Onur Argan

Associations Between Neutrophil Gelatinase Associated Lipocalin, Neutrophil-to-Lymphocyte Ratio, Atrial Fibrillation and Renal Dysfunction in Chronic Heart Failure

Background Atrial fibrillation (AF) and renal dysfunction are two common comorbidities in patients with chronic heart failure with reduced ejection fraction (HFrEF). This study evaluated the effect of permanent AF on renal function in HFrEF and investigated the associations of atrial fibrillation, neutrophil gelatinase-associated lipocalin (NGAL), and neutrophil-to-lymphocyte ratio (NLR) with adverse clinical outcome. Material/Methods Serum NGAL levels measured by ELISA and NLR were compared between patients with sinus rhythm (HFrEF-SR, n=68), with permanent AF (HFrEF-AF, n=62), and a healthy control group (n=50). Results Mean eGFR levels were significantly lower, and NLR and NGAL levels were significantly higher in the HFrEF patients than in the control patients but the difference between HFrEF-SR and HFrEF-AF was not statistically significant (NGAL: 95 ng/mL in HFrEF-SR, 113 ng/mL in HFrEF-AF and 84 ng/mL in the control group; p<0.001). Independent associates of baseline eGFR were age, hemoglobin, NLR, triiodothyronine, and pulmonary artery systolic pressure. In a mean 16 months follow-up, adverse clinical outcome defined as progression of kidney dysfunction and composite of all-cause mortality and re-hospitalization were not different between HFrEF-SR and HFrEF-AF patients. Although NGAL was associated with clinical endpoints in the univariate analysis, Cox regression analysis showed that independent predictors of increased events were the presence of signs right heart failure, C-reactive protein, NLR, triiodothyronine, and hemoglobin. In ROC analysis, a NLR >3 had a 68% sensitivity and 75% specificity to predict progression of kidney disease (AUC=0.72, 95% CI 0.58–0.85, p=0.001). Conclusions Presence of AF in patients with HFrEF was not an independent contributor of adverse clinical outcome (i.e., all-cause death, re-hospitalization) or progression of renal dysfunction. Renal dysfunction in HFrEF was associated with both NLR and NGAL levels, but systemic inflammation reflected by NLR seemed to be a more important determinant of progression of kidney dysfunction.

A simple discharge risk model for predicting 1-year mortality in hospitalised acute decompansated heart failure patients with reduced ejection fraction

Abstract Objective: The risk stratification for prognosis in heart failure is very important for optimal disease management and decision making. The aim of this study was to establish a simple discharge 1-year mortality prediction model by integrating data obtained from demographic characteristics, clinical evaluation, laboratory biomarkers and echocardiographic evaluation of hospitalised heart failure with reduced ejection fraction (HFrEF) patients with acute decompensation. Methods and results: A risk score model was developed based on β-coefficient number of variables in a multivariable logistic regression model which was created with the use of data on clinical, laboratory, imaging and therapeutic findings of 670 patients (65.4% males, 65 ± 11 years) who was hospitalised with acute decompensated HFrEF. The mean left ventricular ejection fraction (LVEF) was 26 ± 9%. Independent predictors of mortality were: age ≥75 years, sodium <130 mEq/L, hepatomegaly at admission, unable to use beta-blocker at discharge and LVEF ≤20%. The 1-year mortality rate was 7.8% in the study population. The existence of each predictor was scored as 1 point and the discharge risk score identified patients into low (0–1 points), intermediate (2–3 points) and high (4–5 points) risk individuals with 3, 15.6 and 44.4% 1-year mortality rates, respectively. The model performance evaluated by concordance index was 0.74. Conclusions: This simple discharge risk score model for hospitalised acute decompensated HFrEF patients using easily determined demographic characteristics, clinical signs, echocardiographic and laboratory data is a valuable and an easy risk assessment tool to use at point-of-care.

Predictors of Long-Term Mortality and Frequent Re-Hospitalization in Patients with Acute Decompensated Heart Failure and Kidney Dysfunction Treated with Renin-Angiotensin System Blockers

Background Assessment of risk for all-cause mortality and re-hospitalization is an important task during discharge of acute heart failure (AHF) patients, as they warrant different management strategies. Treatment with optimal medical therapy may change predictors for these 2 end-points in AHF patients with renal dysfunction. The aim of this study was to evaluate the predictors for long-term outcome in AHF patients with kidney dysfunction who were discharged on optimal medical therapy. Material/Methods The study was conducted retrospectively. The study group consisted of 225 AHF patients with moderate-to-severe kidney dysfunction, who were hospitalized at Kocaeli University Hospital Cardiology Clinic and who were prescribed beta-blockers and ACE-inhibitors or angiotensin II receptor blockers at discharge. Clinical, echocardiographic, and biochemical predictors of the composite of total mortality and frequent re-hospitalization (≥3 hospitalizations during the follow-up) were assessed using Cox regression and the predictors for each end-point were assessed by competing risk regression analysis. Results Incidence of all-cause mortality was 45.3% and frequent readmissions were 49.8% in a median follow-up of 54 months. The associates of the composite end-point were age, NYHA class, respiration rate on admission, eGFR, hypoalbuminemia, mitral valve E/E’ ratio, and ejection fraction. In competing risk regression analysis, right-sided HF, hypoalbuminemia, age, and uric acid appeared as independent associates of all-cause mortality, whereas NYHA class, NT-proBNP, mitral valve E/E’ ratio, and uric acid were predictors for re-hospitalization. Conclusions Predictors for all-cause mortality in AHF with kidney dysfunction treated with optimal therapy are mainly related to advanced HF with right-sided dysfunction, whereas frequent re-hospitalization is associated with volume overload manifested by increased mitral E/E’ ratio and NT-proBNP levels.

