Ekrem Guler

Tenting area reflects disease severity and prognosis in patients with non-ischaemic dilated cardiomyopathy and functional mitral regurgitation.

To define which echocardiographic parameters are related to the degree of functional mitral regurgitation (FMR) and to establish their relationship with clinical status, plasma B‐type natriuretic peptide (BNP) levels, and prognosis in patients with non‐ischaemic dilated cardiomyopathy (NICMP).

Effect of Pulmonary Vein Anatomy and Pulmonary Vein Diameters on Outcome of Cryoballoon Catheter Ablation for Atrial Fibrillation

In this study, we aimed to determine pulmonary vein (PV) variation patterns in patients undergoing cryoballoon ablation for atrial fibrillation (AF) and their impacts on procedural success and recurrence and also to identify predictors for recurrence.

SYNTAX score predicts postoperative atrial fibrillation in patients undergoing on-pump isolated coronary artery bypass grafting surgery.

Objective: Atrial fibrillation (AF) is the most common arrhythmia following coronary artery by-pass graft surgery (CABG). The value of SYNTAX score to predict postoperative atrial fibrillation (PoAF) has not been clearly addressed. We aimed to evaluate this relationship in patients undergoing isolated CABG. Methods: This study was designed as a single-center, non-randomized, observational, prospective study. Ninety-four patients undergoing isolated on-pump CABG, who had sinus rhythm and were older than 18 years, were enrolled. Demographic characteristics of the patients were recorded; SYNTAX score was calculated preoperatively for each patient. The univariate and multivariate logistic regression analysis were used to determine for predictors of PoAF. Results: The median SYNTAX score of the enrolled patients was 21, (56–5). PoAF was observed in 31 (33.3%) patients. Univariate logistic regression showed that age, chronic obstructive pulmonary disease (COPD), red blood cell distribution width (RDW), urea, initial troponin I, peak postoperative troponin I, interventricular septum, left atrial diameter, and SYNTAX score were significantly associated with the frequency of PoAF following CABG. An independent association was identified with age [b 0.088, p:0.023, OR: 1.092, 95% CI (1.012–1.179)], COPD [(b: 2.222, p:0.003, OR: 9.228, 95% CI (2.150–39.602)], and SYNTAX score [(b: 0.130, p:0.002, OR: 1.139, 95% CI (1.050–1.235)]. Conclusion: This study showed that a higher SYNTAX score was related to more frequent PoAF in patients undergoing isolated on-pump CABG.

A review of the fixed dose use of new oral anticoagulants in obese patients: Is it really enough?

Obesity is a significant cause of morbidity and mortality, and it is becoming increasingly prevalent worldwide. Altered pharmacodynamics and pharmacokinetics of drugs in obese patients require dose adjustment according to body weight. New oral anticoagulants (NOACs), which are more frequently used for anticoagulation, are recommended to be used at a fixed dose based on data derived from phase 2 and 3 studies. However, the representation of obese patients [>100 kg or a body mass index (BMI) of >30 kg/m2] in subgroups with a small sample size and reports of various emboli cases under drug treatment have raised suspicions about the adequacy of fixed dose use. To address this issue, we analyzed several patients with a body weight of >100 kg or BMI of >30 kg/m2 participating in NOAC studies and evaluated whether these numbers were sufficient to enable an accurate recommendation of fixed dose use in obese patients.

Warfarin-induced skin necrosis: a ‘novel’ solution to an old problem

We present two cases of skin necrosis occurring after initiation of warfarin therapy, both of which were safely treated with novel oral anti-coagulants (NOACs). The first case is a 52-year-old male, seen after a transient ischemic event. He had non-valvular atrial fibrillation with a high CHA2DS2-VASc score. The patient was started on warfarin to prevent recurrent ischemic events. On the 3rd day of therapy, the patient developed newonset painful skin lesions in both legs (Figure A). A dermatology consult and skin biopsy revealed non-inflammatory thrombosis with focal necrosis. Warfarin therapy was discontinued and the patient was started on dabigatran 150 mg twice daily. Skin lesions were followed conservatively and seen to disappear in a few days, without any recurrence under dabigatran therapy. A search for genetic mutations in the patient revealed no deficiency of protein C and S. The second case involved a 64-year-old male with acute deep venous thrombosis (DVT). This patient was started on warfarin. In the second week of follow-up, the patient admitted with purpuric and painful lesions in his hands (Figure B) with appropriate INR level. A skin biopsy proved that the lesions were suggestive of warfarin-induced skin necrosis. After termination of warfarin, the patient was started on rivaroxaban 15 mg twice daily for 3 weeks, followed by 20 mg once daily as required. A search for genetic deficiencies of protein C and S revealed no mutations. The lesions diminished with discontinuation of warfarin and did not require debridement. We report two cases of warfarin-associated skin necrosis emphasizing that novel anti-coagulants can be safely used in this relatively rare but serious clinical situation. However, no such complications would have been encountered if NOACs were used as the ‘first choice’ drugs, instead of the ‘old habit’ of preferring warfarin. 787

