Emrah Acar

Association between the Gensini Score and Carotid Artery Stenosis

Background and Objectives The aim of this study was to evaluate the association between the extent of coronary artery disease assessed by the Gensini score and/or the SYNTAX score and the significant carotid stenosis in patients undergoing coronary artery bypass grafting (CABG). Subjects and Methods A total of 225 patients who had carotid doppler ultrasonography prior to CABG were included retrospectively. Significant coronary artery disease was assumed as a lumen diameter stenosis of ≥50% in any of the major epicardial coronary arteries. The severity of carotid stenosis was determined by B-mode and duplex ultrasonography. Clinically significant carotid stenosis was defined as peak systolic velocity greater than 125 cm/s. Results The mean value of SYNTAX score and Gensini score was highest in patients allocated to significant carotid stenosis (22.98±7.32, p<0.001 and 77.40±32.35, p<0.001, respectively). The other risk factors for significant carotid stenosis were found to be male gender (p=0.029), carotid bruit (p<0.001), diabetes (p=0.021), left main disease (p=0.002), 3-vessel disease (p=0.008), chronic total coronary occlusion (p=0.001), and coronary artery calcification (p=0.001) in univariate analysis. However, only the Gensini score (odds ratio[OR]=1.030, p=0.004), carotid bruit (OR=0.068, p<0.001), and male gender (OR=0.190, p=0.003) were the independent predictors. The Gensini score cut off value predicting significant carotid stenosis was 50.5 with 77% sensitivity (p<0.001). Conclusion The Gensini score may be used to identify patients at high risk for significant carotid stenosis prior to CABG.

Case images: Treatment of huge saphenous aneurysms with covered graft stents.

A 73-year-old man who had undergone 3-vessel coronary artery bypass grafting 22 years prior was admitted with accelerated angina pectoris. The patient underwent coronary angiography, the findings of which were as follows: 50% stenosis in the proximal and mid-left anterior descending arteries, 100% stenosis in the proximal circumflex artery, 50% stenosis in the right coronary artery, 100% stenosis in the left internal mammary artery-to-left anterior descending artery graft, 70% stenosis in the proximal and 99% stenosis in the midsaphenous vein graft (SVG)-to-obtuse marginal (OM) artery, and consecutive huge saphenous aneurysms in the SVG-to-diagonal artery. The culprit lesion was thought to be 99% stenosis in the mid-SVG-to-OM artery, due to severe narrowness. Therefore, 4.0 x 28mm and 3.5 x 16 mm-stents were implanted across the mid and proximal segments of the SVG-toOM artery, respectively. Following stent placement, the patient described clinical improvement of anginal symptoms. However, compared to angiography performed 1 year prior (Figure A), rapid and advanced enlargement in size of aneurysms was present in the mid segment of the SVG-to-diagonal artery, which had the potential to result in rupture and sudden cardiac death (Figure B). Because surgical correction would have been much too risky, percutaneous coronary intervention was planned. Cardiac computed tomography scan was performed to assess detailed anatomy of saphenous aneurysms (Figure D, E). Three overlapped covered stents, beginning from the distal of the distal aneurysm to the proximal of the proximal aneurysm (4.5 x 26 mm, 4.0 x 26 mm, and 3.5 x 26 mm) were placed using 8-F sheath. Finally, a 4.5 x 32-mm bare metal stent was implanted for the ostial and proximal stenosis of SVG-to-diagonal artery (Figure C). Post-procedure computed tomography angiography revealed no residual aneurysms (Figure F, G). However, the patient was admitted with late covered graft stent thrombosis 2 months after implantation. 276

Case images: Significant obstruction of right outflow tract caused by double-chambered right ventricle.

A 32-year-old woman was admitted to cardiology complaining of persistent dyspnea on exertion. Medical history was unremarkable. On physical examination, ejection systolic murmur at the right sternal border was notable. Transthoracic echocardiography (TTE) revealed normal left ventricular function, mildly dilated right ventricle (RV), moderate tricuspid regurgitation, and significant obstruction of the right outflow tract with a peak gradient of 53 mmHg (Figure A). Transesophageal echocardiography (TEE) showed turbulence in the proximal portion of the RV with a high-velocity jet in color Doppler analysis (Figure B, Video 1*), and subaortic perimembranous ventricular septal defect completely occluded by the septal leaflet of the tricus-pid valve without residual shunt (Figure C). Abnormal muscle bundle was also evident, separating the proximal from the distal infundibular chamber of the RV (Figure B, Video 1*). During surgery, the anomalous muscle bands were successfully resected. Recovery was unevent-ful, with no significant residual gradient across the RV on follow-up echocardiography. Double-chambered right ventricle is a rare congenital heart disorder. Usually, anomalous muscle bundles dissect the RV into 2 pressure compartments often associated with ventricular septal defect. Other frequently associated lesions include pulmonary valve stenosis and discrete subaortic stenosis. TTE is an important first-line diagnostic tool in cases of congenital heart disease, but may pro-vide limited visualization of double-chambered right ventricle in adults, due to the retrosternal position and asymmetrical shape of the RV. TEE is an excellent supplementary tool when used to assist delineation of RV abnormalities and determine concomitant cardiac anomaly. 274

