Murat Günday

Serum uric acid and carotid artery intima media thickness in patients with masked hypertension

Background Serum uric acid is related to hypertension and cardiovascular diseases. Masked hypertension is associated with an increase in cardiovascular risk. The aim of our study was to evaluate the serum uric acid level and its relationship with carotid intima-media thickness (IMT) in patients with masked hypertension. Subjects and methods A total of 114 untreated masked hypertension patients (62 men, 52 women; mean age 44.6 ± 7.9 years) and 38 controls (20 men, 18 women; mean age 44.8 ± 7 years) were included in the study. All patients underwent 24-hour ambulatory blood pressure. Serum uric acid and carotid IMT were measured. Results Serum uric acid was significantly higher in masked hypertension patients when compared to the control group (5.14 ± 1.42 mg/dl, 4.84 ± 1.45 mg/dl, P= 0.01). Masked hypertension patients had significantly higher carotid IMT than control subjects (0.58 ± 0.09, 0.52 ± 0.09, P< 0.001). The masked hypertension group was also divided into two groups according to the median value of the serum uric acid levels (median value: 5 mg/dl). Carotid IMT was significantly higher in patients with a higher uric acid when compared to those with a lower uric acid (P < 0.001). We also found that the serum uric acid level was a good predictor of increased carotid IMT at the receiver-operating characteristic curve. The area under the curve was 66% (95% confi dence interval, 0.56-0.77), and the serum uric acid level was significantly predictive of a high carotid IMT (P = 0.001). Conclusions Our data suggest that the uric acid levels were significantly higher in the masked hypertension group and elevated uric acid levels were associated with increased carotid IMT, indicating that elevated serum uric acid levels might contribute to the increase in cardiovascular risk in masked hypertension.

Association between serum γ-glutamyltransferase levels and coronary microvascular function.

BackgroundSerum &ggr;-glutamyltransferase (GGT) level is an independent risk factor for cardiovascular (CV) disease, and there is a strong association between serum GGT levels and most CV risk factors. However, the role of the serum GGT level as an independent risk factor for coronary microvascular function remains controversial. PurposeWe aimed to determine whether the serum GGT level is independently and specifically associated with coronary flow reserve (CFR) impairment in normal individuals. MethodsWe examined healthy individuals who did not have any major CV risk factors (277), of whom CFR was achieved in 263 (95%). They were divided into three groups according to serum GGT levels. In each participant, CFR was measured using an Acuson Sequoia C256 Echocardiography System. ResultsParticipants with high GGT levels had significantly impaired CFR compared with those with intermediate and low GGT levels (2.82±0.49 vs. 2.71±0.51 and 2.44±0.48 U/l; P<0.0001). After adjusting for potential confounders, including sex, BMI, blood pressure, lipids, and glucose, we found that the serum GGT and high-sensitivity C-reactive protein levels were associated independently with CFR impairment (b=−0.205, P=0.007; b=−0.172, P=0.024). We also found that the serum GGT level was a good predictor of low CFR at the receiver-operating characteristic curve. The area under the curve was 75% [95% confidence interval, 0.65–0.86], and the serum GGT level was significantly predictive of a low CFR (P<0.0001). ConclusionsThese results support a role for the serum GGT level as an independent marker of coronary microvascular damage and inflammation in normal individuals without concomitant risk factors.

Mild carbon monoxide poisoning impairs left ventricular diastolic function.

Rationale: Carbon monoxide (CO) poisoning is associated with direct cardiovascular toxicity. In mild CO poisoning in which cardiovascular life support is not required, the effects of CO on left and right ventricular functions are unknown in patients without cardiac failure. Objectives: Echocardiography was used to determine whether or not mild CO poisoning impairs ventricular function. Twenty otherwise healthy patients with CO poisoning and 20 age- and gender-matched controls were studied. Echocardiographic examinations were performed at the time of admission and 1 week after poisoning. Results: The impairment observed in the left and right ventricular diastolic function at the time of admission was greater than the impairment 1 week after poisoning. Mild CO poisoning did not have a significant effect on systolic function. Carboxyhemoglobin levels were positively correlated with left ventricular diastolic dysfunction, whereas the levels were not correlated with right ventricular diastolic function. Conclusions: In CO intoxication, the development of left and right ventricular diastolic dysfunction precedes systolic abnormality. Patients with mild CO poisoning do not manifest cardiovascular symptoms; however, it should be borne in mind that most of these patients have myocardial involvement.