Factor XIII Val34Leu polymorphism in patients with cardiac syndrome X

BACKGROUND The aim of the study was to examine the frequency of factor XIII polymorphism among patients with cardiac syndrome X (CSX). METHODS This study was designed as a cross-sectional and observational study. Forty-eight female patients with CSX and 36 controls matched by age, gender, diabetes, and hypertension were studied. CSX was defined as typical chest pain during rest or effort, abnormal test result for exercise ECG, and presence of angiographically normal epicardial coronary arteries after ruling out inducible spasm. Factor XIII gene polymorphism was investigated by using CVD Strip Assay (ViennaLab Diagnostic GmbH) commercial kit. RESULTS The frequency of factor XIII (Val/Leu + Leu/Leu) mutation was significantly higher in patients with CSX (43%) than in controls (19%) (p = 0.02). Frequency of the Leu allele was significantly higher in the patient group (23.5% vs. 11.1%, p = 0.04). Factor XIII (Val/Leu + Leu/Leu) mutation (p = 0.01, OR = 3.42; 95% CI 1.22-9.58) and smoking (p = 0.04, OR = 3.33, 95% CI 1.05-10.58) were identified as independent predictors of the disease in multivariate regression analysis. CONCLUSIONS This study indicates that there is an evidence for association between factor XIII Val34Leu polymorphism and CSX.

Hemopericardium and Cardiac Tamponade in a Patient Treated with Dabigatran Etexilate.

Dabigatran etexilate is one of the new oral anticoagulants approved to reduce the risk of stroke in patients with atrial fibrillation (AF). A variety of bleeding complications with dabigatran have been reported, but reports of hemopericardium are rare. We described a case of a 66 year-old female patient with non-valvular AF receiving dabigatran etexilate 150 mg twice daily for one year who suffered from hemopericardium. Her laboratory tests performed 1 year prior were normal and her admission tests revealed acute renal failure and elevated international normalized ratio (INR) level (4.79). Urgent pericardiocentesis was followed by improved renal functions and normalized INR. Dabigatran etexilate is a new oral anticoagulant that is increasingly used in daily practice. However, life-threatening complications warrant caution. Elevated INR may be related with overdose but the association of bleeding risk of dabigatran and INR requires further confirmation.

Relationship between serum osteopontin level and atrial fibrillation recurrence in patients undergoing cryoballoon catheter ablation

OBJECTIVE Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with increased morbidity and mortality. Atrial fibrosis augments recurrence rate following AF catheter ablation. Osteopontin is a multifunctional molecule involved in several pathophysiological pathways, including fibrosis. Presently described is investigation of relationship between serum osteopontin level and AF recurrence after AF cryoablation. METHODS The study was designed to be prospective and observational; 60 patients with paroxysmal (n=47) and persistent (n=13) AF were included. Osteopontin level was measured both before and 6 months after AF ablation with cryoballoon. RESULTS Preprocedure and postprocedure osteopontin level did not differ between the 2 groups of AF patients (p=0.286, p=0.493, respectively). Postprocedure osteopontin level was significantly higher compared with preprocedure value (32.18 ng/mL vs 15.58 ng/mL; p=<0.001). Left atrial diameter, AF type, and preprocedure osteopontin level were related to AF recurrence (p≤0.05). An age-adjusted multivariate logistic regression analysis was conducted to determine independent predictors of AF recurrence. Among these, AF type (ß=2.211; p=0.004; odds ratio [OR]: 9.124; 95% confidence interval [CI]: 2.026-41.094) was found to be the most important factor related to AF recurrence. Preprocedure osteopontin level also predicted AF recurrence independently (ß=0.059; p=0.048; OR: 1.061; 95% CI 1.001-1.125). CONCLUSION Study results revealed persistency of AF and high preprocedure osteopontin level independently predicted AF recurrence in patients undergoing cryoballoon AF ablation. Association of a biochemical marker with AF recurrence might be beneficial to selection of appropriate patients for cryoballoon procedure and assessment of long-term procedural success.

