Korhan Soylu

Late pacemaker twiddler syndrome

Dr. Ihsan Dursun, MD ()) · Prof. Osman Yesildag, FESC Korhan Soylu, MD · Prof. Ozcan Yilmaz · Erdogan Yasar, Tech Murat Meric, MD Ondokuz Mayis Universitesi Tip Fakultesi, Kardiyoloji Bolumu 55139 Kurupelit Samsun/Turkey Tel.: 90-5 32 / 4 30 87 62 Fax: 90-3 62 / 4 57 60 41 E-Mail: ihsandursun@mynet.com Sirs: Twiddler syndrome, known as the rolling up of the pacemaker battery within the pacemaker pocket, was first described in 1968 by Bayliss et al. [1]. Frequently, twisting of the pacemaker battery within the pacemaker pocket ends with the dislocation of the electrode, diaphragmatic stimulation and the loss of capture [2]. This situation is not limited to only cardiac pacemaker batteries. It has also been observed in implantable cardioverter defibrillators [3]. Symptoms begin with the twisting of the pacemaker battery within the pacemaker pocket in which it is implanted. The capture problem is a result of the dislocation of the electrode. Hypoperfusion symptoms such as fatigue, tiredness, confusion, presyncope and syncope can be observed if the patient is completely dependent on the cardiac pacemaker [4]. Except the symptoms related with the failure of the cardiac pacemaker, other symptoms are also observed frequently as well due to the damage of the neigbouring organs. Ipsilateral phrenic nerve stimulation concludes the sensation of the diaphragmatic and abdominal pulsations. Additionally, if the electrodes become more twisted around the battery, rhythmic arm movements can occur due to the stimulation of the brachial plexus [5]. However not all cases display clinical symptoms [3]. Capture or pace problems can also be observed in the electrocardiography (ECG). The ECG is also abnormal if the electrode dislocates intermittently. On a chest X-ray, the electrodes can be seen as bent, twisted or dislocated and fractured [4].

The relationship of coronary flow to neutrophil/lymphocyte ratio in patients undergoing primary percutaneous coronary intervention

PURPOSE It has been known that inflammatory mechanisms play an important role in the coronary artery disease. Our aim in this study was to investigate the relationship between the neutrophil/lymphocyte (N/L) ratio and coronary flow velocity after primary percutaneous coronary intervention (PCI) in patients presenting with ST-segment elevation myocardial infarction (STEMI). METHODS Two hundred and ten patients who had undergone primary PCI were included. The coronary flow velocities were evaluated using the recorded PCI procedures by Thrombolysis in Myocardial Infarction (TIMI) flow grades and corrected TIMI frame counts (cTFC) values. A value of >40 for the final cTFC was accepted as an index of insufficient coronary blood flow. The white blood cell subtypes and counts were determined in the blood samples obtained at the clinics. RESULTS In 165 (78%) of the investigated patients, reperfusion was found to be sufficient (Group I) while in 45 (22%) of them (Group II) insufficient reperfusion was observed (Group II). In-hospital mortality was 7.2% (n=12) in Group I, whereas it was 17.7% (n=8) in Group II (P=0.033). Similarly, one-year mortality was higher in Group II (26.6%, n=12) than in Group I (13.3%, n=22) (P=0.031). N/L ratio was determined to be higher in Group I than in Group II (8.3±6.1 vs. 6.2±5.0; P=0.034). Also, N/L ratio was found as an independent predictor of severe no-reflow development (TIMI 0-1) and of one-year mortality (P=0.01 and P=0.047, respectively). CONCLUSIONS N/L ratio has been found to be an independent indicator for no-reflow development in patients who have undergone PCI for acute STEMI. This simple and low-cost parameter can provide useful information for the relevant risk evaluation in these patients.

