Erol Gürsoy

A case of reversible cardiomyopathy associated with acute toluene exposure

Inhalation of toluene-based products is popular among young adults. It has been shown to have a variety of adverse effects on several organs and systems. Although the heart seems to be a sensitive target organ to toluene, cardiotoxicity has often been ignored, especially in cases of acute toluene abuse, with relatively low concentrations. Thereby, routine cardiac examination and echocardiography for cardiotoxicity should be performed in cases of acute toluene exposure, even though there is no cardiovascular sign or symptoms.

Cardiomyopathies: the value of cardiac magnetic resonance imaging.

Pheochromocytoma is rare and has been documented to present atypically as myocardial ischemia, arrhythmias, or congestive heart failure. In patients with pheochromocytoma, transient cardiomyopathy with hypokinesia of the basal segments of the left ventricle and hyperkinesia of the apex (an inverted Takotsubo contractile pattern) can be observed [5] . Patients with elevated cardiac biomarkers and diffuse ST-T abnormalities on electrocardiography must be evaluated in detail to detect an etiology. Cardiovascular magnetic resonance imaging is a safe, useful, noninvasive modality that can be used in assessing myocardial function and tissue, differentiating and diagnosing cardiomyopathies in suspected myocardial diseases even without wall motion abnormality. Establishing the exact etiology of elevated cardiac biomarkers and echocardiographic abnormalities will help in managing treatments, thus avoiding harmful medications and interventions. Dear Editor, We read with great interest the article by Lee et al. [1] entitled ‘Pheochromocytoma mimicking both acute coronary syndrome and sepsis: a case report’. These authors presented a case of pheochromocytoma mimicking both acute coronary syndrome and sepsis, and advised that pheochromocytoma should be considered as part of the differential diagnosis in a patient with symptoms suggestive of both acute coronary syndrome and sepsis. The patient was evaluated with transthoracic echocardiography, and a dilated left ventricular (LV) chamber without regional wall motion abnormality and preserved LV systolic contractility was observed. Some comments may be of interest. Myocarditis is an inflammatory heart disease that may be caused by different pathogens. Viral pathogens are most frequently identified in endomyocardial biopsies. Most patients will recover without sequelae, but a subset of patients will progress to chronic inflammatory and dilated cardiomyopathy [2] . Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) is a clinical syndrome of transient LV dysfunction, preceded by emotional stress or exacerbation of an existing medical condition. It presents with a myocardial infarct-like clinical syndrome, resulting in angiographically normal coronary arteries and a contractile pattern with hypokinesia of the apical segments [3, 4] . Received: June 11, 2013 Accepted: October 9, 2013 Published online: November 21, 2013

Assessment of association between neutrophil-to-lymphocyte ratio and coronary artery ectasia.

We read with interest the article by Sarli et al entitled ‘‘Neutrophil-to-lymphocyte ratio is associated with severity of coronary artery ectasia.’’ These authors investigated the association between neutrophil-to-lymphocyte ratio (NLR) and coronary artery ectasia (CAE). The NLR, which represents an inflammatory state, was significantly higher in patients with CAE compared to patients with normal coronary arteries. The NLR was also significantly associated with the severity of CAE. Some comments may be of interest. Acute stress and inflammatory states increase blood concentrations of adrenocorticotropic hormone and cortisol that induce redistribution of circulating white blood cells (WBCs) by inhibition of neutrophil apoptosis and activation of lymphocyte apoptosis, thus increasing NLR. Components of the systemic inflammatory response, such as C-reactive protein (CRP), interleukin-6, tumor necrosis factora, and NLR, are associated with the prognosis of inflammatory diseases. The CRP and NLR are independent indicators for the prognosis in patients with CAE, reflecting inflammatory burden. Their role in predicting inflammatory response is more powerful when used in combination. In the Sarli et al’s study, although linear regression analysis revealed that the association between smoking history, WBC count, high-sensitivity CRP (hsCRP) level, NLR, and CAE is significant, a weak correlation was observed between NLR and hsCRP. The hsCRP levels in different types of CAE could explain the weak correlation between NLR and hsCRP. Assessment of NLR has been advocated as a simple and inexpensive prognostic factor in CAE. 4 If multivariate regression analysis as well as receiver–operating characteristic (ROC) curve analysis were performed, the odds ratios of independent predictors, cutoff level of NLR, and sensitivity and specificity of predictors in predicting isolated CAE could have been derived. Besides coefficient b, odds ratio, ROC curve analysis, information on patients using steroids, and anti-inflammatory agents, which could alter the immune response, could provide more detailed information and make the study more valuable.

