Hatice Kemal

Impact of Residual Mitral Regurgitation on Right Ventricular Systolic Function After Left Ventricular Assist Device Implantation

Significant mitral regurgitation (MR) is thought to decrease after left ventricular assist device (LVAD) implantation, and therefore repair of mitral valve is not indicated in current practice. However, residual moderate and severe MR leads to pulmonary artery pressure increase, thereby resulting in right ventricular (RV) dysfunction during follow-up. We examined the impact of residual MR on systolic function of the right ventricle by echocardiography after LVAD implantation. This study included 90 patients (mean age: 51.7 ± 10.9 years, 14.4% female) who underwent LVAD implantation (HeartMate II = 21, HeartWare = 69) in a single center between December 2010 and June 2014. Echocardiograms obtained at 3-6 months and over after implantation were analyzed retrospectively. RV systolic function was graded as normal, mild, moderate, and severely depressed. MR (≥moderate) was observed in 43 and 44% of patients at early and late period, respectively. Systolic function of the RV was severely depressed in 16 and 9% of all patients. Initial analysis (mean duration of support 174.3 ± 42.5 days) showed a statistically significant correlation between less MR and improved systolic function of RV (P = 0.01). Secondary echocardiographic analysis (following a mean duration of support of 435.1 ± 203 days) was also statistically significant for MR degree and RV systolic dysfunction (P = 0.008). Residual MR after LVAD implantation may cause deterioration of RV systolic function and cause right-sided heart failure symptoms. Repair of severe MR, in selected patients such as those with severe pulmonary hypertension and depressed RV, may be considered to improve the patients clinical course during pump support.

Is SYNTAX Score Predictive of Atrial Fibrillation After On-Pump Coronary Artery Bypass Graft Surgery?

Background and Objectives The relationship of synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score and development of atrial fibrillation (AF) after coronary artery bypass surgery (CABG) has not been studied. Therefore, we assessed the relationship between the SYNTAX score and development of AF after CABG (POAF). Subjects and Methods The medical records of consecutive patients, who underwent CABG surgery from January 2013 to September 2015, were retrospectively reviewed for the development of AF in the postoperative period. SYNTAX score, clinical and echocardiographic parameters were evaluated. The independent variables for the development of POAF were defined and their predictive values were measured. Results The study group consisted of 106 patients, of which 36 (34%) developed POAF. Age, hypertension, stroke, chronic obstructive pulmonary disease (COPD), heart failure (HF), diabetes mellitus (DM), left atrial diameter, neutrophil/lymphocyte ratio, platelet large cell ratio, creatinine, blood urea nitrogen and SYNTAX score were identified as important variables for the development of POAF. However, in logistic regression analysis COPD (OR=19.313, 95% CI=2.416-154.407, p=0.005), HF (OR=28.362, 95% CI=2.034-395.515, p=0.013), SYNTAX score (OR=0.863, 95% CI=0.757-0.983, p=0.026), and DM (OR=20.770, 95% CI=3.791-113.799, p<0.001) appeared as independent variables predicting the development of POAF. In receiver operation characteristic analysis, SYNTAX score (≥22.25) (AUC=0.777, 95% CI=0.676-0.877, p<0.001) was one of the strongest predictors for the development of POAF. Conclusion The SYNTAX score level was independently associated with the development of AF after CABG.

Age of Statin Therapy; Statin Therapy With Aging

To The Editor: I have read the article entitled “Effect of statin therapy on mortality in older adults hospitalized with coronary artery disease: a propensity-adjusted analysis” by Rothschild et al. with great interest, recently published in the Journal of the American Geriatrics Society. The investigators reported that analysis failed to show a survival benefit of statins in individuals aged 80 years and older hospitalized with acute or chronic coronary artery disease (CAD). Statin therapy is most commonly used for cholesterol lowering. Statin therapy lowers cholesterol, but also has pleiotropic effect, reduces inflammation, improves endothelial function, has anti-oxidant and anti-inflammatory effects. Previous studies, including Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) and the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) suggested that statins might be beneficial in selected high-risk older adults, but the mean age of PROSPER participants was 75.3 years and in the JUPITER subgroup analysis participants were aged 70 years and older and the mean age was 74. In PROSPECT study, which used virtual-histology IVUS for identification of a necrotic core, increased thick cap fibro-atheroma was shown in patients above 65 years, whereas thin cap fibro-atheroma (TCFA) was more frequent in patients below 65 years. Roth et al have reported significant lipid plaques mainly in younger (<58 years) and mid-aged patients (58–65 years). Elderly patients predominantly had smaller lipid plaques, not fulfilling the criteria for TCFA, embedded in large mixed plaques with fibrosis and frequent calcific components. Changes in atherosclerotic plaques with aging may cause the results in the group over 85 years. In this context, IVUS might be a useful diagnostic tool to determine the group of statins that could be effective in elderly patients.

Assessment of right ventricular systolic function in heart transplant patients: Correlation between echocardiography and cardiac magnetic resonance imaging. Investigation of the accuracy and reliability of echocardiography

Right ventricular (RV) function has great impact on the survival of heart transplantation recipients; therefore, careful evaluation is of high clinical importance. However, there is no standard conventional echocardiographic parameter to assess RV systolic function. Herein, we evaluated the correlation between echocardiographic parameters of RV systolic function and ejection fraction assessed by cardiac magnetic resonance imaging (MRI RVEF) in heart transplantation recipients.