Is crystalloid cardioplegia a strong predictor of intra-operative hemodilution?

IntroductionComplications due to hemodilution (hematocrit value less than 22%) after cardiopulmonary bypass inevitably resulted with significantly greater intensive care requirements, long hospital stays, more operative costs, and increased mortality rates. We tried to identify whether crystalloid cardioplegia is the strongest predictor of intraoperative hemodilution or not.Materials and methodsOne hundred patients were included into this randomized prospective study. Patients were divided into the two groups. Crystalloid cardioplegia were given to the odd-numbered patients (Group 1, n = 50 patients) and blood cardioplegia were given to the even-numbered patients (Group 2, n = 50 patients). St. Thomas-II solution was used in Group-1 and Calafiore cold blood cardioplegia was in Group-2.ResultsAverage intraoperative hematocrit value was 18.4% ± 2.3 in crystalloid group 24.2% ±3.4 in blood cardioplegia group (p < 0.001). The lowest hematocrit value was 15% and 20% in two groups respectively (p < 0.001). In crystalloid group average intraoperative packed red blood cell (RBC) transfusion was 2.3 ± 0.41 units, 0.7 ± 0.6 units blood cardioplegia group (p = 0.001). Average transfused RBC was 2.7 ± 0.8 units in crystalloid group, 0.9 ± 0.4 units blood cardioplegia group (p < 0.001). Multivariate analyses confirmed age (p = 0.005, OR = 3.78), female gender (p = 0.003, OR = 2.91), longer cross-clamp time (>60 minutes) (p = 0.001, OD = 0.97), body surface area <1.6 m2 (p = 0.001, OR = 6.01) and crystalloid cardioplegia (p < 0.001, OR = 0.19) as predictor of intraoperative hemodilution.ConclusionCrystalloid cardioplegia, compared to blood cardioplegia not only causes much more intra-operative hemodilution but also increases the blood transfusion requirement. Hemodilution and increased transfusion increases the intensive care unit and hospital stay, in the early postoperative period.

Successful endovascular treatment of subclavian artery dissection after compression trauma.

Subclavian artery injury may occur as a result of penetrating or blunt trauma. Surgical or endovascular approaches are 2 treatment options. Previous case reports in the literature have described successful treatment of subclavian artery injury. In our case report, a 31-year-old male patient who had been exposed to blunt thorax trauma was admitted to our hospital complaining of chest pains and shortness of breath. During his examination at the hospital, he also complained of numbness in his right arm. The clinical presentation of a subclavian artery dissection after compression tends to be insidious, but a selective arteriography revealed occlusion of the right subclavian artery distal to the vertebral artery. A stent was successfully placed on the second attempt. We present the first case of a posttraumatic dissection of the subclavian artery after compression treated successfully with a stent graft. Subclavian artery injury is extremely rare after trauma but carries a high mortality rate. The incidence accounts for only 3% to 9% of civilian vascular injuries [1,2] and is caused by a penetrating injury or blunt trauma. Standard surgical techniques require wide exposure and dissection in traumatized areas. In some cases, proximal and distal control of the artery is difficult, and additional incisions may be required. In addition, soft tissue injuries and rib fracture may also be present. In recent years, the frequency of use of endovascular interventions for vascular pathologies has increased because of their being less invasive, with shorter procedure times and earlier recovery. Only a few cases have been published that describe endovascular repair of a post blunt traumatic dissection of a subclavian artery. However, ours is the first that describes such an injury caused by compression injury. We report the successful endovascular treatment ☆ Funding: The authors received no financial support for the research and/or authorship of this article. ☆☆ Conflicts of interest: The authors declare that they have no competing interests. 0735-6757/

Unusual Region for Pericardial Malignant Mesothelioma: Cutaneous Manifestation in a Turkish Woman

