Mustafa Demirol

Usefulness of Neutrophil to Lymphocyte Ratio in Prediction of Coronary Artery Lesions in Patients with Kawasaki Disease

BACKGROUND Kawasaki disease is an inflammatory condition. Neutrophil to lymphocyte ratio is a marker reflecting inflammation. AIMS The aim of the study is to evaluate usefulness of neutrophil to lymphocyte ratio in diagnosis of Kawasaki disease and in prediction of coronary artery lesions. STUDY DESIGN Retrospective cross-sectional study. METHODS Seventy-five children with Kawasaki disease and 66 controls were retrospectively enrolled. Their leukocyte, neutrophil, and lymphocyte counts were recorded. Abnormally distributed data were shown as median (interquartile range). Cases having coronary artery diameter two standard deviation above mean were diagnosed to have coronary artery lesions. RESULTS Median age of Kawasaki disease patients was 34 months. Twentyfive of those (33.33%) had incomplete Kawasaki disease and twenty-six (34.66%) had coronary artery lesions. Leukocyte [12.61 (6.09)×10(3)/µL vs. 8.48 (5.58)×10(3)/µL], neutrophil [6.73 (4.10) ×10(3)/µL vs. 4.62 (5.47)×10(3)/µL], and lymphocyte [4.04 (2.91)×10(3)/µL vs. 3.02 (2.57) ×10(3)/µL] counts were significantly higher in Kawasaki disease patients compared to controls (all p values <0.01). However, there was not significant difference between patients and controls regarding neutrophil to lymphocyte ratio [1.72 (1.22) vs. 1.71 (1.88)]. Findings of Kawasaki disease and incomplete Kawasaki disease cases did not differ, while comparison of patients with and without coronary artery lesions revealed significantly higher neutrophil to lymphocyte ratio values in former group [2.02 (1.63) vs. 1.50 (1.28), p=0.01]. The cut-off neutrophil to lymphocyte ratio value for prediction of coronary artery lesions was determined as 1.32. CONCLUSION Neutrophil to lymphocyte ratio values in Kawasaki patients with coronary lesions were significantly higher than the ones without and values greater than 1.32 were useful in prediction of coronary lesions.

Red blood cell distribution width: can it be a predictive marker for long-term valvular involvement in children with acute rheumatic carditis?

In this study, we aimed to evaluate Red blood cell distribution width (RDW) in patients with acute rheumatic carditis during the acute phase and after anti‐inflammatory therapy.

Echocardiographic evaluation of cardiac functions in newborns of mildly preeclamptic pregnant women within postnatal 24–48 hours

Abstract The aim of this study is to detect preeclampsia-related cardiac dysfunction within 24–48 hours of delivery in newborns born from preeclamptic mothers. Forty newborns from mildly preeclamptic mothers formed the study group and the control group was formed by 40 healthy newborns. Cardiac function for the groups were evaluated using conventional echocardiography and myocardial performance index (MPI) within the first 24–48 hours of their lifetime and the results of both groups were compared. A significant difference between the groups was observed especially in the PW Doppler MPI measurements (the left ventricle MPI 0.37 ± 0.09 and 0.26 ± 0.11, p < .001; the right ventricle MPI 0.29 ± 0.08 and 0.26 ± 0.07, p < .035) for the control group and the study group. Elongation in the left and right ventricle MPI was detected to be more significant in terms of comparing systolic and diastolic functions to determine preeclampsia-related cardiac injury in newborns from preeclamptic mothers within the first 24–48 hours of their lifetime. Impact statement Today, the methods which may detect cardiac injury earlier than conventional echocardiographic methods are used for evaluating cardiac functions. Among them, myocardial performance index (MPI) measurement with PW Doppler is the most common ones. While studies are available in the literature evaluating foetal cardiac functions with MPI in foetuses of preeclamptic women, studies evaluating cardiac functions with MPI index within the first 24–48 hours in postnatal period are not available. This is the first study to detect cardiac injury by measuring cardiac functions of the newborns of preeclamptic babies using conventional echocardiography (EF, SF, mitral and tricuspid E/A) and myocardial performance index within the first 24–48 hours of life and compare these values with those of a control group composed of healthy newborns with similar demographic characteristics. According to the results of the study, elongation in right and left ventricle MPI was detected to be more significant compared to systolic and diastolic functions for determining preeclampsia-related cardiac injury in newborns of preeclamptic mothers within 24–48 hours of delivery. Ventricle functions of the newborns of preeclamptic mothers should also be evaluated with MPI measurement besides conventional echocardiographic measurements.

