Mehmet Bostan

The importance of fragmented QRS complexes in prediction of myocardial infarction and reperfusion parameters in patients undergoing primary percutaneous coronary intervention.

OBJECTIVES The QRS complex fragmentations (fQRS) frequently seen on admission electrocardiograms (ECGs) with narrow or wide QRS complex are associated with increased morbidity and mortality. The causative relationship between fQRS and cardiac fibrosis is known, but the relation of fragmented QRS before and after primary percutaneous coronary intervention (p-PCI) with myocardial infarction and reperfusion parameters has not been studied until now. STUDY DESIGN The study included 184 consecutive patients with ST elevation myocardial infarction (STEMI) who underwent p-PCI. Presence or absence of fQRS on pre- and post-PCI ECGs and its change following PCI were investigated. In addition, independent predictors of fQRS were also investigated. Patients with significant organic valve disease and patients having any QRS morphology with QRS duration ?120 ms as well as patients with permanent pacemakers were excluded from the study. RESULTS Patients with fQRS on admission ECG had higher leukocyte counts (p=0.001), higher CK-MB (p=0.001) and troponin levels (p=0.005), increased pain to balloon time (p=0.004), higher Killip score (p<0.001), prolonged QRS time (p<0.001), higher Gensini score (p<0.001) and more frequent Q waves on ECG (p<0.001) in comparison to patients with non-fragmented QRS. In addition, these patients usually had an infarction of anterior territory related to a lesion in proximal LAD and wider jeopardized myocardium (p<0.001). fQRS was significantly related to infarction and myocardial reperfusion parameters before and after p-PCI. In the setting of STEMI, absence of fQRS on admission ECG predicted increased ST resolution, higher reduction in QRS duration, and better myocardial reperfusion. CONCLUSION FQRS may be useful in identifying patients at higher cardiac risk with larger areas of ischemic jeopardized or necrotic myocardium.

The Independent Relationship of Systemic Inflammation With Fragmented QRS Complexes in Patients With Acute Coronary Syndromes

Background and Objectives QRS complex fragmentations are frequently seen on routine electrocardiograms with narrow or wide QRS complex. Fragmented QRS complex (fQRS) is associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events. In this study, we aimed to interrogate the relationship of systemic inflammation with the presence of fQRS in patients with acute coronary syndromes (ACS). Subjects and Methods Two-hundred and twenty eligible patients with ACS that underwent coronary angiography were enrolled consecutively in this study. Patients with significant organic valve disease and those with any QRS morphology that had a QRS duration ≥120 ms as well as patients with permanent pacemakers were excluded from this study. Results Patients with fQRS were of a higher age (p=0.02), had increased C-reactive protein (CRP) levels (p<0.001), prolonged QRS time (p<0.001), extent of coronary artery disease (CAD) (p<0.001), creatine kinase-MB (CK-MB) levels (p=0.006) and Q wave on admission electrocardiography (p<0.001) in comparison to patients with non-fragmented QRS. When we performed multiple logistic regression analysis, fQRS was found to be related to increased CRP levels {odds ratio (OR): 1.2, 95% confidence interval (CI): 1.045-1.316, p=0.007}, QRS duration (OR: 1.1, 95% CI: 1.033-1.098, p<0.001), extent of CAD (OR: 1.5, 95% CI: 1.023-2.144, p=0.037), Q wave (OR: 2.2, 95% CI: 1.084-4.598, p=0.03) and CK-MB levels (OR: 1.0, 95% CI: 1.001-1.037, p=0.04) independently. Conclusion In our study, we found that fQRS was independently related to increased CRP. Fragmented QRS that may result as an end effect of inflammation at cellular level can represent increased cardiac risk by different causative mechanisms in patients with ACS.

Relationship of fragmented QRS with prognostic markers and in-hospital MACE in patients undergoing CABG

