Mehmet Emre Özpelit

Prognostic value of neutrophil-to-lymphocyte ratio in pulmonary arterial hypertension

Objective To evaluate the prognostic value of baseline neutrophil-to-lymphocyte ratio (NLR) in the prediction of long-term mortality in patients with pulmonary arterial hypertension (PAH). Methods This prospective study recorded NLR during initial diagnostic right-sided cardiac catheterization in adult patients with PAH. Demographic, clinical, laboratory and haemodynamic variables were compared by NLR tertile. Univariate and multivariate Cox regression analyses were used to determine whether NLR was independently associated with mortality. Results Adults with PAH (n = 101) were followed-up for mean ± SD 36.8 ± 23.6 months. The number of deaths, New York Heart Association functional capacity (NYHA FC), levels of brain natriuretic peptide (BNP) or C-reactive protein (CRP) and presence of pericardial effusion increased as the NLR tertile increased, but haemoglobin and tricuspid plane annular systolic excursion (TAPSE) decreased. On univariate analysis, high NLR values were associated with mortality, but on multivariate analysis, NLR did not remain an independent predictor of mortality. Baseline NYHA FC, TAPSE, BNP level and pericardial effusion were independent predictors of mortality. Conclusions NLR was correlated with important prognostic markers in PAH such as NYHA FC, BNP and TAPSE. This simple marker may be useful in the assessment of disease severity in patients with PAH.

Rapid retraction of a post-infarction intramyocardial dissecting hematoma.

A 60-year-old male with a recent anterior myocardial infarction (MI) was referred to our hospital for implantable cardioverter defibrillator (ICD) implantation. He was on the 42nd day of MI and clinically stable on admission. Electrocardiography showed right bundle branch block with QS pattern on anterior leads. Transthoracic echocardiographic examination revealed an ejection fraction of 25% with akinesis of the apex and mid-apical segments of anterior and septal walls. In the apical-septal region, a pulsatile cavity with systolic expansion surrounded by a thin endomyocardial border was visualized. Color-Doppler interrogation did not demonstrate any flow within that structure. These findings suggested an intramyocardial dissecting hemorrhage formed after MI. Cardiac magnetic resonance imaging also confirmed an intramyocardial hematoma in the mid-apical anteroseptal region. A conservative approach was assumed as the patient was hemodynamically stable. The planned ICD implantation was postponed due to the high risk of perforation. Subsequently, oral anticoagulant therapy with warfarin was initiated against risk of intracardiac thrombus formation. The existing dual antiplatelet therapy was also continued. One week after hospital discharge, he was rehospitalized due to a very high INR of 6.3. The repeated transthoracic echocardiography revealed an almost complete resolution of the intramyocardial dissecting hematoma and adhesion of the surrounding myocardial layers. Oral anticoagulant therapy was discontinued. Echocardiographic examinations showed no change compared to the last examination during hospitalization. This case illustrates a conservatively managed intramyocardial dissecting hematoma case, in which anticoagulant and antiaggregant therapy yielded a rapid retraction without any complication.

Ergotamine-Induced Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TC) is a recently increasing diagnosed disease showed by transient apical or mid-apical left ventricular dysfunction. It is known as a disease of postmenopausal women, which is usually triggered by emotional or physical stress. Although the trigger is mostly endogenous, some drugs have also been reported as the cause. Published case reports of TC associated with drug usage consist of sympathomimetic drugs, inotropic agents, thyroid hormone, cocaine, and 5-fluorouracil. We present an unusual case of TC in which the possible trigger is ergotamine toxicity.