Elevated levels of vitamin B12 in chronic stable heart failure: a marker for subclinical liver damage and impaired prognosis

Background Elevated vitamin B12 is a sign for liver damage, but its significance in chronic stable heart failure (HF) is less known. The present study investigated the clinical correlates and prognostic significance of vitamin B12 levels in stable systolic HF. Methods A total of 129 consecutive patients with HF and 50 control subjects were enrolled. Data regarding demographics, clinical signs, therapeutic and conventional echocardiographic measurements were recorded for all patients. Right-sided HF was defined as the presence of at least one of the typical symptoms (ankle swelling) or specific signs (jugular venous distention or abdominojugular reflux) of right HF. Cox proportional hazards regression analyses were performed to determine the independent prognostic determinants of mortality. Results Baseline B12 levels in HF patients (n=129) with and without right sided HF were significantly higher compared to healthy controls (n=50): Median 311 pg/mL and 235 pg/mL vs 198 pg/mL, respectively (P=0.005). Folic acid levels were similar between the study groups. Age, ejection fraction, left atrial size, estimated glomerular filtration rate, and direct and indirect bilirubin levels were significantly correlated to serum B12 level in univariate analysis. In multivariate analysis, independent correlates of B12 were direct bilirubin (R=0.51, P<0.001) and age (R=0.19, P=0.028). Patients with HF were followed-up for a median period of 32 months. Median B12 levels were significantly higher in patients who subsequently died (n=35) compared to survivors, but folic acid was not different between the two groups. ROC analysis showed that B12 values ≥270 pg/mL had 80% sensitivity and 58% specificity for predicting all-cause mortality (area under the curve=0.672, 95% CI=0.562−0.781; P=0.003). However, in Cox regression analysis, only left atrial diameter, level of direct bilirubin, and the presence of abdominojugular reflux were independent predictors of death. Conclusion Increased B12 in stable HF patients is associated with increased direct bilirubin due to right HF, indicating a cardiohepatic syndrome, but neither B12 nor folic acid are independently associated with mortality.

Rare Case of Both Left Atrial and Ventricular Compression by Dissecting Aortic Aneurysm

Address for Correspondence: Dr. Onur Argan, Clinic of Cardiology, Kocaeli State Hospital, Kocaeli, Turkey e-mail: onur_argan@yahoo.com ORCID ID: orcid.org/0000-0001-7745-7736 Received: 29 March 2018 Accepted: 22 June 2018 • DOI: 10.4274/balkanmedj.2018.0567 Available at www.balkanmedicaljournal.org Cite this article as: Argan O, Ural D, Bozyel S. Rare Case of Both Left Atrial and Ventricular Compression by Dissecting Aortic Aneurysm. Balkan Med J 2018;35:406-7 ©Copyright 2018 by Trakya University Faculty of Medicine / The Balkan Medical Journal published by Galenos Publishing House. A 75-year-old patient with a history of arterial hypertension was admitted to the emergency service in cardiac arrest. His medical history revealed a thoracic endovascular aortic repair operation that was performed about 2 years ago. According to the information received from relatives, he developed sudden cardiac arrest following chest pain and shortness of breath. The patient’s blood pressure was 70/50 mmHg and the heart rate was 125 pulses/min. ST depression in the D1-AVL-V5-V6 and left ventricular hypertrophy were detected in the electrocardiogram. Parasternal long axis and four-chamber images in the echocardiography showed aortic dissection and compression of the left atrium and the left ventricle caused due to an aneurysm when the patient was evaluated for the first time (Figure 1a). When we repeated the echocardiography before the exitus, the compression of the heart chambers progressed (Figure 1b). Thoracic computed tomography images supported the findings of echocardiography. Compression of the left atrium and ventricle due to 10×11.5 cm descending aorta, including the graft material and the thrombosed pseudolumen, was observed in the computed tomography images (Figure 2a, 2b). The patient with the deep hypotension died shortly after the admission. Written informed consent was obtained from the patients parents. Large dissecting aortic aneurysm compressing the heart chambers sufficient to cause hemodynamic deterioration is a rare condition. Studies have reported about the compression related to the right atrium (1), the left atrium (2), and the right ventricle (3) caused by the aortic aneurysm. To our knowledge, this is the first case of both left atrial and left ventricular compression caused due to the dissecting aortic aneurysm. In a patient with aortic dissection, ischemia, aortic valve insufficiency, and tamponade may cause hypotension. The echocardiographic findings of the present case revealed an additional mechanism that may lead to hemodynamic instability. The descending aorta is very near to the left atrium. Compression of the left atrium and ventricle due to the enlarged aorta results in decreased cardiac output and hypotension. The pleural effusion observed in this case suggests the presence of congestive 1Clinic of Cardiology, Kocaeli State Hospital, Kocaeli, Turkey 2Department of Cardiology, Kocaeli University School of Medicine, Kocaeli, Turkey 3Clinic of Cardiology, Kocaeli University of Health Sciences, Derince Training Research Hospital, Kocaeli, Turkey Onur Argan1, Dilek Ural2, Serdar Bozyel3 Rare Case of Both Left Atrial and Ventricular Compression by Dissecting Aortic Aneurysm Balkan Med J 2018;35:406-7

