Osman Bektaş

Levosimendan accelerates recovery in patients with takotsubo cardiomyopathy

BACKGROUND The aim of this study was to determine the efficacy and safety of levosimendan in takotsubo cardiomyopathy (TC). METHODS The study was conducted in a retrospective design and 42 consecutive patients were enrolled in 6 cardiovascular centers in Turkey. The records of TC patients having left ventricular ejection fraction (LVEF) £ 35% were examined at admission, discharge and recovery period including their clinical and echocardiographic data. RESULTS Of these 42 TC patients, 17 were treated with loading dose and i.v. infusion of levosimendan (group 1) and 25 were treated without levosimendan (group 2). Echocardiographic findings at admission and at discharge were similar and no serious complications were observed in either group. However recovery period including the interval of 50% increase in LVEF, time to achieve the baseline troponin values and hospitalization were significantly lower in patients taking levosimendan. CONCLUSIONS This is the first study using loading dose and subsequent continuous intravenous administration of levosimendan demonstrating accelerated recovery in patients with TC.

Evaluation of cardiovascular risk in patients with Parkinson disease under levodopa treatment

Background Levodopa is the indispensable choice of medial therapy in patients with Parkinson disease (PD). Since L-dopa treatment was shown to increase serum homocysteine levels, a well-known risk factor for cardiovascular disorders, the patients with PD under L-dopa treatment will be at increased risk for future cardiovascular events. The objective of this study is to evaluate cardiovascular risk in patients with PD under levodopa treatment. Methods The study population consisted of 65 patients with idiopathic PD under L-dopa treatment. The control group included 32 age and gender matched individuals who had no cognitive decline. Echocardiographic measurements, serum homocysteine levels and elastic parameters of the aorta were compared between the patients with PD and controls. Results As an expected feature of L-dopa therapy, the Parkinson group had significantly higher homocystein levels (15.1 ± 3.9 µmol/L vs. 11.5 ± 3.2 µmol/L, P = 0.02). Aortic distensibility was significantly lower in the patients with PD when compared to controls (4.8 ± 1.5 dyn/cm2 vs. 6.2 ± 1.9 dyn/cm2, P = 0.016). Additionally, the patients with PD had higher aortic strain and aortic stiffness index (13.4% ± 6.4% vs. 7.4% ± 3.6%, P < 0.001 and 7.3 ± 1.5 vs. 4.9 ± 1.9, P < 0.001 respectively). Furthermore, serum homocysteine levels were found to be positively correlated with aortic stiffness index and there was a negative correlation between aortic distensibility and levels of serum homocysteine (r = 0.674, P < 0.001; r = −0.602, P < 0.001, respectively). Conclusions The patients with PD under L-dopa treatment have increased aortic stiffness and impaired diastolic function compared to healthy individuals. Elevated serum homocysteine levels may be a possible pathophysiological mechanism.

Imaging behind occluded areas with an iatrogenic perforated balloon: A safe, practical, and simple new method of visualizing the distal lumen in total occlusion

OBJECTIVE In the present study, we investigated the effectiveness and reliability of a new method that reveals whether guidewire advanced distal to the lesion is in the lumen in patients with acute (ATO) or chronic coronary total occlusion (CTO). METHODS Forty-one patients with symptomatic ATO and 22 patients with CTO who were admitted into our catheterization laboratory between January 2016 and March 2017 were included. In patients in whom antegrade filling could not be demonstrated after passing 0.014″ guidewire beyond the total lesion, a 1.25 × 15 mm balloon was punctured with a needle outside the operative field to visualize the total lesion. This perforated balloon was then used to deliver an opaque substance through this hole to visualize the distal part. RESULTS The mean age of our 63 patients was 66 ± 12 years. They had diabetes (57%), hypertension (100%), and a history of PCI (85%). The mean procedural time was 27 ± 6.8 min, and the mean volume of contrast material used was 93.9 ± 24 mL. This technique was 100% successful in accurately demonstrating the distal lumen and preventing complications. CONCLUSION This new method we developed is much simpler and more useful than other methods for visualization of the true lumen because we can re-orient the balloon at the time of opaque injection and use 190 cm guidewire without additional costs. Additionally, one balloon is sufficient for the operation.