The successful management of early rupture of abdominal aortic aneurysm with endovascular stenting and instent stenting for endoleak following EVAR; a case report

Please cite this article as: Ozturk Cengiz, Iyisoy Atila, Gursoy Erol, Celik Turgay, Guler Adem, Sahin Mehmet Ali, Bozlar Ugur, Rreka Ardi, Ozturk Ahmet, Balta Sevket, The successful management of early rupture of abdominal aortic aneurysm with endovascular stenting and instent stenting for endoleak following EVAR; a case report, International Journal of Cardiology (2016), doi: 10.1016/j.ijcard.2016.01.151

Two-catheter Ablation Technique in AVNRT Ablation: GATA Experience

This study is aimed to compare the effects of propofol, sevoflurane and isoflurane on cerebral blood flow velocity by using Transcranial Doppler ultrasonography throughout perioperative period. We enrolled 30 healty, male subjects for the study and randomized for three groups [propofol (n=10), sevoflurane group (n=10), isoflurane group (n=10)]. We measured flow velocity of right middle cerebral artery (VMCA), by using Transcranial Doppler ultrasonography from temporal bone window throughout perioperative period [preoperative, intraoperative (under normocapnic and hipocapnic conditions) and postoperative]. After induction of anesthesia using propofol (2mg/kg) and fentanyl (2 μg/kg), laryngeal mask airway was inserted and the anesthesia was maintained with either propofol infusion, or sevoflurane or isoflurane inhalation. There were no significant differences between preoperative and postoperative VMCA measurements for all the groups (p>0,05). The VMCA values under normocapnic conditions were decreased significantly according to awake values in propofol group (p<0,05). According to awake values Sevoflurane produced a little decrease, and isoflurane produced a little increase in VMCA under normocapnic conditions, but the difference was not found significant (p>0,05). Under hipocapnic conditions, VMCA decreased significantly in all groups (p<0,05). In conclusion, it seems to be safe using propofol as an anesthetic agent, especially in patients undergoing neurosurgical prosedure.

The relationship between blood pressure variability and Pooled Cohort Risk Assessment Equations 10-year cardiovascular risk score.

BackgroundRecent attention has focused on the clinical significance of blood pressure variability (BPV) in explaining the adverse cardiovascular consequences of hypertension. We therefore analyze the impact of 24 h BPV on the development of future cardiovascular disease determined by The Pooled Cohort Risk Assessment Equations 10-year risk calculator. Materials and methodsWe analyzed 250 adult patients, ages 40–80 years old. The ambulatory blood pressure monitoring was recorded automatically. We defined the mean blood pressure values, SD, and coefficient of variation (CV) of blood pressure on the basis of the recorded 24 h ambulatory blood pressure monitoring values as an indicator for BPV.Patients were divided into two groups according to their Pooled Cohort Risk Assessment Equations 10-year risk profile (<7.5 and ≥7.5%). ResultsBesides the mean systolic blood pressure (SBP), parameters showing the BPV such as SD and CV of mean blood pressures were also significantly higher in patients with an elevated 10-year risk score compared with others. Only CV of SBP and pulse pressure showed a clear association with the 10-year risk in multivariate logistic regression analysis. The results suggested that each 1% increase in CV of SBP could lead to a 1.258-fold increase in The Pooled Cohort Risk Assessment Equations 10-year risk score. ConclusionIn the present study, we found that independent of baseline SBP, increased CV of SBP within 24 h was associated with increased cardiovascular risk, as assessed by The Pooled Cohort Risk Assessment Equations 10-year risk calculator.

Platelet Distribution Width Should Not be Used Alone as a Direct Indicator of Thromboembolic Disorders

We read with interest the article by Vatankulu et al entitled ‘‘A new parameter predicting chronic total occlusion of coronary arteries: platelet distribution width.’’ These authors aimed to assess whether platelet distribution width (PDW) is associated with the extent of coronary artery disease and coronary total occlusions (CTOs). In multiple logistic regression analysis, PDW (odds ratio 1⁄4 1.2, 95% confidence interval [CI] 1.0-1.4; P 1⁄4 .01) was identified as an independent predictor of CTO. In a receiver–operating characteristic analysis, a cut point of 15.7% for PDW was identified in patients with CTO (area under curve 1⁄4 0.64, 95% CI 0.54-0.75) with a sensitivity of 64% and a specificity of 66%. The authors mentioned that low sensitivity and specificity values of PDW for predicting CTO are due to the positive effect of statins on hematological parameters. They concluded that PDW values can be used as a simple platelet index in predicting the presence of CTO. Some comments may be of interest. Mean platelet volume (MPV) and PDW are easily measured platelet indices that increase during platelet activation. An increase in both MPV and PDW due to platelet activation is a potentially useful marker for the early diagnosis of thromboembolic diseases. Atorvastatin therapy in patients with hyperlipidemia can significantly decrease the MPV without significant change in PDW. If correlation between statin use and PDW values were given, the effect of statins on PDW values could have been determined more precisely. In conclusion, platelet indices should not be used alone as direct indicators of thromboembolic disorders. Although PDW may potentially be useful as a predictive marker of cardiovascular diseases, low sensitivity and specificity reduce the value of PDW for predicting CTO.