Abstract Background. Fragmented QRS complex (fQRS) is associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events. However, its prognostic role has not been studied comprehensively in patients undergoing coronary artery bypass graft (CABG) surgery. In this study, we investigated the relationship between the presence of fQRS, and the prognostic markers and in-hospital major adverse cardiovascular events (MACE). Methods. Two hundred and forty two eligible patients who underwent CABG surgery at our institution were enrolled consecutively. In analysis of fragmentations on electrocardiograms, presence of fQRS was defined as various RSR′ patterns (≥ 1 R′ or notching of S wave or R wave) with or without Q waves without a typical bundle-branch block in two contiguous leads corresponding to a major coronary artery territory. MACE was defined as cardiac death, recurrent myocardial infarction, heart failure, cerebrovascular event, sustained ventricular tachycardia or fibrillation. Results. Patients with fragmented QRS had older age (64 ± 10 vs. 61 ± 9 years, p = 0.03), prolonged QRS time (99 ± 11 vs. 87 ± 11 ms, p < 0.001), higher rate of Q wave on ECG (29% vs. 12%, p = 0.001), higher European system for cardiac operative risk evaluation (EUROSCORE) (4.0 ± 1.9 vs. 2.6 ± 1.6, p < 0.001) and lower left ventricular ejection fraction (LVEF)% (43 ± 12 vs. 60 ± 12, p < 0.001) in comparison to patients with non-fragmented QRS. In addition, the patients with fQRS had longer cross-clamp time (67 ± 23 vs. 55 ± 20 minutes, p = 0.001) and extracorporeal circulation (105 ± 31 vs. 91 ± 30 minutes, p = 0.003), increased inotropic usage (p < 0.001) and prolonged cardiac surgery intensive care unit (53 ± 25 vs. 35 ± 12 hours, p < 0.001) and in-hospital stay after CABG. Conclusion. FQRS may have additional value in the assessment of cardiac function and in prediction of intra- and post-operative hemodynamic instability and adverse cardiovascular events. Fragmentations on admission ECG may be useful for identifying patients with higher risk who will need additional support after CABG surgery.

Relationship of fragmented QRS complexes with inadequate coronary collaterals in patients with chronic total occlusion.

Background Fragmented QRS (fQRS) complexes are defined as various RSR′ patterns (≥1 R′ or notching of S wave or R wave) in two contiguous leads corresponding to a major coronary artery territory. In previous studies, fQRS has been associated with increased morbidity and mortality, sudden cardiac death and recurrent cardiovascular events (CVEs). The causative relationship between fQRS and cardiac fibrosis has been shown in prior studies. The association between inadequate (poor) coronary collaterals and presence of fQRS has not comprehensively been studied in patients with chronic total occlusion (CTO) until now. We tested the hypothesis that the presence of fQRS is associated with inadequate coronary collateral growth. Methods This study had a cross-sectional observational design. The study population consisted of patients who underwent coronary angiography with the suspicion of coronary artery disease at our institution in an outpatient manner. Patients who had CTO in at least one major epicardial coronary artery were included. Coronary angiograms of 148 eligible patients from our database were analyzed again. Ninety-three patients had good and 55 had poor collateral development according to the Cohen–Rentrop method. Results Patients with poor collateral development had higher plasma glucose (130 ± 54 vs. 116 ± 33 mg/dl, P = 0.047) and an older age (65 ± 10 vs. 61 ± 10 years, P = 0.042) in comparison to patients with good collateral growth. The presence and number of fQRS were higher in the poor collateral group than the good collateral group (64 vs. 32%, P < 0.001 and 2.3 ± 2.4 vs. 1.2 ± 2.0, P = 0.002, respectively). Left ventricular ejection fraction was significantly lower in the poor collateral group than the good collateral group (45 ± 11 vs. 51 ± 13, P = 0.014). There was a significant correlation between number of fQRSs and the echocardiographic wall-motion abnormality score (r = 0.662, P < 0.001). In multivariate analysis, only the presence of fQRS was independently related to poor collateral development (odds ratio, 3.559; 95% confidence interval, 1.708–7.415, P = 0.001). Conclusion We found that fQRS was independently related to inadequate coronary collaterals in patients with CTO. fQRS, which may be derived from the effects of myocardial ischemia or scar on myocardial electricity at the cellular level, can represent inadequate coronary collateral development in patients with CTO.

The impact of hypertension on retinal nerve fiber layer thickness and its association with carotid intima media thickness

Abstract Objective. Our aim was to investigate retinal nerve fiber layer (RNFL) thickness in hypertensive patients using spectral-domain optical coherence tomography (SD-OCT) and to evaluate the relationship between RNFL thickness and carotid intima media thickness (CIMT). Methods. This study included 59 patients with hypertension (HT) (53.6 ± 10.7 years) and 54 age-matched healthy controls (51.0 ± 8.1 years). We evaluated anthropometric and metabolic parameters as well as RNFL and CIMT measurements in patients with hypertension and controls. Results. The average RNFL thickness was 86.60 ± 10.86 μm in hypertensive patients and 93.63 ± 7.30 μm in healthy controls (p < 0.001). Selective thinning of the RNFL was found in the superior and inferior quadrants. Mean CIMT values were higher in patients with HT (0.80 ± 0.15 mm) than the healthy subjects (0.71 ± 0.1 mm) (p < 0.001). The average, inferior and nasal RNFL thickness were negatively associated with diastolic blood pressure respectively (r = − 0.112, r = − 0.210, r = − 0.225). There was an inverse correlation between RNFL thickness in the average and superior retinal quadrant and CIMT (r = − 0.201, r = − 0.185). There were no correlations between RNFL thickness and age, body mass index, fasting plasma glucose, lipid parameters, high-sensitive C-reactive protein and microalbuminuria. Conclusion. RNFL thickness is reduced in hypertensive patients and may be associated with atherosclerosis.

