Nuri Kurtoglu

Endovascular stenting of mid-aortic syndrome due to Takayasu arteritis

Abstract Introduction–patients: Takayasu arteritis may involve various parts of the aorta and its major branches. It leads to occlusive or aneurysmal disease of the vessel. It can be treated either with surgery or percutaneous intervention. We report a successful endovascular treatment of stenosis of the descending thoracic and abdominal aorta in a 19-year-old female. Methods–results–conclusions: Self-expandable nitinol stent was deployed and adequate opening of the aorta was obtained in this patient. Long-term durability of endovascular approach is a matter of debate. We also reviewed the sufficiency of endovascular treatment versus surgery.

Ticagrelor-associated thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening, multisystem disease characterized by microangiopathic hemolytic anemia, thrombocytopenia, fever, renal dysfunction, and neurological disorders. Presence of microangiopathic hemolytic anemia, and thrombocytopenia are essential for diagnosis (1,2). In most cases, it is secondary to production of autoantibodies that reduce activity of a disintegrin and metalloproteinase with thrombospondin domain 13 (ADAMTS-13), which cleaves von Willebrand factor (vWF). Decrease in vWF degradation induces microvascular thrombosis, hemolytic anemia, and thrombocytopenia (3). Common laboratory findings include anemia and fragmented red blood cells (schistocytes), reduced platelet count, increased lactate dehydrogenase (LDH) level. Plasma exchange is life-saving treatment for TTP (4). Three thienopyridines (ticlopidine, clopidogrel, and prasugrel) have been found to be related to TTP (5). Ticagrelor is a new agent now preferred to clopidogrel to treat acute coronary syndromes (6). In contrast to the thienopyridine family of drugs, ticagrelor has not previously been associated with TTP. Presently described is the first case of ticagrelor-linked TTP in literature.

Severe Hypokalemia Probably Associated With Sertraline Use

Objective: To report a case of ventricular fibrillation caused by severe hypokalemia probably associated with sertraline use. Case Summary: A 48-year-old male patient experienced ventricular fibrillation and cardiac arrest 2 hours after an uneventful coronary angiography procedure, which revealed normal, unobstructed coronary arteries. Blood chemistry was immediately obtained, revealing a very low potassium (K+) level of 2.44 mEq/L. Other blood electrolytes, including magnesium, ECG, and corrected QT intervals, were all within normal limits. A thorough search for an etiology of hypokalemia, including adrenal gland causes, herbal product consumption, and toxic exposure, did not reveal any identifiable cause. This led us to consider the only drug he was on—sertraline 50 mg per day—as the possible culprit. Discussion: There has been no clear identification of severe hypokalemia associated with sertraline use in the literature. However, there have been a considerable number of self-reported cases of hypokalemia in patients on sertraline therapy. Scoring according to the Naranjo adverse drug reaction scale revealed a probable relationship between severe hypokalemia and sertraline use in our patient. No clear pathogenic mechanism for the effect of sertraline on serum K equilibrium is known. However, considering the number of self-reported incidences and this case report, the effect of sertraline on serum K levels warrants consideration. Conclusions: This is the first documented case report of severe hypokalemia probably associated with sertraline use.

Images in InterventionNative Aortic Valve Thrombosis Leading to ST-Segment Elevation Myocardial Infarction

A 54-year-old male patient with no history of left bundle branch block was admitted to the emergency department with chest pain lasting for 1 h. Electrocardiography demonstrated newly developed left bundle branch block indicating ST-segment elevation myocardial infarction. He was immediately taken

Prognostic value of high on-treatment platelet reactivity

We have read the article by Tekkesin et al. (1) entitled “The first six-month clinical outcomes and risk factors associated with high on-treatment platelet reactivity of clopidogrel in patients undergoing coronary interventions” published in Anatol J Cardiol 2016; 16: 967-73 with great interest. A meta-analysis of 17 studies consisting of 20839 patients indicated that clopidogrel-treated patients with high on-treatment platelet reactivity (HTPR) had a 2.7-fold higher risk for stent thrombosis (ST) and a 1.5-fold higher risk for mortality following percutaneous coronary intervention (PCI) (2). Lack of association of ST and mortality with HTPR in the present study could be linked to the following reasons. Firstly, study population was heterogeneous in stent type and generation. Implantations of bare-metal stents (BMS) and drug-eluting stents (DES) were mentioned without further detail. However, even the second generation DES (everolimus and zotarolimus eluting stents) have lower ST rates than first generation DES (3). Sub-group analysis of HTPR and control groups were not depicted in the study. We think that it could affect the ST and mortality rates. Moreover, platelet function testing after PCI is also of importance in influencing formation of HTPR and control groups. Even though, light transmission aggregometry is historically gold standard, VerifyNow P2Y12 assay and Multiplate analyzer are generally used in studies on HTPR and ischemic events for their advantage of ease of performing. Determination of cut-off level is crucial for the study results. We think that cut-off level should be based on the expert position paper of European Society of Cardiology (4). Additionally, the study by Ko et al. (5) indicated that HTPR measured by VerifyNow assay was able to discriminate patients who were at a higher risk for myocardial infarction and major adverse cardiac events after PCI better than Multiplate analyzer. This could be also a contributing factor for no differences observed in cardiovascular mortality and ST.

