Mustafa Kemal Erol

Diastolic function abnormalities in active rheumatoid arthritis evaluation by conventional Doppler and tissue Doppler: relation with duration of disease.

ObjectiveThe aim of this study was to evaluate left ventricular diastolic function in patients with active rheumatoid arthritis (RA), analyzing conventional Doppler and tissue Doppler echocardiographic imaging (TDI) which is a new echocardiographic application, with special regard to disease duration.MethodsFifty-two patients with active RA and 47 healthy persons were included in this study. Duration of disease ranged from 3 to 324 months (mean 76±85 months). All patients and the control group were evaluated by M-mod, two-dimensional, conventional Doppler echocardiography and TDI.ResultsAmong conventional Doppler transvalvular mitral flow parameters, late diastolic flow velocity (A) and deceleration time (DT) values were higher in patients with RA than that in the control group (p<0.001). E (early diastolic flow velocity)/A ratio was found to be lower in patients with RA than that in the control group (p<0.001). Mitral annular early diastolic velocity (Em), among TDI parameters, was found to be lower in patients with RA than that in the control group (p<0.001). Em/Am (mitral annular late diastolic velocity) ratio was found to be lower in RA patients compared with that in the control group (p<0.001). The relation was found between A (r=0.43, p=0.001), DT (r=0.30, p=0.03), E/A ratio (r=0.40, p=0.004), Em (r=0.32, p=0.02), Em/Am ratio (r=0.30, p=0.03), and E/Em (r=0.32, p=0.02), with disease duration in patients with RA.ConclusionAt present, it is concluded that active RA patients, in the absence of clinical evidence of heart disease, show diastolic dysfunction characterized by impaired E/A ratio, Em/Am ratio, and DT. The relation between diastolic dysfunction and disease duration suggests a subclinical myocardial involvement.

Assessment of right heart function in the athlete's heart.

Abstract It is known that the heart of an athlete has been physiologically adapted by prolonged training. There are a large number of echocardiographic studies which have focused on left ventricular wall thickness and dilatation, but there are few studies concerning right heart function in the athletes heart. The aim of this study was to assess right heart function in elite athletes by conventional and new echocardiographic methods. The study population consisted of 36 elite highly-trained male athletes and 16 age-matched healthy sedentary controls. Right atrial, right ventricular, and inferior vena cava dimensions, and pulsed Doppler measurements of tricuspid inflow and right ventricular outflow were obtained, and systolic (preejection period, ejection time, preejection time/ejection time, QV peak, isovolumic contraction time) and diastolic (E peak, A peak, E/A ratio, decelaration time, isovolumic relexation time) function parameters were measured. The myocardial performance index was calculated as (isovolumetric contraction time + isovolumetric relaxation time)/ejection time. In addition, right ventricular systolic and diastolic functions were determined by Pulsed wave tissue Doppler imaging (S, E, and A velocities) at the lateral corners of the tricuspid annulus. The left ventricular mass index (P < 0.005), and right atrial (P < 0.001), right ventricular (P < 0.001), and inferior vena cava dimensions (P < 0.001) were significantly greater in athletes than in controls. Tricuspid E peak, A peak, E/A ratio, deceleration time, isovolumic relaxation time, preejection period, right ventricular ejection time, preejection time/ejection time, isovolumic contraction time, QV peak, and myocardial performance index were found to be similar in athletes and in controls (P > 0.05). Systolic, early diastolic, and late diastolic tissue Doppler imaging velocities were not significantly different in athletes and controls (P > 0.05). Left ventricular hypertrophy (LV mass index >134 g/m2) was found in 15 of the athletes. Right atrial dimension was greater in the athletes with left ventricular hypertrophy than in those without hypertrophy (P < 0.05). All right ventricular systolic and diastolic echocardiographic parameters were similar in athletes with and without left ventricular hypertrophy (P > 0.05). The results of this study indicate that right ventricular systolic and diastolic functions do not deteriorate in the athletes heart despite significant chamber dilatation. They suggest that these changes are a normal physiologic adaptation to prolonged training.