An unusual presentation of acute pericarditis; a case of transient constrictive pericarditis / Akut perikarditin nadir bir basvuru sekli: gecici Bir konstriktif perikardit vakasi

Classic constrictive pericarditis (CP),a progressive and debilitating condition, is characterized by pericardial fibrosis,with or without calcification, which results in chronic refractory congestive heart failure and for which pericardiectomy is often required. Until relatively recently, the development of constrictive physiology was presumed to be irreversible. But transient constrictive pericarditis,which is rare but well known complication of self-limiting acute pericarditis,shares the same clinical features with the chronic form but resolves without surgical intervention.Most of them have resolved without any surgical interventions by administration of non-steroidal anti-inflammatory drugs (NSAID) or steroids. In this report, we present the case of a patient with transient constrictive pericarditis which subsided conservatively.

The bronchial obstruction as a complication of endovascular repair of aortic pseudoaneurysm in Behçet’s disease

Behçets disease (BD) is an autoimmune disorder affecting multiple organs. Aortic pseudoaneurysm is the most catastrophic lesion in BD. This lesion type is considered as a complicated and challenging pathology by surgeons because of the technical operative difficulties and frequent recurrence. So, the endovascular repair of inflammatory aortic pseudoaneurysm has been used as an alternative to open surgical repair. It is particularly important in patients who are high-risk surgical candidates because of comorbidities. In this report, we present a case and treatment of bronchial obstruction, which caused progressive dyspnea after endovascular repair of aortic rupture, in patient with known history of BD.

Case images: left atrial thrombi which occlude the pulmonary vein in a patient with mitral mechanical prosthesis valve: the role of computed tomography in imaging.

A 70-year-old female patient was admitted to our emergency department with symptoms of congestive heart failure (dyspnea, bilateral leg edema, tachypnea, palpitations,etc.). Her history showed that she had been operated on for rheumatic mitral valve disease, and had a 10year history of mechanical mitral valve replacement with a bileaflet prosthesis (St.Jude, No:27). Cardiovascular examination showed mildly muffled mitral mechanical valve sounds. Electrocardiography (ECG) revealed atrial fibrillation with a heart rate of 110 beats per minute. On lung auscultation, there were bilateral basal rales. Examination of other systems yielded normal findings. Laboratory findings were within normal range and her international normalized ratio was 2,6 adequate in therapeutic interval. After hospitalisation, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) showed moderately increased mitral mechanical valve gradients (a peak at 26 mmHg and a mean at 8 mmHg), a normal mitral valve area of about 2.8 cm2, non-restricted leaflet mobility, mild paravalvular leakage, and also dense spontaneous echocardiographic contrast in the left atrium and the left atrial appendage. The patient had a normal range ejection fraction of about 55%. TEE revealed an annular non-obstructive thrombus on the atrial side of the mitral mechanical valve, and two other thrombi. One of these was separate on the posterior atrial wall and measured 2.3 cm x 1.7 cm, the other was layered on the remaining anterior atrial wall and occluded the left upper pulmonary vein opening (Figure A-C). After heart rate control with intravenous administration of metoprolol, an ECG-gated 64 slice contrast enhanced computerized tomography (CT) was performed to evaluate the coronary artery, mitral mechanical valve and the left atrium, and this depicted the masses, suggestive of thrombus, involving the left atrium and occluding the left upper pulmonary vein connection to the heart (Figure D). There were no significant stenoses in the coronary arteries, and severe lung edema with remarkable deposition of transudates on the fissures and alveoli. Peripheral embolisation is the most common manifestation of left atrial thrombi. Obstruction due to left atrial thrombi is a rare event and when present is usually due to the obstruction of pulmonary veins, and is usually detected by TEE. In our case, CT helped to determine the extent of the thrombus in the left atrium and its relation with the other cardiac structures (valves, etc.). 317