Osman Kayapinar

Silent interrupted aortic arch in an elderly patient.

Patients with complete interruption of the aortic arch (IAA) very rarely reach late adulthood without having undergone surgical intervention. Only a few cases of IAA in adults have been reported in the medical literature. In this case report, we present a late diagnosis of interrupted aortic arch in a 68 year-old male. Our patient was relatively asymptomatic until he presented with fatigue after walking quickly. A guidewire could not be passed to the aortic arch via the femoral approach; descending thoracic aortography revealed complete occlusion of the descending thoracic aorta. Cardiac catheterization via the right brachial artery confirmed the diagnosis of a complete interruption of the aortic arch distal to the left subclavian artery and showed distinct collateral circulation predominantly via the internal mammary arteries. Also, magnetic resonance angiography showed cuttings that reveal the interruption in the aortic arch and the prominent collateral vessels to the descending aorta. This case report was also interesting in that pressure measurements at a proximal point of the interrupted aortic arch were not hypertensive. Using both catheters, placed proximally and distally to the point of the interruption, by simultaneous pressure measurement, it was measured as 120/75 mm Hg at the proximal point, 60/40 mm Hg at the distal point. (Cardiol J 2011; 18, 6: 695-697).

Subintimal angioplasty and stenting in chronic total femoropopliteal artery occlusions: Early- and mid-term outcomes

BACKGROUND This study was conducted to evaluate the initial and mid-term patency rates of chronic total femoropopliteal artery (FPA) occlusions treated by subintimal angioplasty (SIA) and stenting. METHODS From March 2010 to February 2013, 74 patients were included in the study. Seventy two patients with total occlusion of the FPA and good distal runoff (2 or 3 patent vessels) were treated with percutaneous SIA and stenting. All patients had severe claudication or critical limb ischemia. In all cases, the procedure was performed with a contralateral approach. Follow-up was done at 6 months with clinical evaluation and color-Doppler. If it was necessary, peripheric angiography was performed. RESULTS Immediate technical success was achieved in 72 (97%) patients. Two (3%) distal embolizations, 2 (3%) groin hematomas, 1 (1%) femoral pseudoaneurysm and 1 (1%) rupture of the junction-external iliac-superficial femoral artery occurred. All of the complications were treated successfully. Total occlusion in 1 patient and critical occlusion in 3 patients were showed at the 6th month. Patency rate at the sixth month was 94% with a stent length of 13.4 ± 8.2 cm. CONCLUSIONS Percutaneous SIA and stenting for chronic total of the FPA occlusion showed good initial and mid-term patency rates, with few periprocedural complications.

Assessment of myocardial performance index in hypertensive patients with or without hyperuricaemia.

BACKGROUND Myocardial performance index (MPI) is impaired in patients with hypertension. Uric acid is biologically active and can stimulate oxidative stress, endothelial dysfunction, inflammation, and vasoconstriction. Hyperuricaemia may provide a negative contribution to impaired MPI in hypertension. AIM The study was designed to assess the MPI in hypertensive patients with or without hyperuricaemia. METHODS A total of 96 consecutive hypertensive patients were divided into two groups according to levels of serum uric acid (SUA); 49 normouricaemic patients (defined as SUA < 7.0 mg/dL in men and < 6.0 mg/dL in women) and 47 hyperuricaemic patients. SUA levels and other biochemistry parameters were determined by a standard analytical technique. All patients were evaluated by two-dimensional and Doppler echocardiography. RESULTS The two groups were similar according to age, body mass index, and smoking status. Mean MPI value (0.498 ± 0.06 vs. 0.410 ± 0.05, p < 0.001) was significantly higher in the hyperuricaemic group than the normouricaemic individuals and positively correlated with the mean value of SUA levels (r = 0.51, p < 0.001). CONCLUSIONS Our study demonstrated that high SUA levels were significantly associated with impaired MPI in hypertensive patients. SUA may suggest a valuable laboratory finding in assessing the risk of developing subclinical impaired left ventricular global function.

