Mustafa Cemri

Use of long-term combined therapy with inhaled iloprost and oral sildenafil in an adult patient with eisenmenger syndrome.

Eisenmenger syndrome is characterized by elevated pulmonary vascular resistance and right-to-left shunting of blood through a systemic to pulmonary circulation connection. Treatment requires either lung transplantation with intracardiac repair or heart–lung transplantation. There are inadequate data regarding treatment alternatives when the patient is not a candidate for surgery. In this article, we report on the case of a 68-year-old woman with Eisenmenger syndrome related to congenital heart disease who was treated with inhaled iloprost and oral sildenafil for 2 years.

B-type natriuretic peptide and extent of lesion on coronary angiography in stable coronary artery disease.

ObjectiveAlthough it is well established that plasma B-type natriuretic peptide (BNP) levels are higher in patients with acute coronary syndromes, the relationship between plasma BNP level and stable coronary artery disease is not clear. The aim of this study was to examine the relationship between plasma BNP levels and the extent of obstructive lesions on coronary angiography in stable coronary artery patients. MethodsPlasma BNP concentrations were measured in 62 patients with a diagnosis of stable angina pectoris who had a left ventricular ejection fraction (LVEF) ≥45% on echocardiographic evaluation. Coronary angiography was performed for all patients, who were than divided into two groups according to the results of the angiography. Group I consisted of the patients who had a lesion leading to an obstruction of the lumen in any coronary artery by less than 50% or those who had normal coronary arteries. All other patients constituted group II. ResultsIn group I (n=26), the mean plasma BNP level was 64.8±29.5 pg/ml. In group II (n=36), it was 99.7±55.4 pg/ml. BNP was significantly higher in group II (P=0.007) than group I. The BNP concentration of the patients with one-vessel disease (n=12), two-vessel disease (n=16), and three-vessel disease (n=8) were 77.9±34.9 pg/ml, 109.3±67.9 pg/ml, 113.3±48.1 pg/ml consecutively. In this respect, the plasma BNP was significantly higher in the groups with more extended vessel disease (P=0.02). When we compared the patients according to involvement of left anterior descending artery (LAD), BNP levels were significantly higher in this group, (116.1±55.8 pg/ml versus 64.1±30.2 pg/ml; P=0.001). ConclusionPlasma levels of BNP were higher in patients who have stable coronary artery disease with preserved left ventricular systolic function. The level of increase in plasma BNP concentration was positively correlated with the extent of lesion and LAD involvement on coronary angiography.

Independent relationship of serum uric acid levels with leukocytes and coronary atherosclerotic burden.

BACKGROUND AND AIM Epidemiological studies have shown that increased serum uric acid (SUA) level is associated with coronary artery disease (CAD). Leukocytes have been shown to play an important role in the atherosclerotic process. The aim of the study was to investigate whether there is any relationship among SUA, leukocyte counts and coronary atherosclerotic burden in patients who are suspected of having CAD. METHOD AND RESULTS We enrolled 690 eligible patients who had undergone coronary angiography between October 2005 and June 2006 in a consecutive manner. The relationship of SUA with total and differential leukocyte counts and CAD was investigated. Serum uric acid levels (5.57+/-1.64 vs 4.63+/-1.27 mg/dl, p<0.001) and leukocytes were higher in patients with CAD than those with normal coronary arteries (NCA). When we divided the patients into four groups according to the quartiles of SUA, we found that the monocyte count was prominently related with SUA (478+/-165, 553+/-177, 565+/-199 and 607+/-229 mm(-)(3), Q1-Q4, p<0.001). In multivariate analysis, SUA was an independent predictor of CAD (OR, 1.270; 95% CI, 1.087-1.484, p=0.003). When we performed multiple linear regression analyses to determine the independent predictors of inflammatory cells in blood, we found a strong, positive and independent relationship between SUA with neutrophils (beta+/-SE: 206+/-60, p=0.001) and monocytes (beta+/-SE: 35+/-7, p<0.001). CONCLUSION Our study results demonstrated that neutrophils and monocytes which play an important role in inflammation and atherosclerosis were independently related with SUA. This finding suggests an important epidemiologic relation and may provide a possible causative mechanism of SUA in atherosclerotic process.

