Emrah Ermis

Sarcoidosis and the heart: A review of the literature.

Sarcoidosis is a chronic multisystem disorder without any defined etiology. Cardiac sarcoidosis (CS) is detected in 2-7% of patients with sarcoidosis and more than 20% of the cases of sarcoidosis are clinically silent. Cardiac involvement in systemic sarcoidosis (SS) and isolated cardiac sarcoidosis (iCS) are associated with arrhythmia and severe heart failure (HF) and have a poor prognosis. Early diagnosis of CS and prompt initiation of corticosteroid therapy with or without other immunosuppressants is crucial. Electrocardiography, Holter monitoring, and Doppler echocardiography with speckle tracking imaging can serve as the initial steps to diagnosis of CS. Cardiac magnetic resonance (CMR) imaging and positron emission tomography (PET) are promising techniques for both diagnosis and follow-up of CS. This review discusses the main aspects of cardiac involvement in sarcoidosis.

Left ventricular mechanics in Behcet’s disease: A speckle tracking echocardiographic study

Although cardiac involvement is rarely seen in Behcets disease (BD), it is essential to detect subclinical left ventricular (LV) dysfunction for prognostic purposes. Herein we aimed to show the role of two dimensional (2D) speckle tracking echocardiography (STE) in determination of subclinical LV dysfunction in patients with BD. 30 patients diagnosed as BD due to International Study Group Behcets diagnostic criteria and 25 control subjects underwent Doppler echocardiography including pulsed tissue Doppler of the mitral annulus and speckle-tracking echocardiography. LV peak longitudinal strain and strain rate (SR) was calculated in four-chamber (4C), apical long-axis (LAX), and two-chamber (2C) views, and values of the three views were averaged LV global longitudinal strain (LV-GLS) and SR. LV torsion was determined as the net difference in the mean rotation between the apical and basal levels. There was not any significant difference in age and gender between groups. Patients with BD had significantly lower LV longitudinal strain and Sr measurements than the control group. Although LV basal rotation (LVR) basal values were similar in both groups, LVR-apical and LV torsion (LVTR) values were significantly higher in patient group. LVR-apical and LV-GLS were found to have a good positive corelation (r:0.44, p<0.001) (r: -0.56, r: -0.65,respectively. p<0.001). There was a weak positive correlation between LVTR and LV-GLS (r: 0.29, p<0.05). We demonstrated that combined assessment of LV-GLS, LV-GLSR, LVTR and LVR-apical values detected by STE can be useful in determination of subclinical left ventricular dysfunction in BD.

Myocardial deformation and total atrial conduction time in the prediction of cardiac involvement in patients with pulmonary sarcoidosis.

In this study, we aim to evaluate the left atrial global longitudinal strain (LAGLS), total atrial conduction time (TACT) and left ventricle (LV) functions in recently diagnosed pulmonary sarcoidosis (PS) patients.

The Role of Serum Bilirubin Levels in Predicting Troponin Positivity in Non-ST-Segment Elevation Acute Coronary Syndrome.

Data are scant regarding serum bilirubin levels in non-ST-segment elevation acute coronary syndrome (NSTE-ACS). In this study, we evaluated the role of serum bilirubin levels in NSTE-ACS. We enrolled 782 patients who presented to the emergency department with acute chest pain. Patients were divided into 2 groups based on the troponin positivity. Patients with NSTE-ACS who had troponin positivity were included in group 1 (n = 382), and group 2 consisted of the control patients (n = 400). Direct bilirubin (DB) levels (group 1: 0.31 ± 0.37 mg/dL, group 2: 0.20 ± 0.25 mg/dL, P < .001) and total bilirubin (TB) levels (group 1: 0.78 ± 0.56 mg/dL, group 2: 0.62 ± 0.45 mg/dL, P < .001) were significantly higher in group 1. There was a significant and moderate correlation between serum bilirubin levels and admission troponin values (r = .34, P < .001 for TB and r = .42, P < .001 for DB). These results show that serum bilirubin levels were associated with troponin positivity in patients with NSTE-ACS.