– see front matter. Published by Elsevier Inc. of a hemodynamically stable patient with subclavian artery dissection. A 31-year-old male patient complaining of chest pains and shortness of breath was admitted to our hospital. His medical history indicated that he had been exposed to blunt thorax trauma due to compression (he had been crushed between a wall and heavy machinery) 1 to 2 hours before. The posteroanterior chest radiograph showed pneumothorax and multiple rib fractures. Laboratory findings were normal. The pneumothorax and rib fractures were treated medically by oxygen inhalation and pain relief. The patient began to complain of numbness in his right arm during his follow-up examination. The axillary, brachial, radial, and ulnar pulses could not be retrieved by hand. A monophasic signal in the subclavian artery was detected by Doppler sonogram confirming arterial injury. Selective arteriography revealed occlusion of the right subclavian artery distal to the vertebral artery (Fig. 1). Four days later, angiographywas performed by entering the right common femoral artery and two 7 × 50 mm diameter Viabahn covered stents (WL Gore & Associates, Flagstaff, AZ) were placed in the right axillary artery. Balloon angioplastywas performed at proximal to the stent due to local dissection flap. Good flow was confirmed in the angiogram (Fig. 2). Pleural effusion due to dyspnea was detected in the right thorax by thorax ultrasonography. A tube thoracostomy was performed, and approximately 500 mL of hemorrhagic pleural fluid was aspirated from the right thorax. The drain was removed 2 days later, and the patient was discharged from hospital with clopidogrel and acetylsalicylic acid. One month later, a control Doppler sonogram showed a good flow of the stent graft with no leakage. Subclavian artery dissection after blunt trauma and various other causes (such as deceleration subcapital humeral fractures) have been described in the literature [3,4]. However, we did not come across any reports of a subclavian artery dissection after compression. Injury to the subclavian artery is a relatively rare occurrence, and the most frequent cause is penetrating trauma [5]. Blunt injuries generally have lower rates of mortality and morbidity compared with penetrating injuries, although they may be associated with cranial, facial, abdominal, and brachial plexus injuries. A subclavian artery occlusion may be initially missed because of the abundant collateral circulation around the shoulder. The most important symptom of a subclavian artery occlusion is absence of the ipsilateral radial pulse. Fig. 1 The dissection area in the subclavian artery before stent implantation. 457.e2 Case Report A conventional angiography is the criterion standard for diagnosis of these injuries. Alternative methods are Doppler ultrasound, computed tomography, and magnetic resonance angiography. The method used for subclavian vessel repair depends on the location, extent, and cause of injury. Restoration of blood flow using open or endovascular repair is crucial for an optimal outcome. Selected cases may be treated by a subclavian artery exposure through a supraclavicular approach and a restoration of arterial continuity by subclavianFig. 2 A distal runoff is achieved after implantation. carotid transposition. However, the endovascular treatment is a useful alternative due to its being less invasive, with a shorter procedure time, less blood loss, and earlier recovery times. Endovascular covered stent placements eliminate the acute need for surgical dissection, decreasing the risk of damaging important adjacent structures such as the vagus nerve, recurrent laryngeal nerve, and phrenic nerve, and the innominate vein. In a recent study, Carrick et al [6] compared endovascular and surgical treatment methods for subclavian artery dissection and concluded that numerous potential complications are associated with a surgical approach and that endovascular management of subclavian artery injuries is an acceptable technique in appropriate candidates. In addition, Xenos et al [7] proposed that a covered stent is a feasible alternative to open repair in properly selected patients with subclavian or axillary artery injury, resulting in shorter procedure time and less blood loss. In their study, Sixt et al [8] detected that endovascular therapy of subclavian artery obstructions of various etiologies offers good acute success rates even in total occlusions, and the long-term patency rate of stent placement makes it more favorable. However, various complications were also reported in literature. The most common complications are graft thrombosis, stenosis, cerebral embolization, and strut dislocation [9,10]. None of these complications have been observed yet in our patient. An important point to take note of is that these types of injuries are often seen as a result of compression trauma, and so the symptoms may not appear immediately. The continued advances in imaging and stent/stent-graft technology have considerably expanded the indications for endovascular treatment in vascular trauma. In our experience, endovascular treatment of subclavian artery dissection is safe and effective. In addition, it should be considered as the first choice in treatment for this pathology. Murat Günday MD Mehmet Özülkü MD Department of Cardiovascular Surgery Baskent University Konya Training and Research Center Konya 42080, Turkey E-mail address: gundaymurat@yahoo.com Erkan Yıldırım MD Department of Radiology Baskent University Konya Training and Research Center Konya 42080, Turkey Aytekin Güven MD Özgür Çiftçi MD Department of Cardiology Baskent University Konya Training and Research Center Konya 42080, Turkey http://dx.doi.org/10.1016/j.ajem.2012.07.030

Lesion of Aggregated Monocytes and Mesothelial Cells: Mesothelial/Monocytic Incidental Cardiac Lesion

