M.H. Tas

The Impact of Trimetazidine Treatment on Left Ventricular Functions and Plasma Brain Natriuretic Peptide Levels in Patients with Non-ST Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

Background and Objectives The aim of this study was to investigate the impact of treatment with oral trimetazidine (TMZ) applied before and after percutaneous coronary interventions (PCI) on short-term left ventricular functions and plasma brain natriuretic peptide (BNP) levels in patients with non-ST segment elevation myocardial infarction (NSTEMI) undergoing PCI. Subjects and Methods The study included 45 patients who were undergoing PCI with the diagnosis of NSTEMI. The patients were randomized into two groups. The first group (n=22) of the patients hospitalized with the diagnosis of NSTEMI was given conventional therapy plus 60 mg TMZ just prior to PCI. Treatment with TMZ was continued for one month after the procedure. TMZ treatment was not given to the second group (n=23). Echocardiography images were recorded and plasma BNP levels were measured just prior to the PCI and on the 1st and 30th days after PCI. Results The myocardial performance index (MPI) was greater in the second group (p=0.02). In the comparison of BNP levels, they significantly decreased in both of the groups during the 30-day follow-up period (29.0±8 and 50.6±33, p<0.01 respectively). However, decreasing of BNP levels was higher in the group administered with TMZ. The decrease of left ventriclular end-diastolic volume was observed in all groups at 30 days after intervention, but was higher in the group administered with TMZ (p=0.01). Conclusion Trimetazidine treatment commencing prior to PCI and continued after PCI in patients with NSTEMI provides improvements in MPI, left ventricular end diastolic volume and a decrease in BNP levels.

Mean platelet volume levels in patients with cardiac myxoma.

Abstract Thromboembolic events such as cerebrovascular stroke are common and serious complications in patients with cardiac myxomas (CMs). Previous studies have reported that a high mean platelet volume (MPV) level reflects an activated platelet function and has been proven to be an independent risk factor for thromboembolic events. The aim of this study was to evaluate the relation between MPV level and CM. We compared the MPV levels between patients with CM and control subjects, and also evaluated the differences in the MPV levels in patients with CM before and after a successful surgical treatment. Furthermore, we compared the MPV levels in patients with and without cerebrovascular embolic symptoms. Fifty-one consecutive patients (13 men, 38 women, mean age 51.1 ± 16.9 years) who underwent excision of CM in our hospital in the last 13 years and 50 normal subjects as the control group were included in this study. The patients with CM were divided into two groups according to the presence or absence of cerebrovascular embolic symptoms. The preoperative and postoperative MPV levels of each CM patient was evaluated. MPV levels were found to be significantly higher in patients with CM than in control subjects (9.86 ± 1.30 fL vs. 7.63 ± 0.78 fL, p < 0.001). Moreover, the MPV levels significantly decreased after the surgical removal of CM (9.86 ± 1.30 fL vs. 8.68 ± 1.20 fL, p < 0.001). We also found that the MPV values were significantly higher in patients with neurological embolic events (10.55 ± 1.29 fL vs. 9.59 ± 0.78 fL, p = 0.016). We conclude that increased MPV levels might be considered as a marker of increased thromboembolic risk in patients with CM.

Assesment of Myocardial Ischemia by Combination of Tissue Synchronisation Imaging and Dobutamine Stress Echocardiography

Background and Objectives Dobutamine stress echocardiography (DSE) is an important non-invasive imaging method for evaluating ischemia. However, wall motion interpretation can be impaired by the experience level of the interpreter and the subjectivity of the visual assessment. In our study we aimed to combine DSE and tissue syncronisation imaging to increase sensitivity for detecting ischemia. Subjects and Methods 50 patients with indications for DSE were included in the study. In 25 patients we found DSE positive for ischemia and in the other 25 patients we found it to be negative. The negative group was accepted as the control group. There was no significant difference in terms of risk factors and echocardiographic parameters between the two groups, except for wall motion scores. In both groups, left ventricular dyssychrony was accepted as the difference between time to peak systolic velocity (Ts) in the reciprocal four couple of non-apical segments at rest and during peak stress. Timings were corrected for heart rate. We compared the differences of the dyssynchronisation value at rest and during peak stress to determine the distinctions within the groups and between the groups of DSE positive and negative patients. Results We found that stress and ischemia did not create any significant difference over the left intraventricular dyssynchrony with DSE, although at the segmenter level it prolonged the time to peak systolic velocity (p<0.05). These alterations did not show any significant difference between positive and negative DSE groups. Conclusion As a result, this segmenter dyssynchrony and the time to peak systolic velocity, which is corrected for heart rate, did not enhance any new value over DSE for detecting ischemia.

