Okan Erdogan

An interesting diagnostic dilemma: double right coronary artery or high take off of a large right ventricular branch.

We would like to present and discuss the dilemma of an unusual right coronary artery anomaly in two cases. Double right coronary artery or a high take off of a large right ventricular branch are two diagnostic possibilities that may provide difficulty in differentiating such an unusual orientation of coronary arteries based on angiographic views.

Increased Immunoglobulin E Response in Acute Coronary Syndromes

The role of inflammation and mast cell activation has been implicated in atherosclerotic plaque destabilization and rupture. To investigate the role of immunoglobulin E (IgE) in acute coronary syndrome, a prospective clinical study was conducted in patients with acute myocardial infarc tion (AMI), unstable angina pectoris (UAP), stable angina pectoris (SAP), and healthy controls. IgE levels were serially measured and compared in consecutive patients with AMI (n = 16) and UAP (n=14) on days 1, 3, 7, 21 after admission and 3 months later and only once in stable angina pectoris (n = 15) and healthy controls (n = 14). In addition, blood eosinophil and basophil levels on admission were measured in all groups and compared. Initial IgE levels determined at admission in patients with AMI, UAP, and SAP were significantly higher than levels in the control group (p = 0.002). Initial high IgE level in AMI on day 1 increased to a peak by day 7 (p = 0.024), then gradually decreased by day 21 and at 3 months (p = 0.052). High IgE level in UAP persisted by day 7 and gradually decreased by day 21 and 3 months (p = 0.037 and p=0.018, respectively). Blood eosinophil count on admission was significantly higher in UAP than in the control group (p = 0.005). Basophil levels of both AMI and UAP groups on admission were found to be elevated as opposed to control group (p = 0.02 and p = 0.012, respectively). This study demonstrates that the level of IgE significantly increased during the acute phase of acute coronary syndromes and gradually decreased, supporting the role of acute inflammatory response and mast cell involvement in plaque rupture.

Contrast-induced nephropathy: preventive and protective effects of melatonin

Abstract:  Infusion of contrast agents increases osmotic load, viscosity, hypoxemia of the renal medulla and renal free radical production through post‐ischemic oxidative stress. The present experimental study sought to determine whether melatonin, because of its anti‐oxidant properties might have a preventive and protective role against the development of contrast‐induced nephropathy (CIN). Twenty‐four adult male rats were divided into four experimental groups: healthy control rats (CR), rats with CIN (CINR), rats with CIN pretreated with melatonin (CINR1M), and rats with CIN pre‐ and post‐treated with melatonin (CINR2M). In CINR, both serum creatinine (Cr) level and fractional excretion of sodium (FE‐Na) significantly increased, whereas Cr clearance decreased at post‐CIN compared with pre‐CIN period. Rats in CINR1M did not show any improvement in renal function. Cr clearance decreased, whereas both serum Cr level and FE‐Na increased in rats pretreated with melatonin. In contrast, significant improvements were observed in CINR2M. Serum Cr and Cr clearance did not change, whereas FE‐Na significantly reduced in rats pre‐ and post‐treated with melatonin. In conclusion, the present experimental study clearly demonstrated the preventive and protective role of melatonin against the development of CIN.

Stent implantation to the stenosed right coronary artery in a patient whose right and left coronary arteries originate from a single ostium in the right sinus of Valsalva.

The authors report a rare case of a patient who had anomalous origin of left and right coronary arteries from a single coronary ostium in the right sinus of Valsalva. The stenosed right coronary artery was successfully dilated with stent implantation.

Left ventricular pacemaker lead insertion through the foramen ovale--a case report.

This report describes a patient with a 6-year-old pacemaker lead in the left ventricle. Both transthoracic and transesophageal echocardiography unequivocally showed that the lead enters the left ventricle via the foramen ovale and the mitral valve. The patient did not suffer from a thromboembolic event; therefore, we did not proceed with extraction. The importance of this case report is to emphasize the conditions and precautions of proper pacemaker implantation.

Right ventricular function in patients with acute anterior myocardial infarction: tissue Doppler echocardiographic approach.

Objective — Our purpose was to investigate the right ventricular (RV) performance of patients with a first acute anterior myocardial infarction (AAMI) by using pulsed wave Doppler tissue (PWDT) samplings of tricuspid annulus and RV free wall. Methods and results — The study group included 31 patients with AAMI and 20 age-matched controls. Conventional indexes of RV functions were the magnitude of tricuspid annular plane systolic excursion (TAPSE), and the transpulmonary and transtricuspid Doppler parameters. PWDT velocities were obtained by placing the sample volume at the lateral tricuspid annulus and the mid-segment of RV free wall; the peak systolic (S), early (E) and late (A) diastolic PWDT velocities and time intervals from ECG-Q wave to their peaks were analysed. Standard indexes were comparable except TAPSE that was significantly lower in AAMI-patients (p < 0.001). S velocities were similar; A of both regions (p = 0.018 and 0.012) and E of RV free wall (p = 0.011) were significantly increased in AAMI-group. Q-Sa intervals in both regions (p = 0.007 and 0.015) and Q-Ea of tricuspid annulus (p = 0.045) were significantly shorter in patients with AAMI.TAPSE and E of RV free wall had significant negative correlations with left ventricular systolic volume index and right atrial filling fraction (AFF), respectively (r = -0.46, p = 0.01 for both). A of tricuspid annulus had a positive correlation with left AFF (r = 0.42, p = 0.02). Conclusion — PWDT imaging of tricuspid annulus and RV free wall is capable to sensitively detect the adaptive mechanisms and unfavourable diastolic properties of RV dynamics in patients with AAMI.