The Evaluation of Subclinical Right Ventricular Dysfunction in Intermittent and Persistent Mildly Asthmatic Children by Tissue Doppler Echocardiography and the Relationship between Serum NT-proBNP levels: an Observational Study

Bronchial asthma may lead to pulmonary hypertension, right ventricular (RV) dysfunction, and cor pulmonale due to elevated afterload on the RV later in life. The aim of this study was to determine whether serum N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) might serve as a biomarker for detecting subclinical RV dysfunction using echocardiography during the early stages of bronchial asthma.

Prevalence and characteristics of CAAs in the black sea region

DOI: 10.4328/JCAM.5731 Received: 26.01.2018 Accepted: 04.03.2018 Published Online: 08.03.2018 Printed: 01.09.2018 J Clin Anal Med 2018;9(5): 369-75 Corresponding Author: Adnan Kaya, Department of Cardiology, Duzce University School of Medicine, İstanbul, Turkey. GSM: +905324009765 E-Mail: adnankaya@ymail.com ORCID ID: 0000-0002-9225-8353 Abstract Aim: To date there has been no data about the prevalence of coronary artery anomaly (CAA) in the Turkish population of the Black Sea Region who underwent trans-radial coronary angiography. We aimed to determine the frequency and characteristics of CAA in our patients. Material and Method: All the coronary angiographies performed from September 2015 to September 2016 in our hospital were reviewed. Demographic characteristics and laboratory parameters of patients were reviewed retrospectively from the patients’ data set. A total of 1617 patient were included in our study. Results: CAAs were found in 73 patients (4.51%), of whom 41 (56.16%) had intrinsic coronary artery anatomy. Twenty-two (30.13%) patients had anomaly of origination and course and 10 (13.69%) patients had anomaly of coronary artery termination. The mean age was 59.35±11.86 in the study group and 60.11±6.61 in the control group. Myocardial bridge was the most common anomaly in our study with a prevalence of 2.16%. Absent LMCA was the second most common anomaly in our study with a prevalence of 0.80% and coronary artery fistula was third with a prevalence of 0.61%. Discussion: We found the prevalence of CAAs among the Turkish population of the Black Sea Region to be similar to previously published studies from our country. To avoid misunderstandings one must know the normal anatomy of coronary vasculature, variations, and the anomalies. When coronary angioplasty or cardiac surgery is planned in patients with CAA, special attention must be paid not to harm coronary arteries in unexpected locations.

More About the Effect of Dynamic Potassium Change in STEMI

We thank our colleagues for their comments on our article entitled “Effect of Dynamic Potassium Change on InHospital Mortality, Ventricular Arrhythmias, and Long-Term Mortality in STEMI” published in the January 2018 issue of the Angiology. The aim of our paper was to evaluate the effect of serum potassium (K) deviation (from normokalemia to hypokalemia and normokalemia to hyperkalemia) on in-hospital mortality, ventricular arrhythmias, and long-term mortality in ST segment elevation myocardial infarction (STEMI). Uluganyan et al showed an increased risk of mortality and ventricular arrhythmias with admission K levels <3 and 5 mmol/L in STEMI. Similarly, Keskin et al showed the association of mean serum K levels with in-hospital mortality, ventricular arrhythmias, and long-term mortality after STEMI. The former study shows the importance of early intervention to restore serum K levels to normal limits and to perform more frequent serum K measurements according to admission serum K levels. The latter study draws attention to mean serum K levels derived from all K measurements during hospitalization. We showed the importance of serum K measurements even in patients with normal K levels at admission. In any circumstance, in patients with STEMI, serum K level should be checked at least daily, according to these studies. Magnesium, one of the essential minerals that serves as a cofactor in more than 300 enzymatic reactions (blood pressure control, lipid peroxidation, and glycemic control), has a critical role in the cardiovascular system. Only 1% (1.5-2.0 mEq/L, 1.7-2.4 mg/dL) of the total body magnesium circulates (24 g) is in serum; the rest is stored either in bone or soft tissue. The biochemical and cellular effects of magnesium could be summarized as follows: (1) activation of adenosine triphosphatase to produce energy from ATP and stabilizing cell membrane (by providing energy needs of the Naþ-Kþ pump), (2) appropriate cell membrane polarization (malignant arrhythmias caused by low serum magnesium levels), (3) to be a cofactor of the cardiac mitochondria, and (4) modulation of the K proton exchange (protective against K loss). Arterial vasospasm, increased catecholamine release, increased fatty acids and lipids, and intravascular hypercoagulability could be associated with low cellular levels of magnesium. Besides these effects of magnesium on the cardiovascular system are usually overlooked. It was shown that in hospitalized patients only 7% of patients had their magnesium levels checked despite 42% of them having hypomagnesaemia. Unfortunately, we had no routine measurements of admission serum magnesium levels in patients with STEMI in our center. The measurement of serum magnesium levels was performed only in selected patients such as those with malignant cardiac arrhythmias and severe serum electrolyte disturbances; magnesium replacement was administered if levels were low. This could be a limitation which we did not mention. Another issue that was not discussed in the paper was the use of proton pump inhibitors (PPIs). Treatment with PPIs is suggested in patients receiving dual antiplatelet therapy with a class I recommendation and a level of evidence B in the last update of the European Society of Cardiology guidelines. However, PPI usage could be associated with lower magnesium levels. Since most of the study population received PPI treatment during hospitalization, we did not consider reporting PPI usage in the results.