Left atrial mechanical function in patients with essential hypertension

Objective — This study was carried out to assess the left atrial (LA) mechanical function in patients with essential hypertension with two-dimensional echocardiography by means of left atrial volume measurements. Methods — LA volumes were measured echocardiographically in 36 untreated hypertensive patients and 20 age-sex-matched healthy controls according to biplane area-length method. LA volume measurements were done at the time of mitral valve opening (Vmax), at the onset of atrial systole (p wave at the electrocardiography = Vp) and at closure (Vmin). All volumes were indexed for body surface area, and the following left atrial emptying functions were calculated: LA passive emptying volume = Vmax – Vp, LA passive emptying fraction = LA passive emptying volume / Vmax, conduit volume = left ventricular stroke volume-(Vmax- Vmin), LA active emptying volume = Vp- Vmin, LA active emptying fraction = LA active emptying volume / Vp, LA total emptying volume = (Vmax-Vmin), LA total emptying fraction = LA total emptying volume / Vmax. Results — Vmax (p < 0.01), Vmin (p < 0.005) and Vp (p < 0.001) were significantly greater in hypertensives than in controls. Although LA passive emptying volume (p < 0.001), LA passive emptying fraction (p < 0.001), conduit volume (p < 0.005) and LA total emptying fraction (p < 0.05) were found to be significantly lower in hypertensives than in controls, LA active emptying volume (p < 0.001) and LA active emptying fraction (p < 0.01) were found to be significantly greater in hypertensives than in controls. LA total emptying volume (p > 0.05) was similar in both groups. Conclusion — The results of the present study indicate that chronic hypertension is associated with an increased in left atrial volumes, a decrease in left atrial passive emptying function, and an increase systolic pump function. Increased left atrial pump function represents a compensatory mechanism in hypertensive patients with left ventricular hypertrophy.

Pulsed Doppler tissue imaging can help to identify patients with right ventricular infarction.

This study was planned to assess whether tissue Doppler imaging is a useful method for the detection of the right ventricular myocardial infarction. Forty-eight patients with acute inferior myocardial infarction and 24 age- and sex-matched healthy controls were included in this study. Twenty-four patients had electrocardiographic signs of inferior myocardial infarction without right ventricular infarction (group I), and the other 24 patients had electrocardiographic signs of inferior myocardial infarction with right ventricular infarction (group II). From the echocardiographic apical four-chamber view, peak systolic, early diastolic, and late diastolic velocities of the tricuspid annulus at the right ventricular free wall were recorded with the use of pulsed-wave Doppler tissue imaging. The tricuspid annular peak tissue Doppler imaging systolic velocity was significantly lower in group I (14.03 ± 2.57 cm/s, P ≪ 0.005) and in group II (8.50 ± 0.84 cm/s, P ≪ 0.005) than in controls (16.63 ± 2.31 cm/s). The tricuspid annular peak systolic (8.50 ± 0.84 cm/s vs 16.63 ± 2.31 cm/s) and peak early diastolic (10.99 ± 3.28 cm/s vs 19.39 ± 4.3 cm/s) velocities were significantly lower in group II than in group I, as compared with controls (P ≪ 0.001). Peak early diastolic velocity of tricuspid annulus (10.99 ± 3.28 cm/s vs 19.39 ± 4.3 cm/s) was significantly lower in group I than in controls (P ≪ 0.001); however, late diastolic velocity was significantly lower in group II (15.98 ± 5.08 cm/s, P ≪ 0.05) than in group I (18.21 ± 2.63 cm/s, P ≪ 0.05) and in controls (19.02 ± 5.29 cm/s). The results of this study indicate that tricuspid annular peak systolic and early diastolic velocities are reduced in patients with right ventricular infarction. The velocity of the tricuspid annulus by tissue Doppler imaging is simple and can be used to distinguish whether patients with inferior myocardial infarction have right ventricular infarction.

Protective effects of melatonin against myocardial injury induced by isoproterenol in rats.

