Metin Gürsürer

Predictors of atrial fibrillation after coronary artery bypass surgery.

ObjectiveAtrial fibrillation is one of the most common arrhythmias associated with not only increased morbidity after coronary artery bypass grafting but also increased healthcare costs. Many factors are associated with atrial fibrillation onset after coronary artery bypass grafting. We prospectively examined which factors could predict atrial fibrillation after coronary artery bypass grafting. MethodsFifty-seven consecutive patients (37 men, mean age=60.2±12 years) with sinus rhythm before coronary artery bypass grafting are included the study. Clinical, demographic, laboratory and echocardiographic characteristics are all evaluated prospectively. The maximum and minimum P-wave duration (Pmax and Pmin) were measured from the 12-lead surface electrocardiogram. The difference between the Pmax and the Pmin was calculated and defined as P-wave dispersion. Preoperative venous blood samples were taken for N-terminal proBrain natriuretic peptide level analysis. ResultsTen (17%) patients had postoperative atrial fibrillation. Patients with postoperative atrial fibrillation were older (69.4±6 versus 58.2±12 years, P=0.01), had lower ejection fraction (44.1±8.9% versus 54.3±9; P=0.002), higher proBrain natriuretic peptide levels (538±136 pg/ml versus 293±359 pg/ml; P=0.03), longer Pmax (142.2±13.7 ms versus 120.8±21.2 ms; P=0.006) and longer P-wave dispersion (55.0±8.2 ms versus 41.3±14.3 ms; P=0.008) compared with the patients without atrial fibrillation. Univariate analysis showed that increased age (P=0.01), lower ejection fraction (P=0.02), enlargement of left atrium (P=0.02), increased Pmax (P=0.006) and increased P-wave dispersion (P=0.008) and increased level of preoperative proBrain natriuretic peptide (P=0.03) were associated with postoperative atrial fibrillation. Positive correlation was seen between the age and level of proBrain natriuretic peptide (r=0.322 and P=0.015). In multivariate analysis, age (P=0.05), lower ejection fraction (P=0.03), left atrial enlargement (P=0.05), longer Pmax (P=0.01) and P-wave dispersion (P=0.01) were found to be independent predictors of postoperative atrial fibrillation. ConclusionAge, poor left ventricular functions, Pmax and P-wave dispersion are found to be independent predictors of atrial fibrillation after coronary artery bypass grafting.

Long-term prognostic value of stress-redistribution-reinjection Tl-201 imaging in patients with severe left ventricular dysfunction and coronary artery bypass surgery

Objectives: This study sought to evaluate the long-term prognostic significance of stress–redistribution–reinjection Tl-201 imaging in patients with severe left ventricular (LV) dysfunction and coronary artery bypass surgery. Background: Preoperative stress–redistribution–reinjection Tl-201 imaging detects viable but asynergic segments which show functional improvement postoperatively and is considered as a valuable noninvasive method in selection of patients with severe LV dysfunction for revascularization. The long-term prognostic value of the reinjection technique remains unclear. Methods: Fifty-two patients with severe LV dysfunction (mean ejection fraction (EF) 0.32 ± 0.03) who underwent coronary artery bypass surgery in 1993–1994 were included in the study. Patients had follow-up 49 ± 12 months. LV function was assessed by two-dimensional echocardiography. Perfusion was assessed by Tl-201 SPECT imaging and was graded on a four-point scale (0 = normal, 3 = absent uptake) using the 20 segment model. Perfusion index was derived by adding the score of all segments and dividing these by 20. Patients were divided into two groups. Group A comprised patients with seven and more dysfunctional viable myocardial segments. Group B included patients with less than seven dysfunctional but viable segments. Results: Mean EF increased from 0.32 ± 0.03 to 0.46 ± 0.04. Mean perfusion index did not show a significant difference as a whole during follow-up compared to the early postoperative values (0.9 ± 0.4 and 1.1 ± 0.4, p = NS). When adequacy of revascularization was considered, the predictive value of a positive preoperative viability test for functional improvement was 82%. Nineteen cardiac events occurred in group B patients and six in group A patients: six deaths (four from cardiac and two from noncardiac causes), 13 myocardial infarctions (MI). Multivariate Cox survival analysis identified the number of viable segments detected preoperatively (χ2 = 7.2, p = 0.002), postoperative improvement in Tl-uptake (χ2 = 6.6, p = 0.01) and functional improvement (χ2 = 5.3, p = 0.03) postoperatively as independent predictors of cardiac events. Preoperative EF and functional capacity were not associated with cardiac events in long-term prognosis. Conclusion: These data suggest that preoperative stress–redistribution–reinjection Tl-201 imaging, specifically the number of viable segments detected preoperatively and postoperative improvement in Tl-201 uptake provide important long-term prognostic information in patients with severe LV dysfunction who had coronary artery bypass surgery.