Reprogramming the tachycardia parameters with long-detection strategy in patients with pre-existing implantable cardioverter-defibrillator

Abstract Background: A long-detection interval (LDI) programming has been proved to reduce shock therapy in patients who underwent de novo implantable cardioverter defibrillator (ICD) implantation. We aimed to evaluate effectiveness and safety of this new strategy in old ICD recipients. Methods: We included 147 primary prevention patients with ischaemic and non-ischaemic aetiology. Conventional setting parameters (18 of 24 intervals to detect ventricular arrhythmias (VA’s)) were reprogrammed with LDI strategy (30 of 40 intervals to detect VA’s). One monitoring zone (between 360 and 330 ms) and two therapy zones were programmed, treating all rhythms of cycle length <330 ms that met the duration criterion of 30/40 intervals and were discriminated as ventricular tachycardia/ventricular fibrillation (VT/VF). The supraventricular tachycardia (SVT) discriminators were used in all patients. Results: At a median follow-up of 24 months, 12.9% (n = 19) of patients received shock therapies (± antitachycardia pacing (ATP)). Appropriate and inappropriate shocks occurred in 7.5 and 5.4% of patients during follow-up, respectively. Only one patient experienced an arrhythmic syncope during the follow-up period. There was no death related to LDI programming. The LDI programming helped to stop unnecessary in 10 patients (6.8%), who otherwise would have been treated in the conventional programming. Conclusions: LDI programming was found safe and effective. Hence, old ICD recipients will benefit from this strategy.

Phantom tumor of the lung in heart failure patient

In heart failure localized interlober pleural effusion is rare but well-known finding. But there is not enough case reports in the literature. This radiological finding seems like a mass and undergoes resolution quickly, It is also known as vanishing tumor, pseudotumor or phantom tumor. It is difficult to estimate the incidence due to the small number of reported cases. Determination of the mass appearance in chest X-ray should be reminded the phantom tumor especially in heart failure patient. This diagnosis would prevent unnecessary expensive diagnostic procedures, wrong diagnosis and treatment.

Improvement in left ventricular intrinsic dyssynchrony with cardiac resynchronization therapy

Objective: Cardiac resynchronization therapy (CRT) has been shown to induce a structural and electrical remodeling; the data on whether left ventricle (LV) reverse remodeling is associated with restitution of intrinsic contraction pattern are unknown. In this study, we investigated the presence of improvement in left ventricular intrinsic dyssynchrony in patients with CRT. Methods: A total of 45 CRT recipients were prospectively studied. Dyssynchrony indexes including interventricular mechanical delay (IVMD) and tissue Doppler velocity opposing-wall delay (OWD) as well as QRS duration on 12-lead surface electrocardiogram were recorded before CRT device implantation. After 1 year, patients with chronic biventricular pacing were reprogramed to VVI 40 to allow the resumption of native conduction and contraction pattern. After 4–6 h of intrinsic rhythm, QRS duration and all echocardiographic measurements were recorded. Dyssynchrony was defined as IVMD >40 ms and OWD >65 ms. CRT response was defined by a ≥15% reduction in left ventricular end-systolic volume (LVESV) at a 12-month follow-up. Results: Thirty-two patients (71%) showed response to CRT. The native QRS duration reduced significantly from 150±12 ms to 138±14 ms (p<0.001), and dyssynchrony indexes showed a significant improvement only in responders. The mean OWD reduced from 86±37 ms to 50±29 ms (p<0.001), and the mean IVMD decreased from 55±22 ms to 28±22 ms (p<0.001) in responders. The reduction in LVESV was significantly correlated with ΔOWD (r=0.47, p=0.001), ΔIVMD (r=0.45, p=0.001), and ΔQRS (r=0.34, p=0.022). Conclusion: Chronic CRT significantly improves LV native contraction pattern and causes reverse remodeling in dyssynchrony.

The Better Outcomes Associated with Warfarin use in Patients with Heart Failure in Either Atrial Fibrillation or Sinus Rhythm

PP-051 Warfarin use and associated outcomes in patients with chronic heart failure (HF) have not been well described previously. We hypothesized that warfarin is associated with lower risks of cardiovascular mortality in patients with sinus rhythm, atrial fibrillation and pacemaker rhythm. We