Abstract: This study was performed to determine whether melatonin could have a protective effect against myocardial injury (MI) induced by isoproterenol (ISO) in rats. Twenty‐four rats were divided into three treatment groups: (1) control (n = 8): saline solution. (2) ISO (n = 8): ISO only. (3) melatonin + ISO (n = 8). Melatonin (10 mg/kg/day, i.p.) was administered 30 min before the initiation of ISO (150 mg/kg/day, s.c.). Drugs and saline were given at 14:00 hr for two consecutive days. At the end of the second day, blood samples were taken from the abdominal aorta shortly after the rats were anesthetized for the purpose of measuring cardiac troponins T (cTnT) and I (cTnI); hearts were removed, preserved and examined microscopically. Additionally, based on the histological changes in myocardial tissue, the rats were divided into three groups: no change, mild changes and moderate and/or marked changes. The mean cTnT and cTnI values were significantly increased in ISO group compared with control group [(1.29 ± 0.22 ng/mL versus 0.46 ± 0.07 ng/mL, P < 0.0001) and (0.56 ± 0.11 ng/mL versus 0.21 ± 0.01 ng/mL, P < 0.001)], respectively, and were significantly reduced in the ISO + melatonin group (0.65 ± 0.06 ng/mL for cTnT and 0.25 ± 0.01 ng/mL for cTnI) compared with the ISO only group (P < 0.01), respectively. cTnT and cTnI values were significantly increased in rats with moderate and/or marked cardiac changes compared with hearts where there were mild changes and no change (P < 0.05). ISO + melatonin group showed less histological changes than the ISO group (P < 0.01). In conclusion, this study revealed a protective effect of melatonin against ISO‐induced MI in rats, and its potential clinical application in the treatment of MI.

Clinical situations in which coronary CT angiography confers superior diagnostic information compared with coronary angiography

In this review, we aimed to outline the clinical and pathological conditions for which multidetector computed tomography coronary angiography (MDCT-CA) should be the preferred method because of its advantages over conventional coronary angiography (CCA). A consistent body of literature suggests that MDCT-CA is more than just complementary to CCA and that it provides more valuable diagnostic information in certain clinical situations, such as complex coronary artery variations, aorto-ostial lesions, follow-up of bypass grafts, myocardial bridging, coronary artery fistulas, aortic and coronary artery dissections, and cases in which the coronary ostia cannot be cannulated by a catheter because of massive atherosclerosis or extremely tortuous vascular structures.