Malignant mesothelioma is a disease that originates from mesenchymal cells. It is related to the occupational or environmental exposure to asbestos. The treatment remains controversial because it is commonly diagnosed at a very late stage, and the prognosis is very poor. In this report, we present a 37-year-old female patient who was admitted with shortness of breath, palpitation and inability to sleep on her back for the previous 10 days. A large pericardial effusion was detected on echocardiography. Pericardiocentesis was performed and the patient’s symptoms were alleviated. However, approximately 7 months later, she was readmitted to the clinic with complaints of a mass at the incision site. Pathological examination of the mass yielded a diagnosis of pericardial malignant mesothelioma. Malignant mesothelioma is a rare occurrence, and to our knowledge, there are no reports in the English literature of pericardial malignant mesothelioma local invasion to an incision site.

An unusual case of Candida infection producing a fungus ball in the left atrial cavity.

A 58-year-old woman with a history of childhood acute rheumatic fever and resultant mitral valve stenosis was admitted to our cardiovascular surgery clinic complaining of tachycardia, dyspnea, and chest pain. After clinical and radiological findings were evaluated, mitral valve replacement, tricuspid De Vega annuloplasty and plication, and resection of giant left atrium were performed. Atrial thrombus was removed from the top of the left atrial wall. Operation material considered as thrombus was sent to a pathology laboratory for histopathological examination. It was diagnosed with mesothelial/monocytic incidental cardiac lesion (cardiac MICE). Microscopic sections revealed that morphological features of the lesion were different from thrombus. The lesion was composed of a cluster of histiocytoid cells with abundant cytoplasm and oval shaped nuclei and epithelial-like cells resembling mesothelial cells within a fibrin network. Epithelial-like cells formed a papillary configuration in the focal areas. Mitotic figures were absent. Here we present a case which was incidentally found in a patient who underwent mitral valve replacement surgery, as a thrombotic lesion on the left atrium wall.

Does Mild Renal Failure Affect Coronary Flow Reserve after Coronary Artery Bypass Graft Surgery

We report the case of a 75-year-old male patient who was treated in our clinic for septicemia and subacute infective endocarditis caused by toxigenic Candida albicans. Transthoracic echocardiography revealed the presence of a thrombus in the left atrial cavity, and the diagnosis was confirmed by computerized tomography. The patient was operated on urgently. Histological examination of the embolic material removed from the left atrium showed the presence of yeast and hyphal forms of Candida albicans through periodic acid-Shiff stain. The patient was readmitted to the hospital on postoperative day 15, because of reembolism, and died later on. Here we present our approach to the diagnosis and treatment of this rare condition.

Is off-pump coronary artery bypass surgery superior to on-pump coronary artery bypass surgery on postoperative paradoxical ventricular septal motion?

INTRODUCTION There are only a limited number of studies on the link between mild renal failure and coronary artery disease. The purpose of this study is to investigate the effects of mild renal failure on the distal vascular bed by measuring the coronary flow reserve (CFR) in transthoracic echocardiography after coronary artery bypass grafting (CABG). METHODS The study included 52 consecutive patients (12 women and 40 men) who had undergone uncomplicated CABG. The patients were divided into 2 groups. Group 1 included patients with a preoperative glomerular filtration rate (GFR) of 60-90 (mild renal failure), and group 2 included those with a GFR >90. The CFR measurements were carried out through a second harmonic transthoracic Doppler echocardiography. RESULTS The mean age was 60.08 ± 1.56 years in group 1 and 60.33 ± 1.19 in group 2. The mean preoperative CFR was 1.79 ± 0.06 in group 1 and 2.05 ± 0.09 in group 2. The mean postoperative CFR was 2.09 ± 0.08 in group 1 and 2.37 ± 0.06 in group 2. There was a statistically significant difference between the 2 groups as to preoperative creatinine clearance, preoperative estimated GFR, postoperative day 7 creatinine clearance, postoperative month 6 creatinine clearance, postoperative day 7 estimated GFR, postoperative month 6 estimated GFR, preoperative CFR, and postoperative CFR (P < .05). CFR was found to be unaffected by the choice of on-pump or off-pump technique (P = .907). After bypass surgery, there was a significant increase in the mean postoperative CFR, when compared with the mean preoperative CFR (P = .001). CONCLUSION In our study, we detected a decrease in CFR in patients with mild renal failure. We believe that in patients undergoing CABG for coronary artery disease, mild renal failure can produce adverse effects due to deterioration of the microvascular bed.