4). Because of the risk of embolism, he underwent LV thrombectomy. Postoperative pathologic examination of a specimen revealed an organizing thrombus (Fig. 4-5). Postoperative course was uncomplicated, and warfarin therapy was started. Postoperative transthoracic echocardiography revealed mild left ventricular systolic dysfunction with EF 40-45%. There was no thrombus in LV. The patient was referred to rheomatologist for further treatment. Other choices are incorrect because a mass that rapidly occurs in the heart can be only thrombus. Granuloma and sarcoma are slow growing masses relatively to cardiac thrombus. Wegener’s granulomatosis (WG) is a rare form of vasculitis of the smalland medium sized blood vessels affecting mainly the upper and lower respiratory tracts as well as the kidneys (2). The clinical signs and symptoms can be various forms including upper airway disease such as epistaxis, chronic sinusitis. In the lower respiratory tract, nodules, infiltrates, cavitary lesions and pulmonary hemorrhage presenting as hemoptysis are the signs of this vasculitis. WG can also involve the renal microvasculature in up to 75% of cases in the form of rapidly progressive glomerulonephritis and renal failure. Cardiac involvement in WG is not common manifestation, approximately 6-44% of cases having some degree of heart disease (3, 4). Pericarditis and coronary vasculitis are the most common findings (50% of cases), but myocarditis, endocarditis and conduction system defects are also described (5). Cardiac muscle involvement due to WG was noted to occur in 2%< one series of 158 patients (6). The overall mortality rate of WG with cardiac involvement has been reported to be between 15-45% (7). We present a case of WG in which the diagnosis of cardiac involvement was made with echocardiographic imaging modalities. Severe left ventricular systolic dysfunction with giant cardiac thrombus has not been reported previously in any WG patients. We believe that extreme intensity of inflammatory process of WG in our patient resulted in this rare manifestation. Routine cardiovascular surveillance including echocardiography and electrocardiograms are important for the screening and monitoring of the patients with WG.