Left Atrial Mechanical Functions in Elite Male Athletes

I athletic conditioning is associated with hemodynamic changes and affects the loading conditions of the heart. It is known that the heart of an athlete has become physiologically adapted by prolonged training. These changes include an increase in left ventricular (LV) chamber size, wall thickness, and mass. It is reported that athletes involved in mainly static or isometric exercise develop concentric hypertrophy, and in contrast to this, athletes involved in endurance training or isotonic exercise develop eccentric hypertrophy. There are a large number of echocardiographic studies on LV wall thickness and dilatation, but there are very few studies concerning left atrial (LA) mechanical function in the athlete’s heart. This study was undertaken to assess the possible adaptive changes in LA mechanical function in elite athletes. • • • Thirty-six top-level male athletes (21 4 years), all members of the national running team, wrestling team, skiing team, or other professional sports teams (14 runners, 10 wrestlers, 4 boxers, 5 basketball players, and 3 skiers) and 21 age-matched healthy male controls (21 4 years) were included. Mean athletic competition time was 7.7 4.1 years and the mean average training time was 11.5 3.9 hours/week in the athletes. All athletes were in the intense training period. Athletes in the off-training period or during prolonged rest ( 10 days) were not included. All subjects enrolled in this study were free from cardiac disease on the basis of a negative medical history and normal physical examination and electrocardiogram. The subjects who had a history of taking any cardioactive medication or anabolic steroids were excluded from this study. The study protocol was approved by the ethics committee of our institute and all subjects gave written consent for the study. A Vingmed System Five Doppler echocardiographic unit (GE Vingmed Ultrasound, Horten, Norway) with 2.5-MHz FPA probe was used. All echocardiograms were recorded by the same investigator. An echocardiographic study was performed in the left lateral decubitus position, with parasternal long and apical 2-, 4-, and 5-chamber views. Diastolic ventricular septal thickness, diastolic posterior wall thickness, and LV end-diastolic and end-systolic dimensions were measured in the parasternal long-axis view, and LV mass was determined by the method of Devereux and Reichek and indexed to body surface area. A sample volume of pulsed-wave Doppler was placed between tips of mitral leaflets on the apical 4-chamber view. Peak early (E) and late (A) mitral inflow velocities, E/A ratio, and deceleration time of E velocity were obtained. Isovolumic relaxation time was obtained with the sample volume of the pulsedwave Doppler positioned between mitral inflow and LV outflow tract as the time interval from the cessation of aortic flow to the onset of mitral valve inflow. LV end-diastolic and end-systolic volumes were determined from the apical 4-chamber view according to the modified Simpson’s method, and LV stroke volume and ejection fraction were calculated. LA volumes were measured echocardiographically at the time of mitral valve opening (maximal, Vmax), at the onset of atrial systole (p wave on electrocardiography Vp), and at mitral valve closure (minimal, Vmin) according to the biplane area-length method in the apical 4and 2-chamber view. All volumes were corrected for body surface area and the following LA emptying functions were calculated: LA passive emptying volume Vmax Vp; LA passive emptying fraction LA passive emptying volume/Vmax; conduit volume LV stroke volume (Vmax Vmin); LA active emptying volume Vp Vmin; LA active emptying fraction LA active emptying volume/Vp; LA total emptying volume (Vmax Vmin); LA total emptying fraction LA total emptying volume/ Vmax. 10 All measurements were averaged over 3 cardiac cycles. Data are expressed as mean SD. The differences between groups were assessed with the Student’s t test. The relation between different variables was assessed with the Pearson correlation. A p value 0.05 was considered statistically significant. Athletes and members of the control group did not differ significantly in mean age and body surface area (21 4 vs 20 4 years and 1.8 0.2 vs 1.8 0.2 m, respectively, p 0.05). Heart rate was significantly lower in athletes than in controls (p 0.001). Systolic and diastolic blood pressures were similar in both groups (p 0.05). LV end-diastolic diameter and volume were significantly higher in athletes than in controls (p 0.05). LV end-systolic diameter and volume and ejection fraction were similar in the 2 groups (p 0.05). Posterior wall thickness (p 0.01), ventricular septal thickness (p 0.001), and LV mass index (p 0.001) were significantly greater in athletes than in controls. E and A transmitral flow velocity, and E/A ratio were similar in both groups (p 0.05). LA dimension was significantly greater in athletes than in controls (p 0.005) (Table 1). LA volume indexes, Vmax (p 0.005), Vmin (p 0.05), and Vp (p 0.005) were greater in athletes From the Department of Cardiology, Medical School Hospital, and Department of Physical Education and Sport, Ataturk University, Erzurum, Turkey. Dr. Erol’s address is: Ataturk University, Department of Cardiology, Medical School Hospital, 25050 Erzurum, Turkey. E-mail: mkerol@superonline.com.tr. Manuscript received April 10, 2001; revised manuscript received and accepted June 7, 2001.

Strain and Strain Rate Imaging in Evaluating Left Atrial Appendage Function by Transesophageal Echocardiography