N-terminal probrain natriuretic peptide predicts altered circadian variation in essential hypertension.

Diminished nocturnal blood pressure fall in nondipper hypertensive patients are closely associated with poor prognosis. N-terminal probrain natriuretic peptide can also identify poor prognosis in miscellaneous heart diseases. In this study, we aimed to clarify the association between probrain natriuretic peptide levels and diminished nocturnal blood pressure fall in patients with essential hypertension. Twenty-six consecutive nondipper (age: 53±8 years, 14 men) (group 1), and 26 dipper hypertensive patients (age: 52±9 years, 16 men) (group 2), based on ambulatory blood pressure monitoring, and age and sex-matched 28 normotensive participants (age: 50±11 years, 16 men) (group 3) were compared with each other. Although systolic and diastolic ambulatory blood pressure values were similar in hypertensives during the day, those at night were higher in group 1 (P<0.0001). Echocardiographic findings revealed that the left ventricular mass index was higher in both group 1 (184±47) and group 2 (142±39) compared with control participants (102±19) (P<0.0001), but ejection fraction and relative wall thickness were similar in all groups. The transmitral E-wave velocity decreased in group 1 (0.62±0.15 m/s) and group 2 (0.7±0.14 m/sec) compared with group 3 (0.95±0.22 m/s) (P<0.01). The transmitral E/A ratio decreased (0.71±0.12, 0.81±0.2 and 0.79±0.57, respectively P<0.05), and the transmitral E-wave deceleration time increased in group 1 (208±46, 203±38 and 169±42 ms, respectively, P<0.05). The isovolumic relaxation time increased (112±23, 110±18 and 86±11 m/s, respectively, P<0.01). Although group 1 and 2 have a similar number of patients with diastolic dysfunction (23/26 and 22/26, respectively, P>0.05), there were great differences between plasma probrain natriuretic peptide levels (88±20, 58±22 and 47±20 pg/ml, respectively, P<0.0001). In addition, serum uric acid (6.5±1.4, 5.3±1.5 and 5.0±1.9, respectively P<0.001), and creatinine levels (0.88±0.2 and 0.78±0.2 vs. 0.72±0.3, respectively P<0.05) were higher in group 1. These observations suggest that nondipper state may be related to the increase in left ventricular mass index and probrain natriuretic peptide levels and elevation in both plasma uric acid and creatinine levels. Serum probrain natriuretic peptide levels are found to be correlated with left ventricular mass index (Pearsons correlation 469 P<0.0001); but not creatinine (Pearsons correlation 188 P>0.05).

Myocardial Perfusion and Angiographic Findings in Patients with Paradoxical Sinus Deceleration during Dobutamine Technetium-99m Sestamibi-Gated SPECT Imaging

Aims: Dobutamine-gated SPECT imaging allows simultaneous perfusion and function assessment and is an alternative stress method for evaluating coronary artery disease in patients unable to perform treadmill exercise. In some patients, a paradoxical decrease in heart rate has been observed during high dose dobutamine infusion. The purpose of this study was to describe the paradoxical decrease in heart rate observed during dobutamine perfusion scintigraphy and determine its relation to inducible ischemia and angiographic coronary artery disease. Methods and Results: We studied 52 patients who underwent dobutamine-gated 99mTc sestamibi SPECT imaging and coronary angiography within 30 days. Paradoxical deceleration was defined as a decrease in heart rate ≥5 beats/min lasting at least 3 min during dobutamine infusion. Perfusion was graded on a five-point scale (0 = normal; 4 = absent uptake) and wall motion on a four-point scale (0 = akinesia/dyskinesia; 3 = normal) using the 20-segment model. Significant coronary artery disease was defined as ≥50% narrowing of lumen diameter of a major epicardial artery. Paradoxical deceleration occurred in 10 patients (19%, 95% CI 8–30%). A decrease in systolic blood pressure [8 patients (80%), 95% CI 56–92%] with angina [5 patients (50%), 95% CI 23–71%] often accompanied the decrease in heart rate. All 10 patients with sinus deceleration had an inferior wall perfusion defect and 8 of them had a corresponding wall motion abnormality on gated images. Significant coronary artery disease was present in all 10 patients with sinus deceleration, with an increased incidence of right coronary artery stenosis (p = 0.007). Conclusions: Paradoxical deceleration observed during dobutamine perfusion scintigraphy is associated with inducible ischemia and angiographic coronary artery disease and the underlying mechanism for this phenomenon may be the activation of the Bezold-Jarisch reflex.

