Emine Bilen

Relation of left ventricular end-diastolic pressure and N-terminal pro-brain natriuretic peptide level with left atrial deformation parameters

AIMS It has been shown that speckle-tracking echocardiography (STE) is a feasible and reproducible method to assess left atrial (LA) function. The relationship between left ventricular end-diastolic pressure (LVEDP) and brain natriuretic peptide (BNP) with LA deformation parameters has not been studied comprehensively. Therefore, we propose to investigate the effects of invasively obtained LVEDP and BNP level on LA deformation parameters assessed by STE and to show the relationship between them. METHODS AND RESULTS The study population consisted of 62 patients who underwent cardiac catheterization. LVEDP was obtained with a fluid-filled catheter. All patients underwent standard two-dimensional echocardiography. In STE analysis for LA, the peak LA strain at the end of the ventricular systole (LAs-strain) and the LA strain with LA contraction (LAa-strain) were obtained. N-terminal pro-BNP (NT-pro-BNP) levels were measured. The univariate correlation analysis demonstrated that the LAs-strain and LAa-strain had good inverse correlation with LVEDP, and the LAs-strain and LAa-strain only had a moderate correlation with NT-pro-BNP. The area under the receiver-operating characteristic curve of the LAs-strain was 0.96 (0.86-0.99, P < 0.001), and for the LAa-strain, the area was 0.88 (0.74-0.96, P < 0.001) to predict increased LVEDP. A multiple regression analysis demonstrated that the LAs-strain, LAV(max), and LV ejection fraction were independent predictors of increased LVEDP among the covariates examined; however, the LAa-strain and LV mass index were not independent predictors. A borderline statistical significance was found for NT-pro-BNP. CONCLUSION LAs-strain more closely related with LVEDP and NT-pro-BNP level than LAa-strain. LAs-strain thus might be used clinically to predict increased LVEDP.

P-Wave Duration and Dispersion in Patients with Metabolic Syndrome

Background: Metabolic syndrome (MS) has been reported to be associated with an increased risk of atrial fibrillation (AF). The aim of this study was to investigate P‐wave dispersion (PWD) in patients with MS.

Severity of Mitral Stenosis and Left Ventricular Mechanics: A Speckle Tracking Study

Background: It has been shown that mitral stenosis (MS) impairs left ventricular (LV) systolic function; however, this issue has not been studied comprehensively. We aimed to evaluate the role of 2D strain in the assessment of subclinical LV systolic dysfunction in patients with MS. Methods: Seventy-two patients with isolated MS (mild, moderate and severe) and 31 healthy control subjects constituted the study population. 2D echocardiography images were obtained from LV apical 4-chamber (4C), long axis (LAX), and 2-chamber (2C) views. Peak longitudinal strain and strain rate (Sr) were obtained from 4C, LAX, and 2C views. Global strain and Sr were calculated by averaging the three apical views. Results: There were no significant differences in LV ejection fraction and LV systolic or diastolic dimensions between the groups. Patients with MS had significantly lower LV longitudinal strain and Sr measurements than the control group. In addition, there were no significant differences in MS subgroups with respect to LV strain and Sr measurements. Conclusion: We demonstrated that patients with MS had lower LV functions using 2D strain imaging, and this is independent of the hemodynamic severity of MS. In the detection of subclinical LV dysfunction in patients with MS, 2D strain imaging appears to be useful.

