Emre Ertürk

Comparison of Different TEE-Guided Thrombolytic Regimens for Prosthetic Valve Thrombosis: The TROIA Trial

OBJECTIVES The aim of this prospective study was to identify the most effective and safest regimen among different thrombolytic treatment strategies. BACKGROUND The best treatment strategies for prosthetic valve thrombosis have been controversial. METHODS Transesophageal echocardiography-guided thrombolytic treatment was administered to 182 consecutive patients with prosthetic valve thrombosis in 220 different episodes (156 women; mean age, 43.2 ± 13.06 years) between 1993 and 2009 at a single center. These regimens chronologically included rapid (Group I), slow (Group II) streptokinase, high-dose (100 mg) tissue plasminogen activator (t-PA) (Group III), a half-dose (50 mg) and slow infusion (6 h) of t-PA without bolus (Group IV), and a low dose (25 mg) and slow infusion (6 h) of t-PA without bolus (Group V). The endpoints were thrombolytic success, in-hospital mortality, and nonfatal complication rates. RESULTS The overall success rate in the whole series was 83.2%; it did not differ significantly among Groups I through V (68.8%, 85.4%, 75%, 81.5%, and 85.5%, respectively; p = 0.46). The overall complication rate in the whole series was 18.6%. Although the overall complication rate was similar among Groups I through IV (37.5%, 24.4 %, 33.3%, and 29.6%, respectively; p > 0.05 for each comparison), it was significantly lower in Group V (10.5%, p < 0.05 for each). The combined rates of mortality and nonfatal major complications were also lower in Group V than in the other groups, with all differences significant except for comparison of Groups IV and V. By multivariate analysis, the predictors of combined mortality plus nonfatal major complications were any thrombolytic therapy regimen other than Group V (odds ratios for Groups I through IV: 8.2, 3.8, 8.1, and 4.1, respectively; p < 0.05 for each) and a history of stroke/transient ischemic attack (odds ratio: 3.5, p = 0.011). In addition, there was no mortality in Group V. CONCLUSIONS Low-dose slow infusion of t-PA repeated as needed without a bolus provides effective and safe thrombolysis in patients with prosthetic valve thrombosis. (Comparison of Different TRansesophageal Echocardiography Guided thrOmbolytic Regimens for prosthetIc vAlve Thrombosis; NCT01451320).

Assessment of carotid body tumor and its association with tetralogy of fallot: effect of the chronic hypoxia.

This is a rare combined presentation of Tetralogy of Fallot and carotid body tumor (CBT). Hypotheses and further discussion provides data for the development of CBT as a response to chronic hypoxemia. This present study demonstrates and discusses such an occurrence.

The rare complication of Behcet's syndrome: concomitance of coronary slow flow with acute coronary syndrome

Coronary slow flow (CSF) is a phenomenon characterised by delayed opacification of coronary arteries in the absence of epicardial stenosis, in which microvascular and endothelial dysfunction have been implicated in pathophysiology.1 The association between acute coronary syndromes (ACS) and Behcets syndrome is well known but rare, and is especially important due to the tendency to affect young subjects. Besides CSF, vasculitis, aneurysms, coronary vasospasm and thrombo-embolic phenomena may also lead to ACS in Behcets syndrome.2 ,3 Vascular endothelial cell injury and resultant endothelial dysfunction seem to play a …

Prognostic impact of diastolic blood pressure on long-term outcome in patients with non-ST-segment elevation myocardial infarction