Longitudinal Diastolic Myocardial Functions Are Affected by Chronic Smoking in Young Healthy People: A Study of Color Tissue Doppler Imaging

Aims: Many cardiac and hemodynamic alterations occur after acute consumption of cigarettes. The aim of this study is to evaluate the effect of chronic smoking on longitudinal myocardial functions of left ventricle in young, healthy people by using color tissue Doppler imaging modalities. Methods and Results: Ninety‐nine healthy participants were studied. There were 65 smokers and 34 nonsmokers. All subjects were between 20 and 35 years old. Sample volumes were placed on the mid left ventricle in the inner half of the myocardium at the septum, lateral, inferior, and anterior walls. The peak systolic strain (S‐S), peak systolic strain rate (S‐SR), peak early diastolic SR (E‐SR), peak late diastolic SR (A‐SR), peak systolic tissue velocity (S‐TV), peak early diastolic TV (E‐TV), and peak late diastolic TV (A‐TV) values were measured. For the systolic parameters S‐S, S‐SR, and S‐TV values were not different between the groups. For the diastolic parameters smokers had lower E‐SR and E‐TV values than nonsmokers (P = 0.03 for both). Although there was a trend toward higher A‐SR and A‐TV values in the smokers, they were not reaching the statistical significance. Conclusion: Chronic smoking in young, healthy people causes significant alterations in the longitudinal diastolic myocardial function parameters as assessed by color tissue Doppler imaging.

The relationship between epicardial fat thickness and gestational diabetes mellitus

AimGestational diabetes mellitus (GDM) is associated with cardiovascular diseases; however, the relationship between epicardial fat thickness (EFT) and GDM remains unclear. The present study evaluates and compares EFT using transthoracic echocardiography in pregnant women with GDM.Materials and methodsThis cross-sectional study included 129 pregnant women in the third trimester: 65 with GDM (GDM group) and 64 with uncomplicated pregnancies (control group). As defined by the World Health Organization, the diagnosis of GDM was based on an abnormal 2-h oral glucose tolerance test (OGTT) results. We used echocardiography to measure EFT in blood samples for all the participants.ResultsThe postprandial blood glucose level was significantly higher in the GDM group than in the control group (P < 0.001). There were no significant differences in BMI, heart rate, systolic and diastolic blood pressure or lipid parameters between the groups. In the GDM group, isovolumic relaxation time (IVRT) parameters were significantly higher than in the control group. EFT was significantly higher in the GDM group (P < 0.001) and was correlated with postprandial glucose, BMI, age, and heart rate in both the groups. Only postprandial glucose and BMI remained significantly associated with EFT after multiple stepwise regression analysis.ConclusionEchocardiographically measured EFT was significantly higher in the patients with GDM. The findings show that EFT was strongly correlated with postprandial glucose.

Serum neutrophil gelatinase-associated lipocalin levels are correlated with the complexity and the severity of atherosclerosis in acute coronary syndrome

Objective: Neutrophil gelatinase-associated lipocalin (NGAL) is a novel inflammatory marker that is released from neutrophils. In this study, we evaluated the correlation between serum NGAL level and clinical and angiographic risk scores in patients diagnosed with non-ST elevation acute coronary syndrome (NSTE-ACS). Methods: Forty-seven random NSTE-ACS patients and 45 patients with normal coronary arteries (NCA) who underwent coronary angiography were enrolled in the study. GRACE risk score and SYNTAX and Gensini risk scores were used, respectively, for the purpose of clinical risk assessment and angiographic risk scoring. Serum NGAL level was measured via ELISA in peripheral blood samples obtained from the patients at the time of admission. Results: Serum NGAL level was significantly higher in the NSTE-ACS group compared to the control group (112.3±49.6 ng/mL vs. 58.1±24.3 ng/mL, p<0.001). There was a significant positive correlation between serum NGAL levels and the GRACE (r=0.533 and p<0.001), SYNTAX (r=0.395 and p=0.006), and Gensini risk scores (r=0.575 and p<0.001). The intermediate-high SYNTAX (>22) group had statistically significantly higher serum NGAL levels compared to the low SYNTAX (≤22) group (143±29.5 ng/mL vs. 98.7±43.2 ng/mL, p=0.001). Conclusion: NGAL level was positively correlated with lesion complexity and severity of coronary artery disease in patients with NSTE-ACS. Serum NGAL levels on admission are associated with increased burden of atherosclerosis in patients with NSTE-ACS.

