Emrullah Basar

Preload Dependence of Doppler Tissue Imaging Derived Indexes of Left Ventricular Diastolic Function

Doppler tissue imaging (DTI) has been proposed as a tool for the evaluation of diastolic function. Controversy exists regarding whether DTI measurements are influenced by preload. Changes in the circulating volume associated with hemodialysis result in preload reduction. To determine the influence of preload reduction on DTI and standard pulsed‐Doppler transmitral diastolic velocities, 30 patients (mean age 41 ± 14) with chronic renal insufficiency without overt heart disease were studied by DTI and standard pulsed Doppler before and after hemodialysis. From the apical window, DTI sample volume was placed at the lateral and septal mitral annulus and at the midsegment of lateral and septal myocardial wall of the left ventricle. Peak early diastolic annular and myocardial, and peak late diastolic annular and myocardial velocities were measured. Transmitral peak early and late diastolic velocities were also recorded by standard pulsed Doppler. The peak velocity of early diastolic mitral flow decreased from 100 ± 30 to 85 ± 34 cm/s (P < 0.001) after hemodialysis. Hemodialysis elicited marked reduction in early diastolic lateral mitral annular and midlateral myocardial velocities (6.9 ± 3.2 to 6.3 ± 2.9 cm/s, P < 0.04 and 6.7 ± 0.3 to 5.5 ± 2 cm/s, P < 0.001, respectively). Early diastolic, septal mitral annular, and midseptal myocardial velocities were also significantly decreased (5.8 ± 2.8 to 4.6 ± 2 cm/s, P < 0.006 and 6.2 ± 2 to 5.1 ± 1 cm/s, P < 0.008, respectively). Late diastolic mitral annular and myocardial velocities did not change. It is concluded that early diastolic mitral annular and myocardial velocities are affected by acute preload reduction. It is necessary to consider preload when diastolic function is assessed by DTI.

Effects of nebivolol therapy on endothelial functions in cardiac syndrome X.

Endothelial dysfunction is major pathophysiologic mechanism in cardiac syndrome X (CSX), which causes a decrease in plasma nitrite oxide (NO) levels. It was demonstrated that nebivolol improves endothelial function and increases NO release. Despite this pathophysiologic relation, the effect of nebivolol therapy on endothelial function in patients with CSX is unknown. The aim of this study is to evaluate the effect of nebivolol on patients in CSX. Thirty-eight patients who were diagnosed with CSX were prospectively enrolled in the study. The treatment group consisted of 20 patients and the control group consisted of 18 patients. An oral 5-mg dose of nebivolol was given daily and maintained for 4 weeks in the treatment group. Ultrasonographic parameters (brachial artery flow-mediated dilatation [FMD], brachial artery lumen diameters) and inflammatory markers (high-sensitivity C-reactive protein [hsCRP], von Willebrand factor [vWf], and fibrinogen) were measured at baseline and end of the 4 weeks. Brachial baseline lumen diameter, brachial lumen diameter after reactive hyperemia, and FMD were 4.61 ± 0.49 mm, 4.87 ± 0.53 mm, and 5.6% ± 2.3% at baseline. After the nebivolol therapy, there was a significant increase in both brachial artery baseline lumen diameter and lumen diameter after reactive hyperemia (P < 0.001 and P = 0.002). However, there was no significant change in FMD (5.6% ± 2.2% vs 5.3% ± 2.1%, P not significant). Levels of hsCRP, vWf, and fibrinogen were significantly decreased (hsCRP: 3.4 ± 0.49 mg/dl vs 2.97 ± 0.74 mg/dl, P = 0.001; vWf: 107 ± 62 vs 86 ± 58, P = 0.004; fibrinogen: 341 ± 89 mg/dl vs 299 ± 87 mg/ dl, P = 0.01) in the treatment group. Nebivolol therapy may have a favorable effect on endothelial function in CSX. Further studies are needed to confirm the clinical significance of nebivolol therapy in CSX.