Ventricular Tacyhcardia in A Patient with A Previous History of Endocarditis and Ankylosan Spondylitis: A Challenging Case

Cardiac conduction defects are commonly observed in patients with ankylosing spondylitis, infective endocarditis, and aortic valve replacement. Each of these clinical situations can also present with ventricular tacyhcardia by different mechanisms. Here we report the case of a 53-year-old man with a medical history of untreated ankylosing spondylitis and aortic valve replacement who presented with ventricular tachycardia and underwent successful catheter ablation. Most ventricular tachycardia episodes were intermittent and drug resistant, which could have been caused by abnormal automaticity rather than re-entry.

A challenging image during pacemaker implantation

This venographic appearance is compatible with venospasm. Although it is usually known as an arterial phenomenon, severe spasm can be seen in the central veins, as in this case. Venous spasm has been reported during right heart catheterizations and central venous catheter placements for digital subtraction angiography, with an incidence of 2% and 5%, respectively (1). Because of its strongest effect on the venous system, nitroglycerin is a reasonable approach for relieving the spasm. However, venous spasm may not resolve with nitroglycerin. As in our case and in two previously reported cases of central venous spasm during pacemaker implantation, incremental doses of intravenous nitroglycerin failed to relieve the venospasm (2, 3). Venous spasm during pacemaker implantation is a rare clinical entity, with only a few cases reported in the literature (2-4). The exact mechanism of venous spasm remains unknown, but it may be related to the chemical effect of the contrast or a mechanical effect of multiple needle punctures and guidewire placement (2). Paget-Schroetter syndrome is a form of upper extremity deep vein thrombosis that can occur spontaneously or after vigorous exercise. It is also known as effort thrombosis, and the pathogenesis involves extrinsic compression and repetitive injury of the subclavian vein between the first rib and overlying clavicle, particularly during strenuous activities involving arm elevation or exertion (5, 6). Subclavian vein and artery transposition is a very rare anomaly in which the subclavian vein and subclavian artery are switched in position or transposed. In this rare anatomic variation, the usual location of the subclavian artery (cephalad to the subclavian vein) is switched to caudal to the subclavian vein. In such cases, ultrasound imaging is necessary for understanding the anatomic relationship of the artery, vein, clavicle, and lung (7). Lead-induced venous thrombosis is reported in an average of 12% (range 2%-22%) of patients, from several days to 9 years after pacemaker implantation, and only 1% to 3% of patients with upper extremity venous thrombosis develop symptoms (8). In the hospital course and control visit, our patient had no signs or symptoms attributable to venous thrombosis. Indeed, there was no evidence for venous thrombosis on the venography (presence of a collateral vessel, a visible thrombus, and/or long length of the occlusion). Therefore, venous thrombosis is a much less likely possibility (9). This report highlights the importance of using venography after multiple unsuccessful attempts to puncture the subclavian vein and using hydrophilic guidewires in cases of venous spasm with successful cannulation and no good flashback. At the end of the procedure, a venography was performed again and revealed partial reversal of the venospasm (Fig. 3, Video 3). Yavuzer Koza, Ziya Şimşek, Muhammed Hakan Taş, Hüseyin Şenocak Department of Cardiology, Faculty of Medicine, Atatürk University; Erzurum-Turkey

Comparison of the effects of metoprolol or carvedilol on serum gamma-glutamyltransferase and uric acid levels among patients with acute coronary syndrome without ST segment elevation

Objective: Serum gamma-glutamyltransferase (GGT) and uric acid levels measured in patients with acute coronary syndrome without ST segment elevation (NSTEMI) are important in diagnosis and in predicting the prognosis of the disease. There is a limited number of clinical studies investigating the effects of beta-blockers on GGT and uric acid levels in these patients. In our study, we aimed to investigate the effects of beta-blocker therapy on GGT and uric acid levels. Methods: We conducted a randomized, prospective clinical study. Hundred patients with NSTEMI were included in this study, and they were divided into two groups. Fifty patients were administered metoprolol succinate treatment (1 × 50 mg), whereas the remaining 50 patients were administered carvedilol treatment (2 × 12.5 mg). Thereafter, all of the patients underwent coronary angiography. Blood samples were taken at the time of admission, at the 1st month, and 3rd month to detect GGT and uric acid levels. Results: There was no statistically significant difference among the metoprolol or carvedilol groups in terms of the GGT levels measured at the baseline, 1st month, and 3rd month (p=0.904 and p=0.573, respectively). In addition, there was no statistically significant difference among the metoprolol or carvedilol groups in terms of uric acid levels measured at the baseline, 1st month, and 3rd month (p=0.601 and p=0.601, respectively). Conclusion: We found that GGT and uric acid levels did not show any change compared to the baseline values, with metoprolol and carvedilol treatment initiated in the early period in patients with NSTEMI.