Improvement in renal functions with transcatheter aortic valve implantation

Background & Objectives In recent years, emerging transcatheter aortic valve implantation (TAVI) has become an alternative for surgery. However, with advanced age, several co-morbid factors together with contrast agent usage can cause deterioration in renal function and increase in the risk of acute kidney injury (AKI) with poor prognosis in patients with AKI. Therefore, many patients cannot benefit from this treatment. In this study, we aim to examine the effects of TAVI on renal functions. Methods and Results Seventy patients, mean age of 77.6 years, underwent TAVI between July 2011 and December 2012. Estimated glomerular filtration rate (eGFR) was calculated by using the Cockcroft and Gault Formula. Patients were monitored for 48 h for urine output. Stage 1 AKI, according to the VARC-2 AKIN system, developed in only five (7.1%) of the patients after the procedure. There was a statistically significant increase between the mean 1st month eGFRs before (68.2 vs. 61.0, P < 0.01) and after (68.2 vs. 63.6, P < 0.05) the TAVI in the cohort. After TAVI (48.5 mL/min, P < 0.01) and the 1st month (52.1 mL/min, P < 0.01), the eGFR of the 36 (51.4%) patients diagnosed with chronic kidney disease before the procedure showed a statistically significant increase in renal functions. The hospital mortality rate was higher in the group which developed AKI (P < 0.01). First month eGFR showed a more statistically significant increase than pre-TAVI eGFR (62.8 and 69.8, P < 0.05, respectively) in AKI developing patients and this difference - though statistically not significant - continued into the sixth month. Conclusions In this study, we showed that the treatment of aortic stenosis through TAVI allows improvement of renal functions, and that AKI rates will be lower with careful patient selection, proper pre-procedural hydration, and careful use of contrast agent.

Predictors and incidence of access site complications in transcatheter aortic valve implantation with the use of new delivery systems

Objectives: The aim of this single-center study was to assess the incidence and predictors of in-hospital access site complications related to transcatheter aortic valve implantation (TAVI) performed with new delivery systems in our hospital which has the largest case series in Turkey. Materials and method: We performed successful TAVI with the Edwards Sapien XT valve to 127 (46 male) patients via a transfemoral (121), trans-subclavian (5) and transapical (1) approach. Access site complications were defined according to the Valve Academic Research Consortium (VARC) end-point definitions. Results: Vascular complications occurred in 10.1% of patients. There was negative correlation between vascular complications and diameter of the common femoral artery (r = − 0.301, p=0.004), external iliac artery (r = − 0.327, p=0.004) and common iliac artery (r = − 0.324, p=0.004), but positive correlation between diabetes (r =0.240, p=0.008), sheath to femoral artery ratio (SFAR), sheath to external iliac artery ratio (SEIAR), procedure time, discharge time and the Society of Thoracic Surgeons (STS) score (respectively; r=0.339, 0.001, 0.527, 0.361, 0.289, p=0.003, 0.001, 0.001, 0.001, 0.002). The incidence of vascular complications was significantly higher in patients with diabetes and a high STS score. VARC bleeding complications occurred in 11.7 % of patients. The learning curve pointing out the importance of experience was significantly important in decreasing both bleeding and vascular complications. Conclusions: In this study, we demonstrated that major vascular complications related to TAVI decrease with the use of smaller delivery systems and experience and increase with high-risk scores (STS) and the presence of diabetes. In addition, VARC major vascular complications, observed mostly in patients with diabete mellitus (DM) and high STS scores, were associated with vascular diameters. These results further underline the importance of experience and a multidisciplinary team in patient selection and management for TAVI.

Acute coronary syndrome due to complete bare metal stent fracture in the right coronary artery

Stent fracture (SF) was suggested to be an unusual cause of restenosis after drug eluting-stent implantation. However, angiographically visible complete SF after bare metal stent (BMS) implantation is extremely rare. Here we report a case of SF of a BMS representing with acute coronary syndrome (ACS). To our knowledge, this is the first report of early fracture of a BMS in the right coronary artery, resulting in ACS.

Assessment of left atrial phasic functions in heart failure patients with preserved or low ejection fractions

OBJECTIVES We aimed to evaluate left atrial (LA) volumes and phasic functions in heart failure patients with preserved or low ejection fractions. STUDY DESIGN The study consisted of 59 patients (36 men, 23 women; mean age 63.8 years) with heart failure accompanied by low (n=26) or preserved (n=33) ejection fractions. Two-dimensional echocardiographic LA volumes (maximal, minimal and pre-contraction volumes) were obtained and LA phasic functions (reservoir, conduit, and pumping functions) were calculated. The findings were compared with those of age- and sex-matched 30 controls (20 men, 10 women; mean age 60.3 years) without heart failure. RESULTS All LA volumes were found to be significantly increased in both groups with heart failure compared with controls. Left atrial reservoir and pumping functions were significantly lower in patients with preserved ejection fraction than in those with low ejection fraction (p=0.02 and p=0.009, respectively). Left atrial conduit function was significantly lower in heart failure patients with low ejection fraction than in those with preserved ejection fraction (p=0.005). Compared with controls, heart failure patients with either low or preserved ejection fractions exhibited significantly decreased LA phasic functions (p<0.001). CONCLUSION Our results demonstrate that, compared to subjects without heart failure, all phasic LA functions are impaired in heart failure patients with either low or preserved ejection fraction. However, impairment in LA reservoir and pumping functions is more prominent in heart failure patients with preserved ejection fraction.