Recent experience with transcatheter closure of perimembranous ventricular septal defects using duct occluders.

We have read with great interest the paper entitled “Transcatheter closure of perimembranous ventricular septal defects with ductal occluders” published in Cardiology in the Young. First, we would like to congratulate the authors for their study evaluating the feasibility and complications of ductal occluders for closure of perimembranous septal defects in a relatively sufficient number of patients. The conclusion of this study was that ductal occluders might be a promising therapeutic option for the closure of smalland moderate-sized ventricular septal defects. We would like to discuss our experience with ductal occluders in children with perimembranous ventricular septal defects. We performed transcatheter closure of perimembranous ventricular septal defects with Amplatzer duct occluders in 17 cases during the 18-month period: first-generation Amplatzer duct occluder was used in 13 cases and Amplatzer Duct Occluder-II device in four patients. The devices were successfully implanted in 16 of 17 patients. In one patient, the first-generation duct occluder suddenly embolised into the left pulmonary artery soon after its deployment. The device was retrieved and the patient underwent surgical closure of the ventricular septal defect. We usually decide the appropriate type and size of the device based on measurements obtained on left ventricular angiograms. A device that was 1–2mm larger than the defect size was chosen for our first few cases; however, residual leakage was observed in two patients, of whom one had left bundle branch block. Development of embolisation of device in one patient and residual shunt in two patients changed our approach for decision on suitable device size. Therefore, we started to use devices that were 2–4mm larger than the defect size in the following cases, if the anatomy was favourable. We did not observe any embolisation or residual shunt after the change in approach. Left bundle branch block developed 1 day after the procedure in the patient who had the Amplatzer Duct Occluder-II implantation. Echocardiography showed the device moving to the right side during the systole and to the original position during diastole similar to accordion bands. After 1 month of follow-up, the device settled more properly and bundle branch block was improved; however, residual shunt persisted in this patient. Moreover, two retention discs may cause improper positioning of the device mimicking accordion motion, even if we take care to choose a larger Amplatzer Duct Occluder-II device as in this patient. Although it may have advantages regarding reducing the chance of valvular problems and advanced heart block, the fabric-free design and flexible waist might increase the possibility of residual shunt and embolisation; because of these concerns, our current approach is to close proper perimembranous defects using first-generation duct occluders that are 2–4mm larger than the defect. The absence of right-sided retention disc and longer waist length may offer advantages in terms of stability of the device and appropriate alignment after deployment to avoid entrapment of the tricuspid leaflet and right ventricular structures. Although there is a concern that ductal occluders are not designed for the closure of these defects, we share the authors’ conclusion that duct occluders might provide an effective and safe therapeutic option in selected patients with perimembranous ventricular septal defects.