The effects of dialysis-type on left ventricular function in non-diabetic end-stage renal disease patients

Objective In this study we aimed to investigate a possible difference in left ventricular function in patients undergoing peritoneal dialysis (PD) and haemodialysis (HD) using 2D echocardiography. Methods A total of 84 patients were recruited in the study. Both PD and HD groups consisted of 42 end-stage renal disease patients. Patients with left ventricular ejection fraction (EF) < 50%, diabetes mellitus and coronary artery disease were excluded. Baseline characteristics and conventional tissue Doppler echocardiography parameters were recorded. Left ventricular longitudinal (Ls), circumferential (Cs) and radial strain (R) along with strain rate were also recorded in the speckle-tracking echocardiography. These values were compared between the two groups. Results No significant difference was observed between PD and HD patients, in terms of mean time from diagnosis of chronic kidney disease to initiation of the study, mean time from first dialysis to initiation of the study, left ventricular EF, age, sex and heart rate. Left ventricular hypertrophy was also more frequent in HD group and the patients had a higher left ventricular mass index. Left ventricular global Ls, LSRs, LSRe, LSRa and global Rs, RSRs, RSRe, RSRa were detected to be lower in HD patients. Conclusions Longitudinal and radial left ventricular mechanics were found to be better preserved in patients undergoing peritoneal dialysis when compared to haemodialysis patients. Consequently, it can be concluded that peritoneal dialysis provides better protection on left ventricular systolic function compared to haemodialysis.

Sinus node dysfunction requiring permanent pacemaker implantation in a young adult with Klinefelter syndrome.

Patient: Male, 22 Final Diagnosis: Sinus node dysfunction Symptoms: Bradycardia • lassitude Medication: — Clinical Procedure: Pacemaker implantation Specialty: Cardiology Objective: Unusual clinical course Background: Klinefelter syndrome is the most common genetic cause of male infertility and affects approximately 1 in 500 live births. Although accompanying cardiac disorder is not a specific feature of Klinefelter syndrome, rarely associated anomalies such as mitral valve prolapse, atrial septal defect, ventricular septal defect, tetralogy of Fallot, patent ductus arteriosus, and hypertrophic obstructive cardiomyopathy have been reported. A clear association between Klinefelter syndrome and arrhythmic disorders has not yet been demonstrated. Case Report: We report a case of a sinus node dysfunction that required permanent pacemaker implantation in a young adult with Klinefelter syndrome. The patient was consulted to cardiology clinic due to bradycardia. On physical examination, no cardiac abnormality was detected except for bradycardia. Holter results showed sinus arrhythmia with a minimum heart rate of 33 bpm and maximum of 154 Bpm. There were 3612 ventricular premature beats, 30 ventricular pairs, 804 supraventricular premature beats, 7 supraventricular pairs, and 4 supraventricular runs, the longest of which was 5 beats. The patient had defined dizziness and nausea during Holter monitoring. Electrophysiological study (EPS) was planned because existing findings indicated risk of cardiac syncope. Findings of EPS were interpreted as sinus node dysfunction. A permanent pacemaker implantation was performed and the patient has been free of symptoms since. Conclusions: This concomitance should be kept in mind when examining patients with Klinefelter syndrome with bradycardia and/or syncope. It is easily mistaken for epilepsy, which is a commonly encountered abnormality in Klinefelter syndrome.

Spontaneous hemothorax due to dabigatran use in a patient with atrial fibrillation