The relationship between retinal nerve fiber layer thickness and carotid intima media thickness in patients with type 2 diabetes mellitus

AIMS The aim of the present study was to investigate retinal nerve fiber layer (RNFL) thickness in patients with type 2 diabetes mellitus (T2D) using spectral-domain optical coherence tomography and to evaluate the relationship between RNFL thickness and carotid intima media thickness (CIMT). METHODS This study included 171 patients with T2D (53.2 ± 8.8 years) and age matched 61 healthy controls (51.9 ± 8.1 years). We evaluated anthropometric and metabolic parameters as well as RNFL and CIMT measurements in patients with T2D and controls. The Mann-Whitney U test was used to compare the continuous variables and the Chi-square test was used to compare categorical variables. Spearmans rank correlation test was used for calculation of associations between variables. RESULTS The average RNFL thickness was 84.82 ± 11.22 μm in patients with T2D and 92.35 ± 8.45 μm in healthy controls (p<0.001). Mean CIMT values were higher in patients with T2D (0.80 ± 0.1mm) than the healthy subjects (0.72 ± 0.1mm) (p<0.001). A significant negative correlation was found between age and all quadrants of RNFL. There was a negative correlation between average RNFL thickness and HbA1c (r=-0.176), uric acid (r=-0.145), CIMT (r=-0.190) and presence of carotid plaque (r=-0.193). The superior RNFL thickness was negatively associated with HbA1c (r=-0.175), CIMT (r=-0.207) and carotid plaque (r=-0.176). There was also an inverse correlation between the inferior RNFL thickness and HbA1c (r=-0.187) and carotid plaque (r=-0.157). CONCLUSION Thinning of RNFL might be associated with atherosclerosis in patients with T2D.

Successful thrombolysis using recombinant tissue plasminogen activator in cases of severe pulmonary embolism with mobile thrombi in the right atrium.

Hereby, we report two cases of acute pulmonary embolism with concomitant right-sided thrombus, which were successfully treated using recombinant tissue plasminogen activator (rtPA). These patients had life-threatening acute right ventricular failure, which dramatically improved within hours following thrombolysis. These cases emphasize the clinical utility of rtPA for the treatment of life-threatening pulmonary embolism.

Relation of Angiographic Thrombus Burden with Severity of Coronary Artery Disease in Patients with ST Segment Elevation Myocardial Infarction

Background We planned to investigate the relationship of thrombus burden with SYNTAX score in patients with ST elevation myocardial infarction (STEMI). Material/Methods We retrospectively enrolled 780 patients who underwent PPCI in our clinic due to STEMI. Clinical, laboratory, and demographic properties of the patients were recorded. Angiographic coronary thrombus burden was classified using thrombolysis in myocardial infarction (TIMI) thrombus grades. Results Patients with high thrombus burden were older, with higher diabetes prevalence longer pain to balloon time, higher leukocyte count, higher admission troponin, and admission CK-MB concentrations. SYNTAX score was higher and myocardial perfusion grades were lower in patients with high thrombus burden. Multivariate logistic regression analysis revealed SYNTAX score as the strongest predictor of thrombus burden. ROC analysis demonstrated a sensitivity of 75.5%, specificity of 61.2%, and cut-off value of >14 (area under the curve (AUC): 0.702; 95% confidence interval [CI]: 0.773–0.874;P<0.001) for high thrombus burden. Conclusions SYNTAX score may have additional value in predicting higher thrombus burden besides being a marker of coronary artery disease severity and complexity.

Retrieval of embolized tip of port catheter from branch of right pulmonary artery using a macro snare catheter.

Rupture of the silicon port catheter is a relatively rare complication. Ruptured part usually embolizes; therefore, removal of foreign body may be difficult. These ports usually migrate to right-sided chambers, main pulmonary arteries, and pulmonary subbranches. Different devices such as snares, basket catheters, and ablation catheters are utilized for retrieval. Hereby, we report successful extraction of an embolized 10-cm tip of a vascular access port using a macro snare catheter.

A rare complication: Undeflatable balloon of the stent

Percutaneous coronary intervention is an important modality in the treatment of coronary artery disease. These procedures are usually completed successfully, but occasionally serious complications are encountered. In this paper, we present the case of an undeflatable stent balloon, which is an extremely rare complication that has not been described in the literature.