Giant aneurysm of ascending aorta in a child

A 5-year-old boy was referred to the present clinic with severe aortic stenosis and indication of percutaneous balloon valvuloplasty. The patient’s parents were consanguineous in the second degree, and he had no obvious phenotypic dysmorphic features suggesting syndromic etiology, with the exception of short stature, which is under investigation in pediatric endocrinology. Transthoracic echocardiography (TTE) revealed that the aortic valve had 3 cusps and was severely stenotic, with a peak to instantaneous gradient of 100 mmHg. A hypoechoic chamber connected to the ascending aorta was visualized (Figure A, B). As TTE was insufficient for determination of detailed anatomy of this chamber, cardiac catheterization and angiography were performed. Aortic root angiography in left anterior oblique cranial position demonstrated a huge ascending aortic aneurysm of 30x27 mm (Figure D). Aneurysm was confirmed by contrast material injections in other positions (Figure E, F). In addition, stenosis was at supravalvular level close to the origin of the left main coronary artery (Figure F). No intervention was performed, and surgical team was consulted. Meanwhile, cardiac computed tomography (CT) also showed that the aneurysm was originating from the left side of the ascending aorta, and was anteriorly extending (Figure C, G). Most aortic aneurysms are located in the abdominal part of the aorta, and ascending aortic aneurysms primarily occur in the elderly population. Although aortic aneurysms in older adults are usually associated with hypertension, smoking, and hypercholesterolemia, aortic aneurysms in children and young adults generally occur with inherited syndromes. However, in the present patient, the turbulent jet of supravalvular aortic stenosis may have led to weakening of the aortic wall, causing aneurysmatic dilatation. Mycotic and infectious aneurysms may also be found in the pathways of turbulent jet flows, causing endothelial injury. Currently, the patient is under investigation for inherited disorders. 447

Can abnormal ductus venosus peak velocity index for veins in normal fetuses predict failure of functional closure of the foramen ovale in the postnatal period

AIM To investigate whether ductus venosus (DV) wave velocities and/or DV peak velocity index for veins (DV-PVIV) can predict failure of functional closure of the foramen ovale in the postnatal period. MATERIAL AND METHODS Fetal echocardiography was performed in 455 healthy women with uneventful pregnancies between the 20-24th gestational weeks. DV blood flow and DV-PVIV data were collected prospectively. Echocardiography was repeated in healthy subjects on the 30th postnatal day. Four hundred patients met the study criteria. Newborns with clearly visible foraminal flaps, interatrial septal defects smaller than 5 mm and right-to-left shunting through the defect were accepted as patent foramen ovale (PFO) (n=91). Newborns without PFO (n=309) comprised the control group. RESULTS A statistically significant difference was detected between the groups with and without PFO in terms of mean DV-PVIV values, DV-D and DV-a wave velocities (p<0.05 for all). ROC analysis showed that increased DV-PVIV values were related to and predictive of PFO (AUC=0.75; p<0.001) and that a threshold value of 0.62, had a sensitivity of 86.8% (95% CI 78.1-93.0%) and a specificity of 51.7% (95% CI 46.1-57.5%). CONCLUSION DV-PVIV values above 0.62 at the time of fetal echocardiographic examination can predict failure of functional closure of the foramen ovale in the postnatal period.

Assessment of the Influence of Hyperechogenic Focus Detected on Fetal Echocardiographic Examination on Cardiac Functions Through Analyzing Ductus Venous Blood Flow

Ya z›fl ma Ad re si/Ad dress for Cor res pon den ce Dr. Rahmi Ozdemir, Behcet Uz Cocuk Hastanesi, Cocuk Kardiyoloji Klinigi, Izmir, Turkiye Tel.: +90 232 489 56 56/6186 E-posta: rahmiozdemir35@gmail.com Ge lis ta ri hi/Re cei ved: 05.05.2014 Ka bul ta ri hi/ Ac cep ted: 13.08.2014 Yilmaz Yozgat1, Rahmi Ozdemir1, Cem Karadeniz1, Secil Kurtulmus2, Mustafa Demirol1, Mehmet Kucuk1, Utku Karaarslan3, Timur Mese1, Nurettin Unal1 1Dr. Behcet Uz Cocuk Hastanesi, Cocuk Kardiyoloji Klinigi, Izmir, Turkiye 2Katip Celebi Universitesi Tip Fakultesi, Perinatoloji Anabilim Dali, Izmir, Turkiye 3Dr. Behcet Uz Cocuk Hastanesi, Cocuk Yogun Bakim Unitesi, Izmir, Turkiye