PP-071 RIGHT ATRIAL MASS AFTER SURGICAL REPAIR OF ATRIAL SEPTAL DEFECT: THROMBUS MASQUERADING AS A MYXOMA

PP-070 LEFT COMMON PULMONARY VENOUS OSTIUM MIMICKING LEFT ATRIAL APPENDAGE ANEURYSM: ECHOCARDIOGRAPHIC MISDIAGNOSIS U.C. Yuksel, E. Yalcinkaya, E. Yildirim, T. Celik, U. Bozlar, M. Celik, Y. Gokoglan, B. Bugan, S. Firtina, A. Iyisoy, H.K. Kabul. Department of Cardiology, Gulhane Military Medical Academy, Ankara, Turkey; Department of Radiology, Gulhane Military Medical Academy, Ankara, Turkey; Department of Cardiology, Malatya Army Hospital, Malatya, Turkey; Department of Cardiology, Erzincan Army Hospital, Erzincan, Turkey Objective: The two most common pulmonary venous (PV) anomalies are the presence of aright middle PV and common left trunk. Herein, we report a patient with left common pulmonary venous ostium misdiagnosed as left atrial appendage aneurysm on echocardiography. Methods: A 67-year-old female with a medical history of hypertension admitted to our outpatient department for palpitation and dyspnea on exercise. She was advised to undergo routine echocardiography, which showed dilated left ventricle, decreased left ventricular ejection fraction (25%), moderate mitral regurgitation and left atrial appendage aneurysm. She was referred to cardiac computed tomographic angiography (CTA) for delineating anatomy. Results: CTA revealed an unusual pulmonary venous anomaly consisting of a left-sided common and unusually large ostium of left pulmonary veins draining to left atrium and normal coronaries. Conclusion: Cardiac anatomic variants has become increasingly important as the number of radiofrequency ablations has increased. The definite differentiation of pulmonary common ostium from an atrial appendage aneurysm could be made with transesophageal echocardiography, computed tomography and magnetic resonance imaging.

PP-072 PERSISTENT LEFT SUPERIOR VENA CAVA WITH AGENESIS OF RIGHT SUPERIOR VENA CAVA: DIAGNOSIS OF RARE CONGENITAL CONCOMITANCE WITH TRANSESOPHAGEAL ECHOCARDIOGRAPHY

PP-070 LEFT COMMON PULMONARY VENOUS OSTIUM MIMICKING LEFT ATRIAL APPENDAGE ANEURYSM: ECHOCARDIOGRAPHIC MISDIAGNOSIS U.C. Yuksel, E. Yalcinkaya, E. Yildirim, T. Celik, U. Bozlar, M. Celik, Y. Gokoglan, B. Bugan, S. Firtina, A. Iyisoy, H.K. Kabul. Department of Cardiology, Gulhane Military Medical Academy, Ankara, Turkey; Department of Radiology, Gulhane Military Medical Academy, Ankara, Turkey; Department of Cardiology, Malatya Army Hospital, Malatya, Turkey; Department of Cardiology, Erzincan Army Hospital, Erzincan, Turkey Objective: The two most common pulmonary venous (PV) anomalies are the presence of aright middle PV and common left trunk. Herein, we report a patient with left common pulmonary venous ostium misdiagnosed as left atrial appendage aneurysm on echocardiography. Methods: A 67-year-old female with a medical history of hypertension admitted to our outpatient department for palpitation and dyspnea on exercise. She was advised to undergo routine echocardiography, which showed dilated left ventricle, decreased left ventricular ejection fraction (25%), moderate mitral regurgitation and left atrial appendage aneurysm. She was referred to cardiac computed tomographic angiography (CTA) for delineating anatomy. Results: CTA revealed an unusual pulmonary venous anomaly consisting of a left-sided common and unusually large ostium of left pulmonary veins draining to left atrium and normal coronaries. Conclusion: Cardiac anatomic variants has become increasingly important as the number of radiofrequency ablations has increased. The definite differentiation of pulmonary common ostium from an atrial appendage aneurysm could be made with transesophageal echocardiography, computed tomography and magnetic resonance imaging.