Color Doppler Tissue Imaging to Evaluate Left Atrial Appendage Function in Patients With Mitral Stenosis in Sinus Rhythm

Two‐dimensional color Doppler tissue imaging (CDTI) has so far been used, in general, to evaluate ventricular function. In this study, the left atrial appendage (LAA) tissue velocity was measured by CDTI. LAA function in 38 patients with mitral stenosis in sinus rhythm (SR) and 19 healthy subjects undergoing transesophageal echocardiography were examined by CDTI. Systolic tissue appendage velocity (SaV, m/s) was measured at the tip of the LAA in the basal short‐axis view. LAA emptying (LAAEV) and filling (LAAFV) velocities (m/s) were also recorded 1 cm below the orifice of the appendage. LAA ejection fraction was also measured. In addition, two‐dimensional imaging was used to determine the presence of thrombus and/or spontaneous echo contrast (SEC). Patients with mitral stenosis in SR had significantly decreased LAAEV, LAAFV, SaV, and LAA ejection fraction compared to controls (0.34 ± 0.15 vs 0.72 ± 0.17, 0.37 ± 0.13 vs 0.63 ± 0.19, 0.050 ± 0.015 vs 0.071 ± 0.093, and 39 ± 14% vs 69 ± 13%, respectively, P < 0.001, P < 0.001, P < 0.001, and P < 0.001). Among the patients with mitral stenosis in SR, 10 patients had SEC and one had LAA thrombus. Compared with patients without SEC, patients with SEC had decreased LAAEV, LAAFV, SaV, and LAA ejection fraction (0.24 ± 0.05 vs 0.37 ± 0.16, 0.29 ± 0.05 vs 0.39 ± 0.14, 0.039 ± 0.087 vs 0.055 ± 0.015, and 28 ± 14% vs 43 ± 12%, respectively, P = 0.01, P = 0.02, P = 0.01, and P = 0.006). In conclusion, these results suggest that the LAA dysfunction may occur in patients with mitral stenosis in SR and CDTI can successfully be used for the quantification of contraction at the tip of the LAA. (ECHOCARDIOGRAPHY, Volume 21, April 2004)

Color Doppler tissue imaging to evaluate left atrial appendage function in mitral stenosis.

Two‐dimensional color Doppler tissue imaging (CDTI) has so far been used, in general, to evaluate ventricular function. This study examined if the left atrial appendage tissue velocity could reproducibly be measured with CDTI and if they have any predictive value for left atrial appendage (LAA) function and former thromboembolism. Thirty‐six patients (24 women, 12 men; mean age 45 ± 12 years; 18 AF; 11 former thromboembolic stroke) with mitral stenosis undergoing transesophageal echocardiography were examined with CDTI. Peak systolic tissue velocity (m/sec, peak systolic velocity [PSV]) was measured at the tip of the LAA in the basal short‐axis view. LAA flow emptying (LAAEV) and filling (LAAFV) velocities (m/sec) were also recorded 1 cm immediately below the orifice of the appendage. Interobserver and intraobserver variabilities were determined for the PSV. LAA ejection fraction was measured by Simpsons method. Mitral regurgitation, AF, transmitral mean gradient, left ventricular ejection fraction, mitral valve area, and left atrial diameter were used as a covariant for adjustment. The intraobserver and interobserver correlation coefficients for the PSV using CDTI was 0.64 and 0.60, respectively (both P = 0.01 ). LAAEV (0.29 ± 0.09 vs 0.19 ± 0.04, P = 0.001) and LAA ejection fraction (44 ± 12 vs 29 ± 14, P = 0.004) were found to be significantly decreased in the patients with decreased PSV (<0.05 m/sec), even after adjustment. The decreased PSV was positively correlated with the low LAAEV (<0.25 m/sec) and history of thromboembolism ( r = 0.59, r = 0.38 , respectively), and remained a significant determinant of the low LAAEV (OR 50.03, CI 1.46–1738.11, P = 0.02 ), but not of history of thromboembolism (OR 4.29, CI 0.52–35.01, P = 0.08 ) after adjustment. In conclusion, these results suggest that CDTI provides a reproducible method for quantification of contraction at the tip of the LAA. Decreased PSV may be predictive of poor LAA function. (ECHOCARDIOGRAPHY, Volume 20, January 2003)

Intracoronary electrocardiogram and angina pectoris during percutaneous coronary interventions as an assessment of myocardial viability: Comparison with low-dose dobutamine echocardiography