The relationship of micronucleus frequency and nuclear division index with coronary artery disease SYNTAX and Gensini scores

Objective: We aimed to evaluate the relationship of micronucleus (MN) frequency and nuclear division index (NDI) with SYNTAX and Gensini scores and thrombolysis in myocardial infarction (TIMI) frame counts of coronary arteries in patients undergoing coronary angiography. Methods: In a single-center prospective observational study, a total of 63 individuals, 48 consecutive patients with coronary artery disease (CAD) and 15 healthy people were included. Before coronary angiography (exposure to X-ray), blood samples were collected for lymphocyte cultures, MN and NDI measurements. According to the SYNTAX and Gensini scores, patients were allocated into two groups. Group 1 and 2 included the patients with SYNTAX scores <22 and ≥22 points, respectively. Similarly, groups according to Gensini scores included the ones <23 and ≥23 points. MN test was used for in vitro studies in human peripheral lymphocytes. Binucleated lymphocytes were calculated for each patient. Results: MN frequency was significantly higher in group 2 than group 1 and in group 1 than control group (p<0.001). NDI was significantly higher in control group than group 1 and in group 1 than group 2 (p=0.003). MN frequency had positive but moderate correlation with SYNTAX and Gensini scores and TFCs of left anterior descending (LAD), circumflex and right coronary arteries (r=0.394, p=0.003; r=0.458, p<0.001; r=0.425, p<0.001; r=0.469, p<0.001; and r=0.475, p<0.001, respectively). Conclusion: We can conclude that as the degree of atherosclerosis increases and coronary flow worsens, MN frequency increases and NDI decreases. Our results may help to elucidate the relationship of DNA damage in pathophysiology of atherosclerosis and endothelial dysfunction in patients with stable CAD.

Utility of γ-Glutamyl Transferase in Predicting Troponin Elevation in Emergency Departments

Serum γ-glutamyl transferase (GGT) activity is a risk predictor for the development of coronary artery disease and is related to cardiovascular morbidity and mortality. We evaluated the clinical utility of GGT activity in predicting high troponin levels in patients with acute coronary syndrome (ACS) admitted to the emergency department with chest pain. A total of 200 troponin-positive and 203 troponin-negative patients were classified into groups 1 and 2, respectively. γ-Glutamyl transferase activity was significantly higher in group 1 (44 ± 34 U/L) compared with group 2 (31 ± 26 U/L, P = .001). A GGT activity cutoff >25.5 showed 62% sensitivity and 61% specificity in predicting troponin positivity. Logistic regression analysis demonstrated a significant predictive value of GGT for troponin positivity. Spearman rank correlation analysis showed a moderately strong relationship between GGT activity and troponin positivity. Considering the predictive value of high GGT activity for troponin positivity, GGT activity may complement other diagnostic biomarkers for predicting troponin positivity in patients having ACS admitted with chest pain.

Common atrium: A rare congenital heart anomaly.