The effect of nebivolol treatment on oxidative stress and antioxidant status in patients with cardiac syndrome-x

BackgroundFree radical-mediated oxidative stress has been implicated in the etiopathogenesis of several disorders. The aim of this study was to elucidate the effect of treatment with nebivolol on the metabolic state of oxidative stress, and antioxidant status markers in patients with cardiac syndrome-X (CSX), additionally, to compare with the effect of metoprolol treatment. MethodsThirty patients, 17 female and 13 male, with CSX were enrolled in the study. Nebivolol (5 mg/day) or metoprolol (50 mg/day) was administrated for 12 weeks. Twelve hour fasting blood samples, taken at the initiation and on the third month of therapy, were analyzed for the levels of malondialdehyde (MDA), nitrite+nitrate (NOx), and the activity of myeloperoxidase (MPO), superoxide dismutase (SOD). No patient presented additional risk factors for increased reactive oxygen species levels. ResultsCompared with sixteen control participants, patients with CSX had significantly higher activity of MPO and levels of MDA, but significantly lower SOD activity and levels of NOx before treatment. After treatment, MPO activity and MDA levels were significantly reduced; SOD activity and NOx levels were significantly increased with nebivolol but remained unchanged with metoprolol. ConclusionWe have shown that patients with CSX who taken nebivolol have lower serum MPO activity, levels of MDA and higher serum SOD activity, NOx levels when compared with metoprolol treatment. Exercise stress test parameters were also ameliorated in patients who had taken nebivolol in contrast to metoprolol. Nebivolol treatment may be a novel treatment strategy in cases with CSX in the future.

Assessment of aortic wall stiffness in patients with Familial Mediterranean Fever

INTRODUCTION To evaluate aortic wall stiffness and its relation between the aortic stiffness and the left ventricular function in patients with Familial Mediterranean Fever (FMF). METHODS The study population was composed of 31 patients with FMF in attack-free period (12 men, 19 women; mean age: 36+/-7 years) and 27 healthy subjects (10 men, 17 women; mean age: 34+/-7 years) who had volunteered to participate. Aortic stiffness indices, aortic strain and distensibility, were calculated from the aortic diameters measured by echocardiography and blood pressure obtained by sphygmomanometry. RESULTS There were significant differences between the control and the patient group in aortic strain (mean (SD), 7.23+/-2.14 versus 4.91+/-1.66%, p=0.01) and distensibility (4.02+/-1.42 versus 2.84+/-1.46, 10(-6)cm(2)dyn(-1), p=0.001). Although there was no correlation between the aortic stiffness parameters and the left ventricular function parameters, there were significant negative correlations between the disease duration and aortic strain index (r=-0.29, p<0.001), and between the disease duration and distensibility (r=-0.32, p<0.001). CONCLUSION Aortic stiffness measurements were found abnormal in patients with FMF. We have also demonstrated that there were significant correlations between aortic stiffness parameters and disease duration.

Coronary artery perforation: a rare complication of coronary angiography

We report perforation of two side branches of the right coronary artery during selective coronary angiography.We suppose that forceful injection of contrast into a non-dominant artery with severe proximal stenosis could have led to this complication.To the best of our knowledge this is the second reported case of coronary perforation during angiography.

Relationship Between MMP-1, MMP-9, TIMP-1, IL-6 and Risk Factors, Clinical Presentation, Extent and Severity of Atherosclerotic Coronary Artery Disease.