Evaluation of the Relationship Between Arterial Blood Pressure, Aortic Stiffness and Serum Endothelin-1 Levels in Patients with Essential Hypertension

This study has attempted to evaluate the relationship between aortic stiffness, blood pressure (BP) and serum endothelin-1 (ET-1) levels in patients with essential HT. Totally 152 subjects, consisting of 103 patients diagnosed with HT at least 1 year previously and 49 healthy individuals, were enrolled in this study. They were subdivided, on the basis of BP measurements made at home, into three groups as the hypertensives with dysregulated BP (n = 56), the hypertensives with regulated BP (n = 47) and the normotensive controls (n = 49). Statistically significant differences were observed between the three groups with respect to aortic elasticity parameters (p < 0.01 for aortic strain, aortic distensibility and aortic stiffness). Serum ET-1 levels in the three groups were similar (p = 0.101), but a significant correlation was observed between the ET-1 values and the aortic elasticity parameters (p = 0.004). Alteration of the aortic elasticity parameters in patients with HT not only correlates with the serum ET-1 levels indicating endothelial dysfunction but also gives direct clues about status of BP regulation.

Neutrophil-to-lymphocyte ratio for the assessment of hospital mortality in patients with acute pulmonary embolism.

Introduction Neutrophil-to-lymphocyte ratio (NLR), which is an essential marker of inflammation, has been shown to be associated with adverse outcomes in various cardiovascular diseases in the literature. In this study we sought to evaluate the association between NLR and prognosis of acute pulmonary embolism (APE). Material and methods We retrospectively evaluated blood counts and clinical data of 142 patients with the diagnosis of pulmonary embolism (PE) from Ondokuz Mayis University Hospital between January 2006 and December 2012. The patients were divided into two groups according to NLR: NLR < 4.4 (low NLR group, n = 71) and NLR ≥ 4.4 (high NLR group, n = 71). Results Massive embolism (66.2% vs. 36.6%, p < 0.001) and in-hospital mortality (21.1%, 1.4%, p < 0.001) were higher in the high NLR group. In multivariate regression analysis NLR ≥ 5.7, systolic blood pressure (BP) < 90 mm Hg, serum glucose > 126 mg/dl, heart rate > 110 beats/min, and PCO2 < 35 or > 50 mm Hg were predictors of in-hospital mortality. The optimal NLR cutoff value was 5.7 for mortality in receiver operating characteristic (ROC) analysis. Having an NLR value above 5.7 was found to be associated with a 10.8 times higher mortality rate than an NLR value below 5.7. Conclusions In patients presenting with APE, NLR value is an independent predictor of in-hospital mortality and may be used for clinical risk classification.

Is galectin-3 a biomarker, a player-or both-in the presence of coronary atherosclerosis?

Atherosclerosis is a complex process mediated by leukocytes, macrophages and various inflammatory markers. Galectin-3 is secreted by activated macrophages and is involved in cardiac fibrosis, cardiac remodeling, and inflammation. The present study aimed to determine the relationship between the presence and severity of coronary artery disease (CAD) and serum galectin-3 levels. The study included 82 patients with CAD confirmed via coronary angiography and 82 healthy participants as control group. Angiographic CAD was defined as ≥50% luminal diameter stenosis of at least one major epicardial coronary artery. The severity of CAD was determined by the Gensini score; and the serum galectin-3 levels were measured via ELISA. Serum galectin-3 levels were significantly higher in the patient group with CAD than in the control group (12.96±4.92 vs 5.52±1.9 ng/mL, p<0.001). In the correlation analysis, serum galectin-3 showed significant correlation with the Gensini score (r=0.715, p<0.001), number of diseased vessels (r=0.752, p<0.001) and serum hs-CRP level (r=0.607, p<0.001). In addition, multivariate logistic regression analysis showed that the serum galectin-3 levels were significant and independent predictors of the presence of angiographic CAD (OR=3.933, 95% CI 2.395 to 6.457; p<0.001). In the present study, the serum galectin-3 levels were higher in the patients with CAD than in healthy controls. Also, serum galectin-3 levels showed a significant positive correlation with the severity of CAD. An increased serum galectin-3 level may be considered an important activator and a marker of the atherosclerotic inflammatory process in CAD.