Severe tricuspid regurgitation mimicking constrictive pericarditis

Patient: Female, 62 Final Diagnosis: Tricuspid regurgitation Symptoms: Dyspnea exertional • fatigue • leg edema Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Challenging differential diagnosis Background: Tricuspid regurgitation (TR) can mimic some hemodynamic findings of constrictive pericarditis (CP), due to the restraining effect of the enlarged right heart on intact pericardium and on the left ventricle. In this article, we report a case of severe tricuspid regurgitation in which hemodynamic findings were consistent with CP. Case Report: A 62-year-old Caucasian woman presented with right heart failure symptoms. Echocardiography showed enlarged right heart chambers and severe tricuspid regurgitation. Right heart catheterization surprisingly demonstrated a constrictive physiology. Diastolic pressures of both ventricles were elevated and equalized, with a prominent deep and plateau pattern. The patient was re-evaluated with a further focus on constrictive pericarditis. However, echocardiography, thorax CT, and cardiac MRI did not demonstrate any pathological finding related to pericardium. The remaining explanation was that the severe TR itself and secondary right heart enlargement caused the restraining effect on the intact pericardium and on the left ventricle. The pericardium was normal and tricuspid annulus was severely dilated on surgical inspection. The tricuspid valve was replaced with a bioprosthetic valve. The patient did well just after the surgery, with a rapid decrease in cardiac pressures; however, she died due to respiratory failure on the 15th postoperative day. Conclusions: This was a case with right heart failure symptoms in which invasive hemodynamic findings were consistent with constrictive pericarditis and the noninvasive imaging modalities were not. This case illustrates that severe TR can mimic some hemodynamic findings of constrictive pericarditis, due to restraining effect of the enlarged right heart on intact pericardium and on the left ventricle. Lack of significant respiratory changes in hemodynamic parameters that can safely be demonstrated by echocardiography and cardiac MRI suggest a normal pericardium.

Optimal treatment of unligated side branch of internal mammary artery: Coil, amplatzer vascular plug or graft stent? A case report and literature review.

Coronary artery steal syndromes may occur following coronary artery bypass grafting as a result of the presence of large side-branches arising from the internal mammary artery (IMA). Coil embolization, Amplatzer Vascular Plug and graft stents are all used for the treatment of such syndromes. The literature contains limited data on the long-term success of these treatment methods. There is no large series regarding occluded IMA side branches causing coronary steal phenomena, and data on long-term follow-up of this treatment method is also very limited. This report presented two cases and their treatment, and reviewed the advantages and disadvantages of treatment methods and the factors that affect successful treatment.

Directly ventricular septal defect closure without using arteriovenous wire loop: Our adult case series using transarterial retrograde approach

Objective: The standard transcatheter ventricular septal defects (VSD) closure procedure is established with arteriovenous (AV) loop and is called as antegrade approach. The directly retrograde transarterial VSD closure without using AV loop might be better option as shortens the procedure time and decreases radiation exposure. Methods: Our series consist of twelve sequential adult cases with congenital VSDs (seven with perimembranous, four with muscular, one with postoperative residuel VSD). The mean age was 26.9 (Range 18–58), the mean height was 168.75 cm (Range 155–185cm), and the mean body mass index was 23.4 (Range 17.3–28.4). Maximum and minimum defect sizes were 10 and 5 mm and the mean defect size was 6.24 mm. The procedure was performed with left heart catheterization and advancing the delivery sheath over the stiff exchange wire then VSD occlusion from left side. Results: The defects were successfully closed with this technique in eleven patients. In sixth patient, the defect could not be cannulated by the delivery sheath, as the tip of the sheath did not reach the defect and VSD was closed with same sheath by standard transvenous approach using AV loop. We didn’t encounter any complication releated to semilunar or atrioventricular valves. Atrioventricular conduction system was not affected by the procedure in any patients. The median procedure and fluoroscopy times were 66 and 16.5 minutes respectively. Conclusion: Transarterial retrograde VSD closure without using AV loop simplifies the procedure, decreases the radiation exposure, and shortens the procedure time. The only limitation in adult patients is delivery sheath length.

How we eat may be as important as what we eat: eating behaviour and heart rate variability