Background: Matrix metalloproteinases (MMPs) and Tissue Inhibitor of Matrix Metalloproteinases (TIMPs) may be associated with atherogenesis and plaque rupture. We evaluated the relationship between MMP-1, MMP-9, TIMP-1 and IL-6 levels and risk factors, presentation, extent and severity of atherosclerotic coronary artery disease (CAD). Methods: Consecutive patients who underwent coronary angiography were randomly included. The serum concentrations of MMP-1, MMP-9, TIMP-1 and IL-6 were analyzed with ELISA method in 134 patients. Participants were divided into 5 groups; stable angina pectoris (SAP; n= 34), unstable angina pectoris (USAP; n=29), non-ST elevation myocardial infarction (NSTEMI; n=16), acute ST elevation myocardial infarction (STEMI; n=25) and controls (n=30). Coronary angiographic Gensini score was calculated. Results: MMP-1 levels were higher in STEMI and NSTEMI groups compared with USAP, SAP and control groups (STEMI vs USAP p=0.005; STEMI vs SAP p=0.001; STEMI vs control p<0.001; NSTEMI vs USAP p=0.02; NSTEMI vs SAP p=0.027; NSTEMI vs control p<0.001). In STEMI group, MMP-9 levels were higher than USAP and control groups (p=0.002; p<0,001). TIMP-1 levels were not significantly different within all 5 groups. MMP-1 levels were found to be elevated in diabetic patients (p=0.020); whereas MMP-9 levels were higher in smokers (p=0.043). Higher MMP-1, MMP-9 and IL-6 levels were correlated with severe Left Anterior Descending artery (LAD) stenosis and higher angiographic Gensini Score (for severe LAD stenosis; r = 0.671, 0.363, 0.509 p<0.001; for Gensini score; r = 0.717, 0.371, 0.578 p<0.001). Conclusions: Serum levels of MMP-1, MMP-9, and IL-6 are elevated in patients with CAD; more so in acute coronary syndromes. MMP-1, MMP-9 and IL-6 are associated with more extensive and severe CAD (as represented by Gensini score).

Effects of left ventricular systolic dysfunction on left atrial appendage and left atrial functions in patients with chronic nonvalvular atrial fibrillation.

Objective — It has been claimed that left ventricular (LV) systolic dysfunction impairs left atrial (LA) and left atrial appendage (LAA) functions. In this study, we compared the LA and LAA function parameters in patients with chronic nonvalvular atrial fibrillation (AF) with and without LV systolic dysfunction. Methods and results — The study population consisted of 28 patients with chronic nonvalvular AF. Group I consisted of 12 patients with LV systolic dysfunction (mean age: 61 ± 14 years; LV ejection fraction: 44 ± 6%), group II of 16 patients with normal LV systolic function (mean age: 52 ± 15 years; LV ejection fraction: 65 ± 3%). LV ejection fraction (EF) was measured by echocardiography utilizing bi-plane area length method.The following LA and LAA transoesophageal echocardiography parameters were obtained: 1) LA diameter, 2) LAA ejection velocity, 3) LAA filling velocity, 4) LAA ejection fraction, 5) pulmonary venous (PV) systolic velocity, 6) PV diastolic velocity, 7) PV systolic velocity/diastolic velocity ratio.The left atrium diameter was significantly larger in group I than in group II (4.7 ± 0.7 cm vs. 3.8 ± 0.6 cm, p < 0.05). The LAA ejection velocity and LAA ejection fraction were significantly lower in group I than in group II (22.6 ± 15.5 cm/s vs 37.5 ± 11.3 cm/s and 26.9 ± 20.8% vs. 41.3 ± 10.9%, p < 0.05 for both comparisons). The PV systolic velocity and PV systolic velocity/diastolic velocity ratio were significantly smaller in group I than in group II (26.2 ± 14.8 cm/s vs. 51.5 ± 22 cm/s and 0.7 ± 0.6 vs. 1.2 ± 0.5, p < 0.05 for both comparisons). Although decreased LAA filling and PV diastolic velocities were determined in group I, no significant difference existed between groups I and II.Thrombus and/or spontaneous echo contrast (SEC) in the LA and/or LAA were more frequent in group I (75% vs. 18%, p < 0.05). Conclusion — These results indicate that LV systolic dysfunction impairs various LA and LA function parameters and is associated with an increased frequency of SEC and/or LA thrombus in patients with chronic nonvalvular AF.

