Murathan Küçük

The significance of the left atrial volume index in cardioversion success and its relationship with recurrence in patients with non-valvular atrial fibrillation subjected to electrical cardioversion: a study on diagnostic accuracy

OBJECTIVE The aim of this study was to assess the predictive value of the left atrial volume index (LAVI) in electrical cardioversion (ECV) and observe the recurrence rate of atrial fibrillation (AF) after a successful ECV in patients with non-valvular atrial fibrillation. METHOD This study was designed as a diagnostic accuracy and prospective cohort study. Eighty patients (mean age 62±12 years; 52.5% female) were enrolled in study. LAVI was measured using the area-length method and the indexed body surface area. Patients in whom the sinus rhythm (SR) was established following the ECV were assessed according to the clinical and electrocardiography (ECG) findings at the first month and grouped as those with continued SR or recurrent AF. The Students t, Mann-Whitney U, Fishers exact, Chi-square tests, ROC and logistic regression analyses were used for statistical analysis. RESULTS Subsequent to the ECV, SR was achieved in 62.5% (n=50) of the patients. In those where SR was established, the AP-Lad (4.32±0.62 vs. 4.77±0.4 cm/p=0.002) and LAVI (35.3±11.5 vs. 53.1±10.1 mL/m2/p<0.001) values were observed to be lower. ECV success was found to be associated only with the LAVI (OR:1.122, 95%CI: 1.058-1.191, p<0.001). The AUC was found as 0.892±0.041 for the LAVI (95% CI:0.075-0.285, p<0.001). During the controls at the end of the 1st month, SR was maintained in 72% (n=36) of the successful ECV group. Among the patients with maintained SR, the antero-posterior left atrial dimension (4.17±0.62 vs. 4.72±0.5 cm/p=0.004) and LAVI (30.8±6.2 vs. 46.8±13.9 mL/m2/p<0.001) values were also observed to be lower. Only the LAVI was found to be associated with the recurrence of the AF (OR:1.355, 95% CI: 1.154-1.591, p<0.001). The AUC was found as 0.950±0.029 for the LAVI (95% CI:0.063-0.313, p=0.003) CONCLUSION Lower LAVI values before the ECV are strong and independent predictors of the success of the ECV and the maintenance of SR after a successful ECV.

Primer aşırı pıhtılaşma eğilimi olan hastada foramen ovale\'ye tuzaklanmış sağ kalp trombüsü ve pulmoner emboli

Thromboembolic disease is a potentially severe pathology. When its clinical feature implies a massive occlusion of the arterial pulmonary tree and a cardiac failure is ensued, it can be seriously life threatening even for young patients. Less frequent features as right or left atrium thrombosis could increase morbidity and mortality of this disease. We report a case of massive right pulmonary embolism (PE) with entrapped thrombus in patent foramen ovale and right heart failure in a 32- year-old man. Transthoracic echocardiography showed a right atrial thrombus attached to the inter-atrial septum. Following the diagnosis of right heart thrombosis with massive PE, infusion of tissue type plasminogen activator (100 mg in two hours) was administered. Echocardiography performed two days after thrombolysis showed a significant decrease in the right ventricular size and complete lysis of the thrombus in the right heart. By genetic examination, he proved to have factor V ’Leiden’ gene and two thrombophilia genes, all of which were positive in the heterozygous state. He had also a high serum homocysteine.

Infected giant left atrial myxoma: an unusual phenomenon.

1. Abbas AE, Appleton CP, Liu PT, Sweeney JP. Congenital absence of the pericardium: case presentation and review of literature. Int J Cardiol 2005; 98: 21-5. 2. Alizad A, Sweard JB. Echocardiographic features of genetic diseases: Part 8. Organ system. J Am Soc Echocardiogr 2000; 13: 796-800. 3. Eyileten Z, Arıkbuka M, Yazıcıoğlu L, Özyurda Ü. Left pericardial agenesis in a patient with sinus venosus type atrial septal defect. Anadolu Kardiyol Derg 2007; 7: 205-6. 4. Arinaga M, Tanaka K, Miura T, Chujo M, Hadama T, Uchida Y. A case of congenital partial pericardial defect and anomaly of phrenic nerve with cystic bronchiectasis. Jpn J Thorac Cardiovasc Surg 1998; 46: 446-9. 5. Vesely T, Julsrud PR. Congenital absence of the pericardium and its relationship to the ligamentum arteriosum. Surg Radiol Anat 1989; 11:171-4. 6. Centola M, Longo M, De Marco F, Cremonesi G, Marconi M, Danzi GB. Does echocardiography play a role in the clinical diagnosis of congenital absence of pericardium? A case presentation and systematic review. J Cardiovasc Med 2009; 10: 687-5. 7. Gatzoulis MA, Munk MD, Merchant N, Van Arsdell GS, McCrindle BW, Webb GD. Isolated congenital absence of the pericardium: clinical presentation, diagnosis, and management. Ann Thorac Surg 2000; 69: 1209-15. 8. Alexandros H, Yousef S. Pericardial agenesis: a rare cause of chest pain. Postgrad Med J 2010; 86: 380-2. 9. Kandemir Ö, Yıldız Ü, Can B, Kale A, Tezcaner T, Zorlutuna Y. Congenital complete absence of the left pericardium in a patient with ascending aortic aneurysm. Anadolu Kardiyol Derg 2006; 6: 112-1. 10. Drury NE, De Silva RJ, Hall RM, Large SR. Congenital defects of the pericardium. Ann Thorac Surg. 2007; 83: 1552-3.