A 72-years-old male patient admitted to our clinic with the complaint of increasing dyspnea in the last 1 week. He had a medical history of atrial fibrillation and chronic obstructive pulmonary disease. He had been under treatment of 50 mg metoprolol daily and 110 mg dabigatran twice daily for 1.5 years. There was no respiratory sound on the right lower lung field in anterior and posterior aspect. Dullness and decreased thoracic vibration were prominent on the same lung field. Heart rate was 110 beats/min, respiratory rate was 18/min and oxygen saturation was 93% in the room air. Other systemic examination findings were normal. Moderate pleural effusion was detected in the chest X-ray in the right lung (Fig. 1A). Computed tomography scans of the chest also revealed pleural effusion with lobulated contour and 7 cm in diameter in the right hemithorax (Fig. 2). Laboratory findings were as follows; WBC: 12.6 3 10 (4.6–10.2), HGB: 12.9 g/dL (12.2–18.1), Htc: 40.3% (37.7–53.7), Plt: 256 3 10, CRP: 29 mg/dL, ESR: 86 mm/h, PT: 16.9 s (11– 16), INR: 1.27 (0.8–1.25), APTT: 39.5 s (24–34). Dabigatran was discontinued for 24 h and thoracentesis was performed resulting with drainage of significant hemorrhagic material. Blood count findings of pleural fluid were as follows; HGB: 10.8 g/dL (12.2–18.1), Htc: 32.3% (37.7–53.7). Hemothorax was diagnosed considering the ratio of blood/pleural fluid hematocrit which was above 80%. History of trauma was questioned again. However, the patient did not define any history of trauma. The patients was inserted an 8F pleural catheter (Plastimed-ThoracathVR ). An amount of 1100 cc hemorrhagic material was drained in the first day and 250 cc in the second. In the third day, the amount of the fluid was less than 100 cc and it was light-colored. Control chest X-ray demonstrated complete resolution of the fluid and the drain was removed at the fifth day (Fig. 1B). The patient did not have any other reason that would cause hemorrhage except dabigatran use. Dabigatran and B-blocker were discontinued due to life-threatening hemorrhage in the lungs and acetyl salicylic acid in addition to diltiazem therapy was started at the fifth day. New hemorrhage was not observed under these drugs and the patient was discharged asymptomatically. The most common cause of hemotorax is blunt or penetrating trauma. Spontaneous hemothorax develops in the absence of any traumatic reason and is quite rare. Spontaneous hemothorax often accompanies pneumothorax. It occurs due to rupture of vascularized adhesions between parietal and visceral pleura. Isolated hemothorax often develops secondary to coagulopathies, neoplasms, vascular ruptures and pleural endometriosis (1). The main goal of anticoagulant use is to reduce risk of systemic thromboembolic events and stroke. Warfarin has been used quite effectively for this purpose. However, it is subject to increased risk of bleeding and management of dosing is quite difficult. New oral anticoagulants (rivaroxaban, dabigatran and apixaban) are direct thrombin inhibitors and do not require dose management. Dabigatran was found to be superior to warfarin in terms of stroke and systemic embolism prevention in a study who were followed up for 2 years. Major and minor bleeding rates were observed to be significantly lower in dabigatran group with the dose of 110 mg (2). The literaure includes reports about spontaneous hemothorax due to warfarin use. However, INR value was not in the therapeutic range in these cases and warfarin overdose was the main problem (3, 4). Spontaneous hemotorax cases have also been reported in patients using low molecular weight heparin (5, 6). Likewise, unfractioned heparin has also been reported to cause spontaneous hemothorax (7). Unlike, spontaneous hemothorax due to new oral anticoagulants has not been reported previously. Traetment of spontaneous hemothorax is drainage with large chest tube while urgent surgery may be required in massive cases in addition to blood and fluid replacement. In our case, vital signs were stable. There was no clot in the pleural fluid and a total of 1400 cc hemorrhagic fluid was drained. To our knowledge, our case is the first report of a spontaneous hemotorax due to dabigatran use. Our case was treated nonsurgical therapeutic approach via Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article and have no relevant financial disclosures.

Relationship between epicardial fat tissue and left ventricular synchronicity: An observational study

Objective: Left ventricular (LV) systolic synchrony is defined as simultaneous activation of corresponding cardiac segments. Impaired synchrony has some adverse cardiovascular effects, such as LV dysfunction and impaired prognosis. Epicardial fat tissue (EFT) is visceral fat around the heart. Increased EFT thickness is associated with some disorders, such as LV dysfunction and hypertrophy, which play a role in the impairment of LV synchrony. However, the relationship between EFT and LV systolic synchrony has never been assessed. Thus, we aimed to evaluate the possible relationship between EFT and LV synchrony in this study. Methods: The study population consisted of 55 consecutive patients (mean age 46.4±13.4 years, 32 female) without bundle branch block (BBB). EFT and LV systolic synchrony were evaluated by transthoracic echocardiography using 2D and tissue Doppler imaging. Maximal difference (Ts-6) and standard deviation (Ts-SD-6) of time to peak systolic (Ts) myocardial tissue velocity obtained from 6 LV basal segments were used to assess LV synchrony. Multiple regression analysis was used to detect the independently related factors to LV synchrony. Results: The mean values of EFT thickness, Ts-6, and Ts-SD-6 were found to be 2.7±1.6 mm (ranging from 1-7 mm), 20.1±14.2 msec, and 7.7±5.6, respectively. EFT thickness also was independently associated with Ts-6 (β =0.332, p=0.01) and Ts-SD-6 (β =0.286, p=0.04). Conclusion: EFT thickness is associated with LV systolic synchrony in patients without BBB.