Background: This study was planned to assess whether strain rate (Sr) and strain (S) echocardiography is a useful method for functional assessment of the left atrial appendage (LAA). Material and Methods: Fifty‐seven consecutive patients underwent a clinically indicated study. LAA late empty velocity (LAAEV) was calculated as a gold standard for left atrial appendage function. Real‐time 2‐dimensional color Doppler myocardial imaging data were recorded from the LAA at a high frame rate. Analysis was performed for LAA longitudinal strain rate and strain from midsegment of lateral wall of LAA. LAA strain determines regional lengthening expressed as a positive value or shortening expressed as a negative value. Peak systolic values were calculated from the extracted curve. Results: Spearman correlation test results showed a statistically significant positive correlation was between the S, Sr variables and LAAEV (LAAEV vs S; r = 0.886, P < 0.001; LAAEV vs Sr: r = 0.897, P < 0.001, respectively). Strain and strain rate values were also significantly lower in patients with spontaneous echocardiographic contrast when compared with those without (strain; 2.42 ± 0.98 vs 13.1 ± 5.9, P < 0.001 and strain rate: 0.97 ± 0.54 vs 3.34 ± 1.15, P < 0.001, respectively). In addition, LAA strain and strain rate values were significantly lower in the patients with LAA thrombus (strain; 2.15 ± 0.96 vs 8.35 ± 6.9, P < 0.001, strain rate; 0.79 ± 0.46 vs 2.30 ± 1.48, P < 0.001, respectively). Conclusion: S and Sr imaging can be considered a robust technique for the assessment of the LAA systolic deformation.

Assessment of regional left ventricular functions by strain and strain rate echocardiography in type II diabetes mellitus patients without microvascular complications

OBJECTIVES We evaluated regional left ventricular myocardial functions by strain (S) and strain rate (Sr) echocardiography in patients with type II diabetes mellitus (DM) without microvascular complications. STUDY DESIGN The study included 40 DM patients (20 women, 20 men; mean age 52.4 ± 7.9 years) without microvascular complications, and 40 healthy controls (20 women, 20 men; mean age 52.8 ± 10.1 years). Left ventricular functions were evaluated by conventional Doppler, tissue Doppler, and S-Sr echocardiography. Longitudinal peak systolic S and Sr were measured from the basal, mid and apical segments of the left ventricle walls. Patients with DM duration of >3 years (n=24) and receiving medical therapy for DM (n=30) were also evaluated. RESULTS Conventional Doppler findings were similar in the patient and control groups. Among tissue Doppler variables, only early diastolic mitral annular velocity (Em) was significantly decreased (10 ± 2.9 vs. 11.4 ± 3.2 cm/sec, p<0.05), and accordingly, mitral inflow E/Em ratio was significantly increased (7.3 ± 2.5 vs. 6.3 ± 2, p<0.05) in patients with DM. The two groups were similar with respect to systolic S and Sr values, except for apical-lateral S, mid-anterior S, basal-anteroseptal S, apical-anterior Sr, and mid-anteroseptal Sr (p<0.05, for all). Patients with DM duration of >3 years and receiving medical therapy showed similar changes as the overall patient group. CONCLUSION The frequency of left ventricular diastolic dysfunction was higher in patients with DM. Irregular distribution of systolic S and Sr indices in the left ventricular segments may indicate that DM leads to heterogeneous myocardial involvement also in the early period.

Left atrial remodeling in acute anterior myocardial infarction.

Background: Our goal in this study was to examine the changes in the left atrial functions over a period of 3 months by using left atrial volume measurements in patients with anterior myocardial infarction (MI). Methods and Results: Seventy‐three patients with anterior MI who consulted our hospital in the first 12 hours starting from the onset of the chest pain and who exhibited ST elevation were enrolled in the study. The left atrial functions of the patients were evaluated by transthoracic echocardiography for a total number of four times; first at the time of the visit to the hospital, then in the first week, and then in the first and third months. Eight (10.95%) of the 73 patients included in the study died during the follow‐up. The remaining 65 patients completed the 3‐month study period. Of these 65 patients, primary percutaneous transluminal coronary angioplasty (PTCA) was performed for 24 (36.9%) patients and thrombolytic therapy was given to 13 (20%), whereas 28 (43.1%) patients were given only medical treatment. Left atrium (LA) maximum transverse diameter, LA maximum, minimum, and presystolic volume, LA active emptying volume and fraction were found to increase significantly in comparison to baseline detected for this parameter in the first and third months (P < 0.001). However, LA passive emptying volume and fraction was found to decrease significantly in comparison to baseline detected for this parameter in the first and third months (P < 0.001). Conclusions: An increase in the diameter, volume, and dimensions of LA during atrial remodeling was detected. LA passive emptying fraction was found to decrease, whereas atrial active emptying function was found to increase to compensate for this change.