Background: Hypertension is a well-established risk factor for cardiovascular disease, and low systolic blood pressure (SBP) is a powerful adverse prognosticator in acute coronary syndrome. We sought to investigate the relationships between diastolic blood pressure (DBP) and outcomes in patients with non-ST-segment elevation myocardial infarction (NSTE-MI). Methods: We performed a retrospective review of 122 consecutive medical records of patients (mean age: 58 10 years, 73% men) with NSTEMI who underwent coronary angiography. All patients did not have any previous cardiac events or valvular disease. Patients were classified as DBP 70 mmHg and DBP >70 mmHg. The number of diseased vessel (one vessel, two vessel and three vessel and/or left main coronary artery disease) and SYNTAX score were calculated from the angiograms to assessed the extent and severity of coronary artery disease (CAD). Two year cardiac mortality was evaluated based on medical records and telephone visits. Results: There were no significant differences between the groups in terms of age, gender, medical therapy during hospital stay and at discharge, glomerular filtration rate, and ejection fraction. As expected SBP was lower in patients with DBP 70 mmHg. The patients with DBP 70 mmHg tended to have multivessel coronary artery disease (47.5% vs 25.4%, P 1⁄4 0.009) and higher SYNTAX score (20.3 15.2 vs 14.8 70 13.6, P 1⁄4 0.037). The two year mortality rate was 10.2%. Mortality rates were not significantly different for the two groups (11.3% vs 6.5%, P 1⁄4 0.14). Conclusion: In this study, we showed that low DBP associated with severe CAD in patients with NSTE-MI. Although the mortality rate was higher in low DBP group, this difference did not reach statistical significance as the power of the study was possibly too small to reach significance.

Parachute-like mass at the superior vena cava occurring after diagnostic right heart catheterization evaluated with real-time three-dimensional transesophageal echocardiography

A 47-year-old woman was admitted to our hospital with respiratory failure. She had chronic dyspnea in her medical history and had underwent noninvasive and invasive procedures in a local clinic 1 year earlier. Transthoracic echocardiography (TTE) had revealed normal left ventricular systolic function and a pulmonary artery systolic pressure of 45 mmHg. Thoracic computed tomography (CT) with contrast had been unremarkable. Subsequently, diagnostic right heart catheterization (RHC) had been performed via the femoral approach but had provided insufficient clues for differential diagnosis. On admission, physical examination revealed hypotension and diminished bilateral respiratory sounds, most prominently in the right lung. The clinical findings were suggestive of pulmonary embolism. TTE revealed a mobile mass in the right atrium (RA). Conventional transesophageal echocardiography (TEE) disclosed a mass 6 cm in length attached with a stalk to the superior vena cava (SVC) (Fig. 1a). The real-time three-dimensional echocardiography (RT-3D TEE) demonstrated that the mass was composed of multiple sac-like structures separated by thin membranes, enlarging like a parachute when filled with the blood flowing through the SVC, and causing it to move back and forth through the tricuspid annulus into the right ventricule during diastole (Fig. 1b). Surgery revealed an 8-cm-long lobulated mass with a central cavity in the RA (Fig. 2). It was attached with a 2-cm-long stalk to the SVC wall 3 cm away from the RA. The main pulmonary artery and proximal branches were explored; thrombectomy was performed. Although the mass and the thromboembolized material were completely removed, the patient died on the 11th postoperative day due to respiratory failure. Histopathologic examination and immunofluorescence staining of the mass demonstrated a giant thrombus with a stalk made of endothelium and vascular smooth muscle tissue. This case demonstrates a fatal complication of RHC. Due to the fact that CT, which was performed before the diagnostic RHC, had showed no mass in the right heart or major intrathoracic veins, and morphologic characteristics that we detected during RT-3D TEE were not compatible with a tumor or vegetation, we considered that the mass could be a thrombus. However, it was too large to be transmitted from peripheric veins and duplex ultrasound of deep veins was normal. The patient did not have any reported coagulation disorder in her medical history and, hence, no any further investigation was made at the time of admission. Histopathologic examination and immunofluorescence staining of the stalk part of the mass showed that it was a tubular structure covered outside with an endothelial and a vascular smooth muscle layer and ruptured at its tip, which made us think that the thrombus might have been initiated in situ after a ruptured hematoma at the SVC wall that had resulted from a possible trauma during RHC. Although RHC is seems to be relatively harmless, it should be performed at experienced centers in order to avoid infrequent but fatal complications [1]. RT-3D TEE may be useful in differentiating intracardiac masses and may provide additional information to the surgeon for optimal surgical planning [2]. E. Erturk M. Ozkan O. M. Gursoy (&) Department of Cardiology, Kartal Kosuyolu Heart Training and Research Hospital, Denizer Caddesi Cevizli Kavsagi, No: 2 Cevizli/Kartal, Istanbul 34846, Turkey e-mail: m.ozangursoy@yahoo.com