Prediction of no-reflow and major adverse cardiovascular events with a new scoring system in STEMI patients

BACKGROUND No-reflow is associated with a poor prognosis in STEMI patients. There are many factors and mechanisms that contribute to the development of no-reflow, including age, reperfusion time, a high thrombus burden, Killip class, long stent use, ejection fraction ≤40, and a high Syntax score. In this study, we aimed to evaluate the parameters associated with no-reflow prediction by creating a new scoring system. METHODS The study included 515 consecutive STEMI patients who underwent PCI; 632 STEMI patients who had undergone PCI in another center were included in the external validation of the scoring system. The correlations between 1-year major adverse cardiac events and low/high risk score were assessed. RESULTS In this study, seven independent variables were used to build a risk score for predicting no-reflow. The predictors of no-reflow are age, EF ≤40, SS ≥22, stent length ≥20, thrombus grade ≥4, Killip class ≥3, and pain-balloon time ≥4 h. In the derivation group, the optimal threshold score for predicting no-reflow was >10, with a 75% sensitivity and 77.7% specificity (Area under the curve (AUC) = 0.809, 95%CI: 0.772-0.842, P < 0.001). In the validation group, AUC was 0.793 (95%CI: 0.760-0.824, P < 0.001). CONCLUSION This new score, which can be calculated in STEMI patients before PCI and used to predict no-reflow in STEMI patients, may help physicians to estimate the development of no-reflow in the pre-PCI period.

Fragmented QRS complexes are associated with left ventricular dysfunction in patients with type-2 diabetes mellitus: a two-dimensional speckle tracking echocardiography study

Abstract Background: Heart failure may develop independently of coronary artery disease in diabetes mellitus (DM) patients. Fragmented QRS (fQRS) is a marker of myocardial fibrosis or scar tissue and is related to an increase in cardiovascular adverse events. In this study, we examined the utility of speckle tracking echocardiography (STE) in assessing LV function in DM patients with fQRS. Methods and Results: The current study included 178 consecutive patients diagnosed with type-2 DM. The patients included were separated into two groups: those with (n = 50) and without (n = 128) fQRS. The two groups were compared by obtaining LV strain values with STE. Statistically significant differences were also identified between fQRS(−) and fQRS (+) groups with respect to Lv-GLS (p < .001), maxLAVI (p = .020), minLAVI (p < .001), E velocity (p < .001), Em velocity (0.002), E/Em ratio (<0.001) SRe (p < .001), SRe/SRa ratio (p < .001), SRivr (p < .001) and E/SRivr ratio (p < .001). In the multiple linear regression analysis, fQRS (β = −2.077, p = .002) and DM duration (β = −0.216, p = .021) were identified as independent predictors of Lv-GLS. However, fQRS (β = 4.557, p = .001) and minLAVI (β = −2.198, p = .031) were also found to be independent predictors of E/SRivr. We also performed multiple logistic regression analysis and identified Lv-GLS (β = −0.557, p = .001), minLAVI (β = −0.769, p = .001), E/Em ratio (β = 0.650, p = .001) and E/SRivr (β = 0.105, p = .001) as independent predictors of fQRS. Conclusıons: The results of this study revealed that subclinical LV dysfunction was more common in diabetic patients with fQRS. Therefore, determination of fQRS could be an indicator of the diabetic CMP in patients with DM.

Comparison of the Framingham risk and SCORE models in predicting the presence and severity of coronary artery disease considering SYNTAX score

Objective: Although various risk stratification models are available and currently being used, the performance of these models in different populations is still controversial. We aimed to investigate the relation between the Framingham and SCORE models and the presence and severity of coronary artery disease, which is detected using the SYNTAX score. Methods: The observational cross-sectional study population consisted of 227 patients with a mean age of 63.3±9.2 years. The patients were classified into low- and high-risk groups in the Framingham and SCORE models separately. Following coronary angiography, the patients were classified into SYNTAX=0 (SYNTAX score 0), low SYNTAX (SYNTAX score 1–22), and high SYNTAX (SYNTAX score>22) groups. The relation between the risk models and SYNTAX score was evaluated by student t test, Mann–Whitney U test or Kruskal–Wallis test and Receiver operating characteristic analysis were used to detect the discrimination ability in the prediction of SYNTAX score>0 and a high SYNTAX score. Results: Both the Framingham and SCORE models were found to be effective in predicting the presence of coronary artery disease, and neither of the two models had superiority over each other [AUC=0.819 (0.767, 0.871) vs. 0.811 (0.757, 0.861), p=0.881]. Furthermore, both models were also effective in predicting the extent and severity of coronary artery disease [AUC=0.724 (0.656, 0.798) vs. 0.730 (0.662, 0.802), p=0.224]. When the subgroups were analyzed, the SCORE model was found to be better in predicting coronary artery disease extent and severity in subgroups of men and diabetics {[AUC=0.737 (0.668, 0.844) vs. 0.665 (0.560, 0.790), p=0.019], [AUC=0.733 (0.684, 0.798) vs. 0.680 (0.654, 0.750) p=0.029], respectively). Conclusion: In addition to their role in predicting cardiovascular events, the use of the Framingham and SCORE models may also have utility in predicting the extent and severity of coronary artery disease. The SCORE risk model has a slightly better performance than the Framingham risk model.