Impact of early (3 months) dual antiplatelet treatment interruption prior to renal transplantation in patients with second-generation DES on perioperative stent thrombosis and MACEs

OBJECTIVE Early cessation of dual antiplatelet therapy (DAPT) is related to stent thrombosis (ST). The use of second-generation everolimus- and zotarolimus-eluting stents is associated with low restenosis rates and short duration of clopidogrel usage. Non-cardiac surgery in recently stent-implanted patients is associated with major adverse cardiac events (MACEs). Chronic renal failure patients awaiting renal transplantation may also undergo coronary stent implantation prior to surgery. Here we aimed to investigate the safety of early (3 months) DAPT interruption in second-generation drug-eluting stent (DES)-implanted renal transplant recipients. METHODS In total, 106 previously stent-implanted chronic renal failure patients who underwent renal transplantation were retrospectively enrolled. Three groups were formed according to stent type and the duration of DAPT: early-interruption (3 months from DES implantation), lateinterruption (3-12 months from DES implantation), and bare-metal stent (BMS; at least 1 month from BMS implantation) groups. RESULTS Comparison among BMS, DES-early and DES-late groups indicated no difference in ST, myocardial infarction, death, and MACEs. In addition, no difference was observed in ST (p=0.998), myocardial infarction (p=0.998), death (p=0.999), and MACEs (p=0.998) between DES-early and DES-late groups. CONCLUSION Early (3 months) interruption of antiplatelet treatment with second-generation stents before renal transplantation seems to be safe and does not lead to increase in the occurrence of ST and MACEs.

Timing of coronary artery bypass surgery in patients with non-ST-segment elevation myocardial infarction and postoperative outcomes.

Introduction The aim of the study was to assess whether a cardiac troponin T (cTnT) level 1 ng/ml or below threshold is safe and to evaluate mid-term follow-up results in stable patients with non-ST-segment elevation after acute myocardial infarction. Material and methods Among cTnT positive patients who presented to the emergency unit with chest pain and received coronary angiography, 100 patients who underwent isolated coronary artery bypass grafting (CABG) constituted the study group (group 1). The same number of patients (n = 100) who were cTnT negative and underwent an isolated CABG operation under elective conditions were selected as the control group (group 2). Results Among preoperative criteria, group 1 had significantly higher smoking rates (74% vs. 41%, p = 0.0001), and significantly lower ejection fraction values (47.1 ±8.25, 54.69 ±8.73, p = 0.0001). There were no significant differences between the groups with respect to operative parameters. Postoperative follow-up periods were significantly longer in group 1 (23.25 ±14 vs. 17.55 ±7.95 months, p = 0.001). Average waiting time for cTnT to drop below the 1 ng/ml threshold value was 5.73 ±2.95 (1–12) days. Intra-aortic balloon pump use in Groups 1 and 2 was 3% and 1%, respectively. There were no hospital mortalities in either group. Mortality rates at mid term were 6% in both groups. Conclusions This study compared two groups positive and negative for preoperative cTnT. The findings show that it is safe to wait until cTnT levels decrease to the 1 ng/ml threshold value in cTnT positive patients having a stable course. This waiting period is not very long, which is significant with respect to potential complications.

Giant aortic pseudoaneurysm presented with acute coronary syndrome by compressing the coronary arterial system.

A 36-year-old man was presented with acute coronary syndrome. He had a history of an aortic valve replacement (AVR) operation 7 years ago and a redo AVR because of the aortic prosthesis dehiscence 6 months ago. Coronary angiography revealed a severe stenosis in the left anterior descending artery (LAD) ( Panel A , see Supplementary data online, Video S1 ). The other coronary arteries were normal. A bare-metal stent was implanted in the LAD; 2 months after discharging, the patient was admitted with …