The particular interactions of the traditional cardiovascular risk factors with different circulating specific leukocyte subtype counts in blood: an observational study.

OBJECTIVE The pathogenesis of atherosclerosis is multifactorial, however the impact of inflammatory cells in this process is well known. Different traditional cardiovascular risk factors (CVRFs) may have specifically different effects on leukocyte subtype. Thus, these special interactions may induce different vascular involvement forms due to the altered endothelial damage and vascular repair mechanisms. The aim of the present study was to investigate whether there is any specific relationship between the leukocyte subtypes and the traditional CVRFs and to evaluate the independency of possible relationships. METHODS The study had a cross-sectional observational design. The study population consisted of the patients who underwent coronary angiography with a suspicion of coronary artery disease (CAD) at our institution in an outpatient manner. We enrolled 677 consecutive eligible patients with CAD or normal coronary arteries (NCA) and investigated the associations of traditional CVRFs, demographic properties and biochemical parameters including fasting plasma glucose (FPG), creatinine, serum uric acid level (SUA) and lipids with total circulating inflammatory cell (WBC, leukocytes) and subtype counts including neutrophils (N), lymphocytes (L) and monocytes (M). As a dependent variable, total leukocyte count and subtypes, and neutrophil/lymphocyte ratio (N/L ratio) which has been found to being related with increased vascular risk and events were investigated in the groups determined by the presence or absence of CVRFs and CAD by the univariate analyses and then multiple linear regression analyses. RESULTS When we performed multiple linear regression analyses to determine the independent associations of inflammatory cell subtypes, we have found that FPG had an independent incremental association with WBC (β±SE:4.2±1.4, p=0.004) and N (β±SE:4.2±1.2, p=0.001). Current smoking had an independent incremental association with WBC and all cell subtypes (for WBC, N, L, and M: β±SE: 748±161, p<0.001; β±SE: 556±136, p<0.001; β±SE: 185±69, p=0.007; β±SE: 38±20, p=0.061, respectively) and SUA had an independent incremental association with WBC (β±SE: 115±43, p=0.008), N (β±SE: 107±38, p=0.005) and M (β±SE: 26±6, p<0.001). Hypertension had an independent incremental association with WBC (β±SE: 431±140, p=0.002) and N (β±SE: 315±118, p=0.008). Male gender had an independent incremental association with only M (β±SE: 52±20, p=0.010). Family history of CAD had an independent decremental association with WBC (β±SE: -327±139, p=0.019) and N (β±SE: -326±121, p=0.007). Finally, age had an independent decremental association with WBC (β±SE: -32±7, p<0.001) and L (β±SE: -16±3, p<0.001). The N/L ratio was independently related with increased age (p<0.001), FPG (p=0.003) and SUA (p=0.012). CONCLUSION Our study results demonstrate that leukocyte subtypes have different specific associations with traditional CVRFs. We found that FPG affects specifically N while SUA affects specifically N and M, and current smoking affects nonspecifically on all cell subtypes. While hypertension with N and male gender with M were specifically related, age and family history of CAD were only related to L. These different interactions may lead to different endothelial damage and vascular repair mechanisms.

Dual coronary artery–pulmonary artery fistulas

A 62-year-old man presented with exertional angina. His physical examination and electrocardiogram were normal. Myocardial perfusion scintigraphy showed ischemia of the anterior wall of the left ventricle. The patient’s echocardiographic examination was normal. Coronary angiography revealed dual coronary artery fistulas originating from the first diagonal and conus branches of the right coronary artery and opening into the main pulmonary artery (Figures 1 and ​and2).2). Coil occlusion of the fistulas was recommended to the patient. Figure 1) Coronary angiography (90° left anterior oblique, 0° caudal projection) Figure 2) Coronary angiography (46° left anterior oblique, 0° caudal projection)