Assessment of 25-OH vitamin D levels and abnormal blood pressure response in female patients with cardiac syndrome X

Objective: Vitamin D deficiency is associated with coronary artery disease, hypertension, heart failure, endothelial dysfunction, and metabolic syndrome. The pathophysiology of cardiac syndrome X (CSX) involves many pathways that are influenced by vitamin D levels. This study aimed to investigate the relationship between vitamin D deficiency and abnormal blood pressure response to exercise in patients with CSX. Methods: This was a cross-sectional and observational study. Fifty females with normal epicardial coronary arteries who presented with typical symptoms of rest or effort angina and 41 healthy age-matched female controls, were included. Patients with cardiomyopathy, severe valvular disease, congenital heart disease, and left ventricular hypertrophy were excluded. All patients underwent stress electrocardiography examination and 25-hydroxy (OH) vitamin D level measurements. Results: Levels of 25-OH vitamin D were significantly lower in CSX patients (9.8±7.3 ng/mL vs. 18.1±7.9 ng/mL; p<0.001). Systolic blood pressure (SBP) (188±15 mm Hg vs. 179±17 mm Hg; p=0.013) and diastolic blood pressure (DBP) (98±9 mm Hg vs. 88±9 mm Hg; p<0.001) during peak exercise were higher in CSX patients. Levels of 25-OH vitamin D were negatively correlated with peak SBP (r=–0.310, p=0.004) and peak DBP (r=–0.535, p<0.001) during exercise. To discard the multicollinearity problem, two different models were used for multivariate analyses. In the first model, metabolic equivalents (METs) (p=0.003) and 25-OH vitamin D levels (p=0.001) were independent predictors. METs (p=0.007), 25-OH vitamin D levels (p=0.008), and peak DBP were determined as independent predictors in the second multivariate model. Conclusion: In patients with CSX, 25-OH vitamin D levels were lower than those in controls; moreover, 25-OH vitamin D deficiency was also associated with higher levels of peak DBP during exercise. (Anatol J Cardiol 2016; 16: 961-6)

Which one is Worse? Acute Myocarditis and Co-existing Non-compaction Cardiomyopathy in the Same Patient

Non-compaction cardiomyopathy is a relatively rare cardiac condition known to be found in 0.12 per 100,000 cases characterized by increased trabeculations in the ventricular wall due to embryologic malformation predisposing malignant ventricular arrhythmias [1,2]. Although acute postviral myocarditis has been well-documented in the medical literature, co-existence of these two clinical entities is extremely uncommon [3–5]. A 21-year-old male without any previous cardiac history presented with retrosternal chest pain and dyspnea lasting for three days. He was having a flu-like syndrome during the last week with symptoms of sore throat and myalgia. ECG showed diffuse ST elevations without any reciprocal changes [Table/Fig-1a]. Laboratory analysis showed marked increase in white blood cells with lymphocyte dominance. Both C-reactive protein, Troponin-I and N-terminal pro BNP levels were significantly increased. Transthoracic echocardiography (TTE) showed hypokinesis of the apical and postero-lateral walls with an ejection fraction of 42%. Prominent apical trabeculations were noted along with marked spontaneous echo-contrast in the left ventricular cavity [Table/Fig-1b] [Video 1]. Colour Doppler analysis demonstrated the entrance of blood flow between these trabeculations [Table/Fig-1c] [Video 2]. Although clinical history was compatible with acute myocarditis with a fulminant course, non-compaction cardiomyopathy was also suspected as a differential diagnosis. Cardiac magnetic resonance imaging (MRI) with contrast study was performed in order to further explore the pathology. Diffuse hypokinesis of the dilated ventricle along with marked trabeculations especially on the apico-anterior wall strengthened the diagnosis of non-compaction cardiomyopathy [Table/Fig-1d,​,1e]1e] [Video 3,4]. However, there was also strong evidence for acute myocarditis shown by diffuse edema in T2A sequences as well as late contrast enhancement in the subepicardial layer of the posterolateral and apical walls [Table/Fig-1f]. Myocarditis was treated conservatively. Symptoms and laboratory findings diminished in a few days with ongoing systolic dysfunction. After discharge, the patient was referred for implantable cardioverter defibrillator (ICD) implantation to prevent sudden death for non-compaction cardiomyopathy. [Table/Fig-1a]: ECG on presentation showing diffuse ST elevations without any reciprocal changes [Table/Fig-1b]: TTE in apical two-chamber view showing marked trabeculations and spontaneous echo-contrast [Table/Fig-1c]: TTE with colour Doppler. Note the entrance of blood flow between the trabeculations [Table/Fig-1d]: Cardiac MRI, short-axis view demonstrating marked trabeculations (arrows) in the left ventricular cavity [Table/Fig-1e]: Cardiac MRI, long axis view represents the dilated left ventricle along with prominent trabeculations (arrows). [Table/Fig-1f]: Late contrast enhancement of the subepicardial layer of apical and lateral walls (arrows) compatible with myocarditis Despite the typical signs and symptoms supporting a diagnosis of myocarditis, clinicians should be alert for investigating additional causes of heart failure using comprehensive imaging modalities such as cardiac MRI. Present case demonstrates the laboratory, ECG and imaging features of such a patient that was initially treated conservatively for acute myocarditis and subsequently referred for ICD implantation for prevention sudden cardiac death.