Effect of Dynamic Potassium Change on In-Hospital Mortality, Ventricular Arrhythmias, and Long-Term Mortality in STEMI

We evaluated the effect of serum potassium (K) deviation on in-hospital and long-term clinical outcomes in patients with ST-segment elevation myocardial infarction who were normokalemic at admission. A total of 2773 patients with an admission serum K level of 3.5 to 4.5 mEq/L were retrospectively analyzed. The patients were categorized into 3 groups according to their K deviation: normokalemia-to-hypokalemia, normokalemia-to-normokalemia, and normokalemia-to-hyperkalemia. In-hospital mortality, long-term mortality, and ventricular arrhythmias rates were compared among the groups. In a hierarchical multivariable regression analysis, the in-hospital mortality risk was higher in normokalemia-to-hypokalemia (odds ratio [OR] 3.03; 95% confidence interval [CI], 1.72-6.82) and normokalemia-to-hyperkalemia groups (OR 2.81; 95% CI, 1.93-4.48) compared with the normokalemia-to-normokalemia group. In a Cox regression analysis, long-term mortality risk was also higher in normokalemia-to-hypokalemia (hazard ratio [HR] 3.78; 95% CI, 2.07-7.17) and normokalemia-to-hyperkalemia groups (HR, 2.97; 95% CI, 2.10-4.19) compared with the normokalemia-to-normokalemia group. Ventricular arrhythmia risk was also higher in normokalemia-to-hypokalemia group (OR 2.98; 95% CI, 1.41-5.75) compared with normokalemia-to-normokalemia group. The current study showed an increased in-hospital ventricular arrhythmia and mortality and long-term mortality rates with the deviation of serum K levels from normal ranges.

The predictive role of modified TIMI risk index in patients with ST-segment elevation myocardial infarction

Abstract Background: The prognostic value of thrombolysis in myocardial infarction (TIMI) risk index (TRI) has been reported in patients with coronary artery disease. In this study, we evaluated the additional prognostic value of blood urea nitrogen (BUN) level to the TRI in patients with ST-segment elevation myocardial infarction (STEMI). Methods: We evaluated the in-hospital and long-term (3-year) prognostic value of modified TRI (mTRI) in patients with STEMI. The mTRI is calculated using the following equation; mTRI = (TRI × BUN)/10. Patients were stratified into 5 groups according to 20-point increments of mTRI. Results: The patients with higher mTRI had significantly higher in-hospital and long-term mortality. The risk for in-hospital and long-term mortality was highest for those within the Q5 (36.8 and 42.3%, respectively) and it was significantly higher than all the other groups (p < .001 for both). Conclusions: In this study, the prognostic value of TRI has been augmented by multiplication of TRI with BUN/10. Therefore, we present a pilot study of association of mTRI with overall STEMI patients.