The relationship between atrial electromechanical delay and P-wave dispersion with the presence and severity of metabolic syndrome.

OBJECTIVES In this study, we aimed to investigate the association between the presence and severity of metabolic syndrome (MetS) with intra- and inter-atrial electromechanical delay (AEMD) and P-wave dispersion (PWD). STUDY DESIGN A total of 144 patients (72 MetS patients and 72 age- and sex-matched control subjects) were included in the study. Patients with MetS were classified into three groups based on the number of MetS criteria as follows: Group 1 (patients with three MetS criteria), Group 2 (patients with four MetS criteria) and Group 3 (patients with five MetS criteria). Intra- and inter-AEMD were measured from parameters of tissue Doppler imaging. PWD was calculated from the 12-lead electrocardiogram. RESULTS Both inter-AEMD (22.9±15 vs. 11.5±14, p<0.001) and intra-AEMD (23.6±12 vs. 8.3±19, p<0.001) were found to be significantly longer in patients with MetS than the control group. Similarly, PWD (49±25 vs. 36±24, p=0.001) were found to be significantly longer in the MetS patients than the controls. However, both inter-AEMD and intra-AEMD and P wave measurements were not found to be associated with the severity of MetS. While inter and intra-AEMD were better correlated with LV mass index and LA volume index, PWD correlated better with mitral inflow Doppler parameters. According to multivariate analyses, inter-AEMD, HDL-C, and systolic and diastolic blood pressure were found to be independent predictors, whereas E/A and LDL-C had borderline significance. For the intra-AEMD, systolic and diastolic blood pressure, body mass index and E/A were found to be independent predictors. CONCLUSION In patients with MetS, inter- and intra-AEMD, and P dispersion were found to be lengthened when compared with the controls. However, these parameters were not associated with the severity of MetS.

Comparison of Transthoracic and Transesophageal 2-Dimensional Speckle Tracking Echocardiography

OBJECTIVES Two-dimensional (2D) strain imaging has been established as a reliable and reproducible technique for the assessment of left and right ventricular function using transthoracic echocardiography (TTE). However, the reproducibility of transesophageal echocardiographic (TEE) 2D strain imaging and the agreement with TTE 2D strain imaging remains unclear. In the present study, the authors studied the reproducibility of TEE 2D strain imaging parameters. DESIGN A comparative, observational clinical study. SETTING The echocardiography laboratory of the tertiary referral center. PARTICIPANTS Healthy individuals with a suspected patent foramen ovale. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirty-four patients were included in the study. None of the patients had any structural cardiovascular disease. TTE and TEE images of the subjects were recorded and analyzed offline (EchoPAC 6.1; GE Vingmed Ultrasound AS, Horten, Norway). Longitudinal strain and strain rate measurements of the 4 chambers, the apical long axis, 2 chambers, and the right ventricle were obtained for each record of TTE and TEE. The mean age of the patients in this study was 36 ± 9.2 years. Bland-Altman analysis showed that there were generally good agreements between strain and strain rate measurements on TEE and TTE. The inter- and intraobserver agreement for TEE parameters was good. CONCLUSIONS Transesophageal 2D strain imaging is a reproducible method to measure ventricular function and has a good agreement with TTE 2D strain imaging.

Assessment of the relationship between aortic stiffness and left ventricular functions with echocardiography in patients with Sjögren's syndrome.

Capable of multi‐organ involvement in Sjogrens syndrome (SS), cardiac findings of pulmonary effusion, left ventricular diastolic dysfunction and pulmonary hypertension are seen in patients with SS. Aortic stiffness (AS) reflects the mechanical tension and elasticity of the aorta. In this study, our aim is to determine if there is any differences in AS and left ventricular function between patients diagnosed as SS and healthy control groups.