Type 1 neurofibromatosis complicated by pulmonary arterial hypertension: a case report

Neurofibromatosis type I (NF1) is a rare genetic disease caused by mutations in the NF1 gene, which encodes the tumor suppressor neurofibromin. Precapillary pulmonary hypertension is a severe complication of NF1, initially described in patients with advanced parenchymal lung disease, which may complicate the course of NF1. Presently described is a case of neurofibromatosis complicated by pulmonary hypertension.

Aorta-right atrial tunnel leading to heart failure

Congential aorta-right atrial tunnel (ARAT) is a rare anomaly. Many patients are asymptomatic and diagnosis can be made during investigation of systolic and diastolic continuous murmur heard on cardiac oscultation. In some patients, symptoms such as palpitation, dyspnea, and fatigue on exertion can be seen. With transthoracic and transesophageal echocardiography diagnosis can usually be made, but more definite diagnosis is possible with coronary angiography, aortography, and computerized tomography. Herein with the data from current literature we will discuss a case who was admitted to our clinic with symptoms of heart failure and diagnosed with ARAT.

Assessment of left atrial function using speckle tracking echocardiography in ankylosing spondylitis: a case-control study

The aim of this study is to assess the left atrium (LA) deformation parameters by using 2D speckle tracking echocardiography (2D-STE) in ankylosing spondylitis (AS) patients and to evaluate the relationship between these parameters and AS clinical indexes. 30 patients with AS (22 males, 8 females) and 30 healthy individuals (19 males, 11 females) were enrolled in this study. Transthoracic echocardiography was performed to both groups. Besides the conventional echocardiographic parameters, the LA strain parameters; including systolic-reservoir (LA S-S), early diastolic-conduit (LA S-E), late diastolic-contraction (LA S-A) were measured. No significant difference was found between two groups in terms of conventional echocardiographic parameters except mean deceleration time (DT). Mean DT was prolonged in the AS patients compare with the control group (173.5 ± 22.5 vs. 155.3 ± 36.7, p = 0.025). In the AS patients, LA S-S (48.3 ± 9.4 vs. 56.9 ± 10.1, p = 0.001), LA S-E (26.4 ± 6.4 vs. 31.6 ± 7.3, p = 0.005) and LA S-A (21.9 ± 4.7 vs. 25.4 ± 5.7, p = 0.013) values were statistically lower than the control group. Also a negative correlation was observed between the Bath Ankylosing Spondylitis Metrology Index (BASMI) and LA S-S (r = − 0.509, p = 0.004), LA S-E (r = − 0.501, p = 0.005). Our study demonstrated that 2D-STE is a useful method to determine the left atrial involvement in AS patients without the clinical evident of cardiovascular disease.

Akut inferior miyokard infarktüsü ile prezente olan tip A aortik diseksiyon

Aort diseksiyonu, aortun media ve intima tabakasinin birbirinden ayrildigi, hizli tani ve tedavi gerektiren, olumcul seyreden bir kardiyovaskuler acildir. Acil serviste gogus agrisi nedeniyle cekilen elektrokardiyografilerde akut miyokard infarktusu bulgulari saptanabilir. Hizli tani ve akut miyokard infarktusunden ayirici tanisi icin transtorasik ekokardiyografi ve multidedektorlu bilgisayarli tomografinin onemi buyuktur. Biz bu yazimizda acil servise gogus agrisi sikayeti ile basvuran, elektrokardiyografide akut inferior miyokard infarktusu bulgulari olan ancak transtorasik ekokardiyografi ile aort diseksiyonundan suphelendigimiz, multidedektorlu bilgisayarli tomografi ile de tanisini kesinlestirdigimiz 83 yasinda bir kadin hastayi sunduk.