The aims of this study were to evaluate the diagnostic value of intracoronary electrocardiogram (ECG) and presence of angina pectoris during percutaneous coronary interventions in the prediction of myocardial viability assessed by low‐dose dobutamine echocardiography (LDDE). Seventy‐one patients (60 men; mean age, 54 ± 11 years) with recent Q‐wave MI and angiographically documented regional wall motion abnormality in the presence of a significant (≥ 70%) nonocclusive stenosis of the infarct‐related vessel who were referred for angioplasty were prospectively included in the study. The intracoronary ECG was recorded using coronary angioplasty guidewire. Significant ST segment elevation was defined as a new or worsening ST segment elevation of ≥ 0.1 mV at 80 msec after the J‐point. Angina pectoris was noted as present or absent during balloon inflation. All patients underwent LDDE for viability assessment. Significant ST segment elevation in the intracoronary ECG and chest pain were observed in 56 (78.9%) and 49 (69%) of the 71 patients. Viability was present on LDDE in 52 (92.9%) of 56 patients with and 3 (20%) of 15 without ST segment elevation. Viability was detected in 45 (91.8%) of 49 patients with and 10 (45.4%) of 22 without angina pectoris during balloon occlusion. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ST segment elevation for viability were 94.5%, 75%, 92.9%, 80%, and 90.1%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of angina pectoris for viability were 81.8%, 75%, 91.8%, 54.5%, and 80.3%, respectively. The present study demonstrated that a simple assessment of ST segment elevation in the intracoronary ECG or angina pectoris during coronary angioplasty can be used to assess myocardial viability identified by LDDE in patients with previous MI. Catheter Cardiovasc Interv 2003;60:469–476.

Use of ischemia-modified albumin in diagnosis of coronary artery disease.

ObjectiveThe diagnosis of coronary artery disease (CAD) is an important clinical problem. Ischemia-modified albumin (IMA) has been demonstrated to be a helpful marker in detecting myocardial ischemia. In this study, we have investigated the diagnostic importance of IMA in CAD. Method and resultsFifty patients with chest pain were enrolled in the study. IMA levels were measured on admission and within 30–60 min after exercise by albumin cobalt-binding test. Coronary angiography was performed in all patients after the exercise test. The mean preexercise IMA level was 83±27 U/ml in the patient group. IMA levels before the exercise test were similar in both patient and control groups (P>0.05). The mean IMA level in the patient group was, however, higher than in the control group after the exercise test (P=0.001). The sensitivity, specificity and positive and negative predictive values of the postexercise IMA levels >85 in diagnosis of CAD were 78, 73, 0.81 and 0.73%; respectively. Postexercise IMA levels were higher in patients with chest pain, ST depression and downsloping and horizontal ST depression of 2 mm or more. ConclusionIMA levels after the exercise test increased in patients with CAD. Our study results indicate that postexercise IMA levels can be helpful markers in the diagnosis of stable CAD in clinical practice.

Evaluation of left atrial appendage functions in patients with thrombus and spontaneous echo contrast in left atrial appendage by using color Doppler tissue imaging.

Objective: Thrombus and spontaneous echo contrast (SEC) develops in the left atrial appendage (LAA) when LAA function is disturbed. Decrease of left atrial appendage emptying velocity shows LAA dysfunction. The purpose of this study is to examine the incidence of SEC and/or thrombus in LAA in patients with acute myocardial infarction and to assess the LAA function using color Doppler tissue imaging (CDTI) of the patients with detected SEC and/or thrombus.

Application of the Vena contracta Method for the Calculation of the Mitral Valve Area in Mitral Stenosis