Evaluation of plasma chemerin levels in patients with non-dipper blood pressure patterns

Background Chemerin is a novel adipokine that plays a role in inflammation and atherosclerosis. Although there are several correlations between hypertension and the inflammatory system, there is still insufficient information about the relationship between blood pressure variability and inflammatory markers. In this study, we aimed to determine whether chemerin levels are elevated in non-dipper patients compared with dippers and healthy controls. Material/Methods This study was composed of a group of 90 patients: 60 hypertensive patients and 30 healthy control subjects (12 males, mean age 53.2±15.4 years). Ambulatory blood pressure monitoring devices (ABPM) were connected to all patients. Using data from the ABPM, hypertensive patients were divided into 2 groups: 30 dipper patients (12 males, mean age 52.5±15.1 years) and 30 non-dipper patients (11 males, mean age 54.6±13.0 years). Complete blood count and biochemistry were measured by standard methods and plasma chemerin concentrations were quantified by ELISA. Results Non-dipper patients demonstrated higher chemerin levels compared to dippers and normotensives (219.7±16.3 vs. 182.4±21.4 ng/ml; 219.7±16.3 vs. 85.4±38.1 ng/ml, respectively, p<0.001 for both comparisons). A receiver operating characteristic curve analysis revealed that the optimal cut-off value for chemerin to predict a non-dipping pattern was 201.4, with 90% sensitivity and 90% specificity. There was a positive correlation between chemerin levels and all ambulatory blood pressure values in all hypertensive patients. Conclusions Chemerin, which plays a role in inflammation and atherosclerosis, was higher in non-dippers compared to dippers and normotensives. Additionally, chemerin shows positive correlations with blood pressure.

A Forgotten Guidewire Causing Intracardiac Multiple Thrombi With Paradoxical and Pulmonary Embolism

A woman aged 70 years was transferred from another medical centre to our hospital because of shortness of breath, hemoptysis, and ischemic changes in the right foot (Fig. 1A). She had chronic renal failure and had been enrolled in a hemodialysis treatment program for 6 years. Transesophageal echocardiography showed a guidewire in the right atrium and right ventricle, with multiple mobile thrombi attached to it. The guidewire entered the right atrium through the superior vena cava, passed into the right ventricle through the lateral tricuspid valve annulus, and then looped in the right ventricle. One of the thrombi was entrapped within a patent foramen ovale and oscillated between right and left atria (Fig. 1B; Video 1 ; view video online). Pulmonary computed tomography angiography showed emboli in the segmental artery of the right lower lobe and a subsegmental artery of the left lower lobe. Because of the precarious state of the patient and the risk of further emboli, it was decided to take the patient for emergency cardiac surgery. The intracardiac guidewire and multiple thrombi were removed successfully (Fig. 1C). Unfortunately, because of multiple comorbidities, hemodynamic instability, and profound acidosis, she died on the second postoperative day. Vascular interventional procedures are widely used, resulting in increased complication rates. Guidewire loss may lead to thrombosis, embolism, sepsis, arrhythmia, or perforation. Loss of a complete guidewire is a rarely reported complication. Percutaneous retrieval is the preferred treatment, with low complication and high success rates. Various devices and techniques, such as loop snares, 2-wire or triplewire technique, basket retrievers, special catheters, grasping