Determining subclinic left ventricular dysfunction according to dialysis type in end-stage renal disease patients

We have read the article by G€ unaydın et al. [1] entitled ‘The effects of dialysis-type on left ventricular function in non-diabetic end-stage renal disease patients’ with great interest. In their study, the authors reported that subclinic left ventricular dysfunction was observed earlier in haemodialysis (HD) patients than in peritoneal dialysis (PD) patients by using 2D speckle tracking echocardiography. We have the following comments and concerns. It has been shown that left ventricular deformation parameters measured using the 2D speckle tracking method may give more detailed information about cardiac function [2]. In the study by G€ unaydın et al. there is no information regarding the inter-observer and intraobserver variability [1]. It would be helpful if the authors provided inter-observer and intra-observer reproducibility values in order to estimate reliability of left ventricular deformation analysis in the study population. Also, we were wondering if there was any difference between HD and PD patients in terms of volume status? We thought that authors should state the left ventricular end-diastolic volume index and the inferior vena cava diameter for each group to evaluate the fluid status of patients. Moreover, in previous studies, it has been shown that decreased global longitudinal strain values could be associated with microvascular ischaemia caused by myocardial fibrosis or myocardial stunning in end-stage renal disease (ESRD) patients [3,4]. Liu et al. demonstrated a significant association between decreased global longitudinal strain values and increased cardiac troponin levels in ESRD patients [5]. In addition to the existing parameters, measuring cardiac troponin levels in a study population could provide insights into the pathogenesis of subclinic left ventricular systolic dysfunction seen in these patients. In conclusion, to verify the 2D speckle tracking echocardiography as a useful tool for evaluating left ventricular systolic function between HD and PD patients, the factors mentioned above should be taken into consideration.

Value of CHA2DS2-VASc score and gender in predicting PCI outcomes in ST segment elevation myocardial infarction

To the Editor, We have read the article by Satilmisoglu et al. [1] entitled ‘Prognostic value of CHA2DS2-VASc score in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention’ with great interest, which was published in Acta Cardiol 2016;71:663–669. In their study, authors divided 604 patients with ST segment elevation myocardial infarction (STEMI) into three risk groups according to CHA2DS2VASc score: low-, moderateand high-risk group, respectively, and they reported that the rates of in-hospital and long-term all-cause and cardiovascular mortality were the highest in high-risk group. This is a well-written study, and we would like to draw attention to the genderrelated differences that can affect the results of the present study. Satilmisoglu et al. reported that CHA2DS2-VASc score >2 points had a predictive value for all-cause mortality in STEMI. As female gender represents 1 point in CHA2DS2VASc score, we think that gender becomes more important factor in this study population. In the present study, 0% of the patients in low-risk group and only 12.1% of the patients in moderate-risk group were female, while 46.5% of the patients in high-risk group were female. It has been shown that female patients had a higher risk for poorer outcome in ST segment elevation myocardial infarction [2]. Also it has been described that psychological pathologies like depression, anxiety and anger are possible risk factors for worse outcome in female patients with cardiovascular diseases [3]. Another important factor is that preconditioning and pre-infarction angina is related with decreased left ventricular dysfunction in males with acute coronary syndrome rather than in females [4]. In conclusion, as the 46.5% of study population in high-risk group are female, to verify whether the CHA2DS2-VASc score provides an additional risk stratification beyond that provided by conventional risk scores, gender-related factors should be taken into consideration in the present study.

Effects of prasugrel on membrane potential and contractile activity of rat ventricular myocytes

BACKGROUND Though prasugrel is one of the important P2Y12 inhibitors currently in use for antiplatelet therapy, its potential effects on contractility and electrical activity of ventricular myocytes have not yet been investigated. Hence this study was designed to study the impact of prasugrel on contractile function and membrane potential of isolated ventricular myocytes. METHODS Freshly isolated rat ventricular myocytes were used in this study. Myocyte contraction was measured during electrical stimulation of cardiomyocytes and the action potential (AP) recordings were obtained with current clamp mode of the patch-clamp amplifier. RESULTS AP duration and fractional shortening of ventricular myocytes did not show any change with the administration of 1μM of prasugrel. However, remarkable depolarization of resting membrane potential followed by apparent fibrillation episodes was detected in the cardiomyocytes. Similar events were observed in the contractile activity of myocytes during field stimulation. Also, a higher concentration of prasugrel (10μM) elicited repeated fibrillations, which disappeared after washout or nitric oxide synthase (NOS) inhibition with L-NAME. In contrast, the same concentration of ticagrelor, another P2Y12 inhibitor did not induce fibrillation events though it decreased the contractility of ventricular myocytes significantly. The perfusion of ventricular myocytes with L-NAME did not alter the negative inotropic effect of ticagrelor. CONCLUSIONS Prasugrel, a widely used antithrombotic agent, may induce depolarization in the membrane potential of myocytes as well as fibrillation via NO mediated pathway.