Hyponatremia and heart failure: the overlooked piece of the puzzle

Hyponatremia may occur with a high, low, or normal serum osmolality. Pseudohyponatremia is an artifact of measurement as a result of interference between abnormally high concentrations of lipids or proteins and sodium. In pseudohyponatremia, the serum osmolality is usually normal (1). In hypertonic hyponatremia, the serum osmolality is more than 295 mOsm/kg. Hypertonic hyponatremia occurs when the plasma contains an osmotically active substance such as mannitol or excess glucose. The serum Na concentration falls approximately by 1.6 mEq/L for every 100 mg/dL rise in the serum glucose concentration above the normal concentration (1). Hypovolemic hyponatremia is associated with a deficit in serum sodium and total body water. Sodium loss is more prominent than water loss. As sodium deficits can be due to renal or extrarenal losses, urine sodium may be <30 mmol/L or >30 mmol/L, respectively (2). In chronic heart failure, the incidence of hyponatremia is approximately 20–30%, and loop diuretics have less potential for causing hyponatremia than thiazides (2). In our patient, we considered hypotonic hyponatremia (effective serum osmolarity<275 mOsm/kg, urine sodium concentration<30 mmol/L, and high urine osmolality>1.003) as a consequence of water retention. Despite fluid restriction, ultrafiltration, and intravenous diuretic therapy, hyponatremia did not resolve. After reviewing the relevant literature, we did not find any possible offending drug other than thiazide or loop diuretics that could be associated with hyponatremia. However, according to 4766 reports from the FDA and social media, 4619 people reported having side effects when taking rivaroxaban. Among them, 8 (0.17%) had hyponatremia (3). As in our case, hyponatremia was found among those who take rivaroxaban, especially for those who are females, more than 60 years old, have been taking the drug for <1 month, also take medication hydrochlorothiazide, and have atrial fibrillation/flutter. After the cessation of rivaroxaban, serum sodium levels continuously increased, and the patient was discharged from the hospital with a serum sodium level of 136 mmol/L. At the two-week followup, her serum sodium level was 138 mmol/L.

The Association Between Aortic Pulse Wave Velocity and Chronic Kidney Disease

To the Editor: We read with interest the article entitled “Progression of Aortic Pulse Wave Velocity in Patients With Chronic Kidney Disease” by Tholen and colleagues in a recent issue of The Journal of Clinical Hypertension. They evaluated the natural progression of arterial stiffness (AS) in patients with chronic kidney disease (CKD). Age, systolic blood pressure (BP), and diabetes were associated with accelerated progression. Interestingly, loss of renal function had no significant impact. We have some comments about this study. The acute effects of hemodialysis on arterial stiffness parameters are still debatable. Therefore, we wonder about the number of patients receiving hemodialysis in the present study. Indeed, in hemodialyzed patients, arterial stiffness is associated with calcification and progressed with the progression of atherosclerosis. Although it has not been replicated, several studies have shown an association between AS and renal function in patients with CKD. In the study population, baseline aortic pulse wave velocity (PWV) levels are significantly different in the three groups. Also, this study includes patients at very high risk with a small cohort and results cannot be extrapolated to other clinical situations. bBlockers can limit the destiffening of the arterial wall or increase its stiffness. Tholen and associates did not give any information about drug usage other than statins and renin-angiotensin-aldosterone-system blockers. Aortic systolic BP increases with age and after 50 years of age, PWV increases and leads to augmentation of central systolic BP. Also, it can be influenced by diurnal variability in BP. Should it be expected to draw such a conclusion from only two measurements (baseline and after 12 months) as the authors suggested? Finally, long-term arterial remodeling, which may need several months to develop, contributes to the normalization of AS beyond BP-lowering. Therefore, we question the statement that highlights 1 year as a short time interval in the discussion section.

An Aortic Pseudoaneurysm following Bentall Procedure.

We describe a rare case of an ascending aortic pseudoaneurysm detected incidentally at coronary angiography in a 64-year-old man with a history of a Bentall procedure 8 years previously. The patient underwent reoperation, with longitudinal opening and cleaning of the aortic pseudoaneurysm and graft repair of the defect. This report highlights the insidious late onset of pseudoaneurysm and the importance of its detection and treatment.

Effects of radiofrequency ablation on levels of cardiac biochemical markers in patients with atrioventricular nodal re-entry tachycardia.

Address for Correspondence/Yaz›şma Adresi: Dr. Ziya Şimşek, Osmangazi Mah. Tuna Sok. Gökdemir Sitesi A Blok K:6 D:29 25100, Erzurum-Türkiye Phone: +90 442 231 84 82 E-mail: ziyamposta@hotmail.com Accepted Date/Kabul Tarihi: 25.04.2013 Available Online Date/Çevrimiçi Yayın Tarihi: 26.09.2013 ©Telif Hakk› 2013 AVES Yay›nc›l›k Ltd. Şti. Makale metnine www.anakarder.com web sayfas›ndan ulaş›labilir. ©Copyright 2013 by AVES Yay›nc›l›k Ltd. Available on-line at www.anakarder.com doi:10.5152/akd.2013.229 Hakan Duman, Ziya Şimşek, M. Hakan Taş, Fuat Gündoğdu, Hüsnü Değirmenci, Eftal M. Bakırcı, Selami Demirelli, Hikmet Hamur, Orhan Demir