Objective Diet exerts a crucial role on cardiovascular health. Evidence is mainly based on the content and the amount of dietary intakes. Some recent reports demonstrated that eating behaviour may also be of significant importance in cardiovascular health. In this study we aimed to investigate the effects of eating behaviour on heart rate variability (HRV) in healthy subjects. Methods and results In total, 521 healthy subjects with 24-hour Holter ECG recordings filled out a special questionnaire about their eating behaviour and lifestyles. From these patients, 425 subjects were healthy and had recordings suitable for analysis. Five types of eating behaviour were assessed in the questionnaire: (1) adherence to the Mediterranean diet (using the MedDietScore), (2) skipping breakfast, (3) late night eating, (4) having snacks, and (5) rapid eating. Physical exercise level and active working status of the subjects were also assessed. The root mean square of successive differences (RMSSD) was used for assessment of HRV. RMSSD values were lower in subjects skipping breakfast compared to subjects having breakfast regularly (26.32 vs 31.52 P = 0.02). Other behavioural patterns did not have any effect on the HRV parameters. Ageing, male sex, sedentary lifestyle and no active working were also found to be associated with reduced HRV in univariate analysis. In multivariate regression analysis, age and skipping breakfast were the only parameters significantly associated with a lower RMSSD (β: –0.222, P: 0.008 and β: –0.191, P: 0.020, respectively) Conclusions The findings of this study showed that skipping breakfast may be a cause of cardiac autonomic dysfunction.Objective Diet exerts a crucial role on cardiovascular health. Evidence is mainly based on the content and the amount of dietary intakes. Some recent reports demonstrated that eating behaviour may also be of significant importance in cardiovascular health. In this study we aimed to investigate the effects of eating behaviour on heart rate variability (HRV) in healthy subjects.Methods and results In total, 521 healthy subjects with 24-hour Holter ECG recordings filled out a special questionnaire about their eating behaviour and lifestyles. From these patients, 425 subjects were healthy and had recordings suitable for analysis. Five types of eating behaviour were assessed in the questionnaire: (1) adherence to the Mediterranean diet (using the MedDietScore), (2) skipping breakfast, (3) late night eating, (4) having snacks, and (5) rapid eating. Physical exercise level and active working status of the subjects were also assessed. The root mean square of successive differences (RMSSD) was used for assessment ...

Design and rationale of dabigatran's stroke prevention in real life in Turkey (D-SPIRIT).

OBJECTIVE The D-SPIRIT registry is designed to investigate the safety and efficacy of dabigatran etexilate in patients with nonvalvular atrial fibrillation (NVAF) and to collect data on outcomes in clinical practice. METHODS The D-SPIRIT is a national, prospective, observational, post-marketing registry involving patients with NVAF who have been taking dabigatran etexilate therapy for stroke prevention for a minimum of 6 months prior to enrollment. The registry will collect and analyze data from routine care, enrolling up to 600 patients in 9 centers. Patients will be followed up for 2 years to evaluate effectiveness and safety. A sample size of 600 subjects is proposed based on the following assumptions; Two-sided significance level of 0.05 (1-sided significance level of 0.025), ischemic stroke incidence rate of 0.768%-1.111%, hemorrhagic stroke incidence rate of 0.109%-0.130%, transient ischemic attack incidence rate of 0.722%-0.623%, therapy discontinuation incidence rate of 40% at day 730, and duration of enrollment period of 12 months with non-uniformed enrollment rate. Ethics approval was given by Dokuz Eylül University Ethics Committee of Clinical Research (2014/54) and approved by the Turkish Ministry of Health. CONCLUSION Potential results of D-SPIRIT registry will add data from clinical practice to those from the RE-LY trial to expand knowledge of dabigatran etexilate treatment in patients with NVAF.

Spontaneous spinal epidural hematoma developing after percutaneous coronary intervention: early diagnosis, early intervention, and good outcome.

A 56-year-old female patient hospitalized with diagnosis of acute coronary syndrome underwent early coronary intervention. Anticoagulant and antithrombotic treatment was administered, including acetylsalicylic acid, clopidogrel, and heparin in periprocedural period. Severe back pain and rapidly progressing paraplegia developed in early period of follow-up. The patient underwent surgery immediately after diagnosis of spontaneous spinal epidural hematoma (SSEH) causing pressure, and decompression was performed. The patient rapidly improved without recurrence through early diagnosis and early surgical intervention. A common problem encountered by interventional cardiologists is back pain in patients who have undergone interventions in the femoral region and have lain in the same position for an extended period. Clinical onset of SSEH includes similar complaints, a fact of which cardiologists should be aware. Early diagnosis and early intervention may provide a good outcome, as is reported in the present case.

PP-129 An Unusual Pacemaker Syndrome Case: Recurrent Pericardial Tamponade

A B S T R A C T S junctional bradycardia and regained consciousness. Short-term of second degree atrioventricular block was observed before normal sinus rhythm. Dual-chamber pacemaker with rate drop response was implanted to the patient. His further clinical course was uneventful. Conclusions: Prolonged asystole during HUT has been proposed to identify a distinct subgroup of patients with neurocardiogenic syncope. Management including permanent pacemaker implantation might be performed for prevention of syncope. Physicians should be aware of potential complications such as prolonged asystole during HUT.