Unique Spontaneous Unhealed Chronic Multivessel Coronary Artery Dissection in an Elderly Man: A Case Report and Review of the Literature

Spontaneous coronary artery dissection (SCAD) is relatively uncommon. It often occurs in healthy, middle-aged women without overt risk factors for atherosclerosis and is associated with the peripartum period. The pattern and severity of presentation are variable. There are only 5 reports in the literature about multivessel involvement. The etiopathogenesis of SCAD is unclear. Treatment strategy is not standard but is usually tailored to clinical features. Long-term survival of patients with SCAD who have had no problem at the initial event is good. The authors report the first case of unhealed chronic multivessel SCAD in the literature.

Assessment of viable myocardium and prediction of postoperative improvement in left ventricular function in patients with severe left ventricular dysfunction by quantitative planar stress-redistribution-reinjection 201-Tl imaging

A noninvasive approach to determine viable but asynergic myocardium will be clinically significant in identifying patients with coronary artery disease and severe left ventricular dysfunction who will benefit most from coronary bypass surgery. Accordingly, 12 patients (mean ejection fraction 0.32 +/- 0.03) underwent quantitative planar stress-redistribution-reinjection thallium scintigraphy and radionuclide ventriculography before and 8 weeks after revascularization for viability and segmental and global left ventricular function assessment, respectively. Reinjection scan showed new fill-in in 63% of segments without redistribution. Postoperative improvement in perfusion and function of asynergic segments were significantly better in viable compared to nonviable segments (P < 0.001, P < 0.01, respectively) with a strong correlation between improvement in 201-T1 uptake and function (P < 0.001). When adequacy of revascularization was considered, the predictive value of a positive preoperative viability test for functional improvement was 83%. Finally, mean ejection fraction and global wall motion score increased significantly after revascularization for the group as a whole (0.32 +/- 0.03 to 0.44 +/- 0.04, P < 0.001 and 24.08 +/- 2.90 to 33.16 +/- 3.32, P < 0.001, respectively). Thus, preoperative quantitative planar stress-redistribution-reinjection thallium imaging detects viable but asynergic segments which improve function postoperatively and may be valuable in selection of patients with severe left ventricular dysfunction for revascularization.

Myocardial Functional and Textural Findings of the Right and Left Ventricles and Their Association with Cellular Adhesion Molecules in Behcet's Disease

Aim: This study was designed to assess whether ultrasonic reflectivity, evaluated by integrated backscatter analysis was associated with the severity of inflammation and diastolic dysfunction of the left (LV) and right ventricles (RV) in Behçets disease (BD). Methods: The study consisted of 20 patients with BD and 18 healthy controls. The expression of CD11b and CD63 on the surface of granulocytes and monocytes were measured by flow cytometry. RV and LV diastolic functions were assessed by tricuspid and mitral annular tissue Doppler recordings, respectively. Backscatter cyclic variation (CV) and maximal intensity (IB) were measured in RV lateral wall, interventricular septum, and posterior LV wall from parasternal long‐axis view, apex from apical four‐chamber view, anterior, inferior, and lateral LV walls from parasternal short axis view. Results: The mean fluorescence intensity (MFI) of CD11b on granulocytes and CD63 on monocytes in BD patients was higher than those of controls. Patients with BD had smaller mitral and tricuspid annular early diastolic wave velocities and early/late diastolic wave velocity ratios (E/A) than controls. MFI of CD11b and CD63 was inversely correlated with tricuspid and mitral annular E/A in BD patients. CV of RV and global CV of LV were found to be diminished in BD patients than controls. CV of RV and global CV of LV showed a direct correlation with tricuspid and mitral annular E/A ratio, respectively. Conclusion: There is an association between the levels of cellular adhesion molecules, deterioration of diastolic function, and altered myocardial ultrasonic reflectivity in BD.