The relation between vitamin B12 and SYNTAX score

BACKGROUND Vitamin B12 is required in the metabolism of homocysteine. Vitamin B12 deficiency has been implicated in endothelial dysfunction and cardiovascular disease via hyperhomocysteinaemia. However, the association of vitamin B12 and the severity of coronary artery disease has not been studied to date. AIM This study was conducted with the aim of evaluating the relationship between vitamin B12 and SYNTAX score. METHODS Medical records of consecutive patients who underwent coronary artery bypass grafting surgery were retrospectively reviewed. The study group consisted of 127 patients. Vitamin B12, other biochemical parameters, clinical and echocardiographic parameters, and SYNTAX score were evaluated for all patients. RESULTS Patients with vitamin B12 deficiency had a higher prevalence of cardiovascular risk factors such as diabetes mellitus, and history of transient ischaemic attack/stroke and heart failure. The SYNTAX score was significantly higher in patients with vitamin B12 deficiency (29.2 ± 4.9 vs. 22.5 ± 4.5, p < 0.05). CONCLUSIONS In our study, we found a significant relationship between vitamin B12 deficiency and SYNTAX score, demon-strating the severity and complexity of coronary artery disease.

Letter by Cerit et al Regarding Article, “Thyroid Function and Sudden Cardiac Death: A Prospective Population-Based Cohort Study”

We have read the article by Chaker et al1 with great interest. The investigators reported that although participants with subclinical or overt hypo- or hyperthyroidism did not have a higher risk of sudden cardiac death (SCD) than euthyroid participants, higher free thyroxine (FT4) levels were associated with an increased risk of SCD, even in euthyroid participants.1 Thyroid hormone has a stimulatory effect on β-adrenergic signaling, leading to positive chronotropic, dromotropic, …

Spider-Like Coronary Anatomy; the True Spider!

A 55 year-old man was admitted to the hospital with typical chest pain; the ECG and cardiac biomarkers were normal. He had a history of hypertension and coronary angiography (CAG) a year ago due to unstable angina pectoris and a drugeluting stent was implanted at the left anterior descending (LAD) coronary artery. CAG was performed at admission due to persistent chest pain and a single right coronary ostium was seen at the right coronary sinus, where LAD artery, left circumflex coronary (LCx) artery and right coronary artery (RCA) arose altogether. Non-significant plaques were seen at LAD and LCx, whereas RCA was obstructed from the middle segment and retrograde perfusion was observed (Figure 1A and 1B). The patient was treated conservatively and reported no chest pain 12 months later. The single coronary ostium is classified into 20 categories based on the ostiums location and our patient had characteristics of type IID3 (Figure 1C). Although type IID coronary anomaly has been described before, it has been reported only once and this is the second case of literature showing a single coronary ostium originating from the right coronary ostium.

Double-edged blinde, hemorrhagic or cardioembolic cognitive impairment

We appreciated much for Dr. Cerits comments on our article. Evidence from meta-analysis conducted by Kalantarian, et al.,[1] has suggested that AF is associated with a high risk of cognitive impairment (CI) and dementia (D), with or without a history of clinical stroke. Several mechanisms have been considered for the relationship of AF and CI. One explanation is the presence of the same risk factors such as hypertension, heart failure, diabetes mellitus in the both of conditions. Another potential mechanism is that AF comprises all the components of Virchoffs triade (hyper-coagulable state in AF, statis of blood in remodeled left atrium and structural injury of the heart) that leads to thrombus formation in left atrium/left atrial appendage and finally to clinical and subclinical strokes. Other potential mechanisms include: brain hypo-perfusion due to beat-to-beat variability in the length of the cardiac cycle and reduced cardiac output, the pro-inflammatory state in AF and peri-ventricular white matter lesions.

A huge echolucent structure resembling cyst adjacent to left atrium: Revealing persistent left superior vena cava with 4D echocardiography.

Fig. 1 – Persistent left superior vena cava mimicking defect, bicuspid aortic valve, coarctation of aorta, coronary sinus ostial atresia, and cor triatriatum. A 81-year-old male was admitted to syncope and palpitation. He had history of hypertension and paroxysmal atrial fibrillation. Physical examination was normal. Cranial MRI was normal. 2D and 4D transthoracic echocardiography revealed normal findings except moderate mitral regurgitation and a hugely dilated coronary sinus suggestive of a PLSVC in apical 4-chamber view (Fig. 1). Agitated saline contrast study from the left antecubital vein demonstrated prior contrast enhancement of this giant coronary sinus before the right atrium on 2D and 4D transthoracic echocardiography (Fig. 2). We thought his syncope attack due to orthostatic hypotension. The patient was discharged with warfarin, angiotensin-converting enzyme inhibitor, and beta-blocker.

A case of coronary microfistula: A newborn microfistula

Coronary artery fistula is an abnormal connection between a coronary artery and a cardiac chamber, a great artery or the vena cava. Although coronary artery fistulas are known to be congenital malformations they might occur due to infection, trauma or may be iatrogenic. We present a case with acquired coronary microfistula, without any history of interventional procedure.