We present a case of an asymptomatic 23-year-old woman who was referred for an abnormal routine electrocardiogram. Her past medical history was normal. She had a previous uneventful pregnancy with a healthy child. During auscultation, a mild holosystolic murmur was heard at all auscultation points, gaining intensity at the apex and mesocardiac area. While S1 was normal, a widely split S2 was heard. Pulse rate was 92/min and arterial blood pressure was 130/85 mmHg. There was no pretibial edema and the lungs were clear. There was no physical congenital abnormality. Her electrocardiogram was in normal sinus rhythm with a complete right bundle branch block. Oxygen saturation measured with finger pulse oximetry was 89%. Chest radiography showed increased pulmonary vascularity, mild cardiomegaly and left atrial enlargement (Figure A). Complete absence of the interatrial septum and normal left ventricular dimensions and functions were detected in transthoracic echocardiography. The main pulmonary artery and right ventricle were dilated and a paradoxical motion of the interventricular septum was observed. Mitral and tricuspid valve attachments to the interventricular septum were on the same anatomic plane, and there was no cleft of the mitral valve (Figure B, C, Video*). Doppler examination revealed mild mitral and moderate tricuspid regurgitation. Systolic pulmonary arterial pressure was 40–45 mmHg. A major vessel opening to the left side of the atrium was thought to be a pulmonary vein. The inferior and superior vena cava were opening normally into the right side of the atrium. The patient was informed about the disease and its progression and referrred for corrective surgery. Common atrium (CA) is a rare congenital anomaly in adults and is also known as single atrium or cor triloculare biventriculare. Rastelli et al. described three characteristic findings of CA: 1) complete absence of the interatrial septum, or a small strand of tissue present in the cephalad wall of a common chamber, 2) absence of interventricular communication, 3) an accompanying cleft in the anterior leaflet of the mitral valve. Similarly, our patient had a common atrium without an interatrial septum and absence of interventricular communication, but did not have a cleft on the anterior mitral leaflet. Patients with CA are usually admitted in late childhood or young adulthood with nonspecific symptoms like dyspnea, palpitation, fatigue or syncope. Interestingly, despite undergoing a challenging process—pregnancy—in her past medical history, our patient remained asymptomatic. Herein we present an asymptomatic patient diagnosed incidentally and showing an unusual disease presentation. According to the current data, echocardiography is the first line diagnostic tool, and corrective surgery is the mainstay of therapy. Additionally, early diagnosis is crucial before progression to Eisenmenger syndrome, which is a contraindication for corrective surgery. 579

Traumatic Coronary Artery Dissection in a Young Woman after a Kick to Her Back

We present the case of a 38-year-old woman admitted to our outpatient clinic with accelerating back pain and fatigue following a kick to her back by her husband. Upon arrival, we detected ST segment elevation in the D1, aVL, and V2 leads and accelerated idioventricular rhythm. She had pallor and hypotension consistent with cardiogenic shock. We immediately performed coronary angiography and found a long dissection starting from the mid-left main coronary artery and progressing into the mid-left anterior descending (LAD) and circumflex arteries. She was then transferred to the operating room for surgery. A saphenous vein was grafted to the distal LAD. Since the patient was hypotensive under noradrenaline and dopamine infusions, she was transferred to the cardiovascular surgery intensive care unit on an extracorporeal membrane oxygenator and intra-aortic balloon pump. During follow-up, her blood pressure remained low, at approximately 60/40 mmHg, despite aggressive inotropic and mechanical support. On the second postoperative day, asystole and cardiovascular arrest quickly developed, and despite aggressive cardiopulmonary resuscitation, she died.

An isolated single L-II type coronary artery anomaly: A rare coronary anomaly.

The incidence of congenital artery anomalies is 0.2-1.4%, and most are benign. Single coronary artery (SCA) anomalies are very rare. The right coronary artery (RCA) originating from the left coronary system is one such SCA anomaly, and the risk of sudden cardiac death (SCD) increases if it courses between the pulmonary artery and aorta and coexists with other congenital heart diseases. Additionally, coursing of the RCA between the great vessels increases the risk of atherosclerosis. We herein present the case of a 57 year-old man who was admitted to our cardiology outpatient clinic and diagnosed with an SCA anomaly in which the RCA arose from the left main coronary artery (LMCA) and coursed between the pulmonary artery and aorta. However a critical stenosis was not detected in imaging techniques, and myocardial perfusion scintigraphic evidence of ischaemia was found in a small area. Therefore, he was managed with conservative medical therapy.

Double Right Coronary Artery Arising From Separate Ostia

We present a rare case of double right coronary artery (RCA) arising from separate ostia. A 62 years old male patient was admitted with acute onset retrosternal chest pain. ECG was suggestive of sinus rhythm with intraventicular conduction delay and pathological q waves in D3 and avF derivations without any significant ST segment elevations. In the coronary angiography, we detected double RCA, each had its own ostium arising separately from right aortic sinus with complete occlusion seen in one RCA. Plaques were present in left coronary arterial system. Guidewires could not be passed in the completely occluded right RCA and conservative therapy was recommended. Double RCA is a congenital coronary anomaly with a potential of atherosclerotic coronary artery disease which needs regular monitoring.