Objectives: The vena contracta is the narrowest region of the regurgitant or stenotic jet just downstream the orifice and reflects the size of that orifice. This study was performed to assess the accuracy of the vena contracta width (VCW) in evaluating the severity of mitral stenosis (MS) and to compare the mitral valve area (MVA) determined by VCW with MVAs obtained by other more traditional echocardiographic methods. Methods: We studied 59 patients (43 females, 42 ± 14 years) with MS. VCW was measured in the apical four chamber view by Doppler color flow mapping. The largest diameter of the VCW during diastole was measured for at least three cardiac cycles and averaged. MVA was calculated from the following equation: πr2, where r = VCW/2. MVA was also determined by planimetry, the pressure half-time method, and by the Gorlin formula. Results: In this study, the width of the vena contracta ranged from 0.89 to 1.73 cm (mean 1.30 ± 0.21). MVA, calculated based on the VCW, ranged from 0.63 to 2.35 cm2 (mean 1.36 ± 0.41). MVA by VCW (1.36 ± 0.41 cm2) showed good correlations with three comparative techniques: (1) the cross-sectional area by planimetry (1.35 ± 0.36 cm2, mean difference = 0.21 ± 0.16 cm2, y = 0.91x + 0.14, r = 0.79, SEE = 0.26 cm2, p < 0.001); (2) the area derived from the Doppler pressure half-time (1.27 ± 0.32 cm2, mean difference = 0.22 ± 0.19 cm2, y = 0.97x + 0.13, r = 0.76, SEE = 0.27 cm2, p < 0.001), and (3) the area derived from the Gorlin equation in the 18 patients who underwent catheterization (1.27 ± 0.35 cm2, mean difference = 0.19 ± 0.16, y = 0.98x + 0.05, r = 0.81, SEE = 0.26 cm2, p < 0.001). Conclusions: These findings suggest that Doppler color flow imaging of the MS jet in the vena contracta can provide an accurate estimation of MVA and appears to be potentially applicable in the assessment of the severity of MS.

Propranolol diltiazem cardiac and thyroid functions in hyperthyroidism

Sirs, Beta-blockers, especially propranolol, have long been used to treat symptoms of hyperthyroidism resulting from an activated sympathetic system, such as tachycardia, sweating, fine tremor and nervousness, and there is wide experience with these agents. There are some conditions such as congestive heart failure, chronic obstructive lung disease and occasionally diabetes which limit the use of P-blockers including cardioselective P,-antagonists (Cooper et al., 1985). Recently, Roti et al. suggested that diltiazem, a calcium channel blocking drug, may be used as an adjunctive biosynthesis of thyroid hormone and have no effect on the thyroid’s ability to release thyroid hormone into the circulation, amelioration of the symptoms of hyperthyroidism may take several weeks (Cooper et al., 1985). In some patients it is necessary to give another drug such as propranolol during that time to alleviate the adrenergic symptoms. Propranolol is not acceptable for some patients because of its side-effects. We conclude that diltiazem can be used in hyperthyroid patients in place of propranolol, where P-blockers are contraindicated.

Long term clinical outcomes of brachytherapy, bare-metal stenting, and drug-eluting stenting for de novo and in-stent restenosis lesions: Five year follow-up

BACKGROUND We aimed to investigate the effects of brachytherapy, drug-eluting stent (DES) and bare metal stent (BMS) applications in the treatment of coronary artery disease, on five-year clinical outcomes and mortality. METHODS Two hundred and seventeen patients who were treated in our clinics between January 2000 and December 2003 with brachytherapy, DES, or BMS for both de novo and in-stent restenosis lesions were included in this cohort study. Of these 217 patients, 69 received brachytherapy, 80 were given BMS and 68 were given DES. The clinical outcomes of the patients during hospitalization and over a long-term follow-up were evaluated. Cardiovascular events, revascularizations and mortality rates were compared among the three groups over a five-year follow-up. RESULTS The mean age was 60.1 ± 9.5 years in the brachytherapy group, 55.7 ± 9.2 years in the BMS group, and 58.9 ± 9.8 years in the DES group (p = 0.44). All-cause mortality rates were 20 (29%) brachytherapy patients, 22 (27.5%) BMS patients, and four (5.9%) DES patients (p = 0.01). Cardiovascular event was the cause of death for 14 (20.3%) brachytherapy patients, 16 (20%) BMS patients and four (5.9%) DES patients (p = 0.001). All-cause mortality rates were 20 (29%) brachytherapy patients, 22 (27.5%) BMS patients and four (5.9%) DES patients. All-cause and cardiovascular mortality rates were significantly lower in the DES group compared to both the BMS and the brachytherapy groups (p = 0.01 and p = 0.001, respectively). CONCLUSIONS DES application for in-stent restenosis and de novo lesions was superior to brachytherapy and BMS application with respect to all-cause and cardiovascular mortalities.