Acute effect of DDD versus VVI pacing on arterial distensibility.

Pulse wave velocity (PWV) is a new technique and frequently used today to determine the elastic distensibility of great arteries. Increased arterial stiffness and PWV have been proposed as possible mechanisms in the initiation and/or progression and/or complications of atherosclerosis and cardiovascular disease. We evaluated the acute effect of two frequently used pacing modes (DDD vs. VVI) on arterial distensibility using PWV. Methods: Seventeen patients (age, 56 ± 14 years) implanted with DDD pacemakers were included in the study. All patients were pacemaker dependent and continuously paced at the programmed rate. PWV was measured first in DDD mode, and then the mode was switched to VVI, and PWV was measured again at the same programmed heart rate as in the DDD mode. Results: Although systolic blood pressure significantly decreased from 129 ± 18 to 119 ± 16 mm Hg (p = 0.001) after switching the mode from DDD to VVI, diastolic blood pressure (81 ± 12 vs. 80 ± 13 mm Hg; p = 0.38) did not change. In addition, PWV significantly increased from 11 ± 2.46 m/s in DDD mode to 11.29 ± 2.43 m/s (p = 0.01) after having been programmed to VVI mode. Conclusions: Our results suggest that VVI pacing increases PWV, and therefore decreases arterial distensibility, and thus may contribute to the development and progression of atherosclerosis.

Parachute mitral valve abnormality and bicuspid aortic valve in an asymptomatic adult patient

Transesophageal echocardiography of a 54-year-old asymptomatic man revealed a bicuspid aortic valve (Figure 1, upper left panel) and elongated chordae converging and inserting into one of the papillary muscles. There was a redundant anterior mitral leaflet, as well as a rudimentary posterior leaflet during systole (Figure 1, upper right panel). Mitral commissural and a two-chamber view during diastole demonstrated a papillary muscle and elongated chordae, as well as a parachute-like mitral valve abnormality (Figure 1, bottom left and right panels). Figure 1) Transesophageal echocardiography revealing a bicuspid aortic (Ao) valve (upper left panel), a redundant anterior mitral leaflet (AML) and a rudimentary posterior leaflet during systole (upper right panel). Mitral commissural and two-chamber view during ... Parachute mitral valve is a rare congenital cardiac anomaly in which the chordae tendinae of both leaflets of the mitral valve insert into a single papillary muscle. This is called a ‘true parachute’ mitral valve, whereas the presence of two papillary muscles, with all chordae inserting into one muscle, is called a ‘parachute-like’ mitral valve (1). A true parachute mitral valve is usually associated with mitral stenosis and may cause symptoms early in life. Despite the presence of moderate mitral regurgitation, the asymptomatic course of our patient until adulthood may likely be explained by the absence of mitral stenosis.

Management of a patient with active rheumatoid arthritis and suspected tuberculosis causing effusive-constrictive pericarditis

In the following case report we present a patient who has been admitted for pericardial effusion causing cardiac compression with active rheumatoid arthritis and suspected tuberculosis. The patient was successfully treated with intravenous pulse steroid for active rheumatoid arthritis, with prophylactic anti-tuberculosis agents for suspected tuberculosis and with surgical pericardiectomy for the thickened pericardium as well as recurrent pericardial effusion.

Comparison of antihypertensive efficacy of carvedilol and nebivolol in mild-to-moderate primary hypertension: a randomized trial

OBJECTIVE The aim of the present study is to compare the antihypertensive effects of carvedilol and nebivolol in mild-to-moderate hypertensive patients. METHODS It is a prospective; placebo-controlled, cross-over, double-blind, randomized, single-center clinical trial. Patients (n=20) who were first diagnosed with mild to moderate systemic hypertension according to mean ambulatory blood pressure measurements > 130/85 mmHg and no previous antihypertensive therapy were prospectively enrolled into the study. After 10 days of placebo run-in period, they were randomized within the same group as cross-over design to one month carvedilol 25 mg and one month nebivolol 5 mg regimen given once daily in the morning. The primary outcome variables were systolic and diastolic blood pressures determined by 24-hour ambulatory blood pressure measurements. Mutlivariate analysis of variance for repeated measurements with 3x2 factorial design was used for statistical analysis of results. RESULTS The study group consisted of 6 women and 14 men whose mean age was 42.9±12.8 years (range 19-63 years). Mean heart rate was significantly decreased after commencing both carvedilol (70.2±5.2 bpm) and nebivolol (64.9±3.9 bpm) treatments compared to placebo (78.8±5.2 bpm) (p<0.05). Both carvedilol (133.8±9/86.6±8.6 mmHg) and nebivolol (134±8.7/85.6±7.4 mmHg) significantly decreased mean systolic and diastolic blood pressures compared to placebo (143.9±8.9/94.4±9.2 mmHg), respectively (p<0.05). However, there was no significant difference in decreasing either systolic or diastolic blood pressure between nebivolol and carvedilol therapies (p>0.05). No side effects were recorded during both carvedilol and nebivolol treatments. CONCLUSION Although both carvedilol and nebivolol effectively decreased blood pressure compared to placebo, they showed similar efficacy for lowering blood pressure.