Refik Emre Altekin

Determination of right ventricular dysfunction using the speckle tracking echocardiography method in patients with obstructive sleep apnea.

BACKGROUND The speckle tracking echocardiography (STE) method shows the presence of right ventricular (RV) dysfunction before the advent of RV failure and pulmonary hypertension in patients with cardiopulmonary disease. We aimed to assess subclinical RV dysfunction in obstructive sleep apnea (OSA) using the STE method. METHOD Twenty-one healthy individuals and 58 OSA patients were included. According to severity as determined by the apnea-hypopnea index (AHI), OSA patients were examined in three groups: mild, moderate and severe. RV free wall was used in STE examination. RESULTS Right ventricle strain (ST %) and systolic strain rate (STR-S 1/s) were decreasing along with the disease severity (ST - healthy: -34.05 ± -4.29; mild: -31.4 ± -5.37; moderate: -22.75 ± -4.89; severe: -20.89 ± -5.59; p < 0.003; STR-S - healthy: -2.93 ± -0.64; mild: -2.85 ± -0.73; moderate: -2.06 ± -0.43; severe: -1.43 ± -0.33; p < 0.03). Correlated with the disease severity, the RV early diastolic strain rate (STR-E) was decreasing and the late diastolic strain rate was increasing (STR-E - healthy: 2.38 ± 0.63; mild: 2.32 ± 0.84; moderate: 1.66 ± 0.55; severe: 1 ± 0.54; p < 0.003; STR-A - healthy: 2.25 ± 0.33; mild: 2.32 ± 0.54; moderate: 2.79 ± 0.66; severe: 3.29 ± 0.54; p < 0.03). The STR-E/A ratio was found to be in a decreasing trend along with the disease severity (healthy: 1.08 ± 0.34; mild: 1.06 ± 0.46; moderate: 0.62 ± 0.22; severe: 0.34 ± 0.23; p < 0.03). CONCLUSIONS Subclinical RV dysfunction can be established in OSA patients even in the absence of pulmonary hypertension and pathologies which could have adverse effects on RV functions. In addition to the methods of conventional, Doppler and tissue Doppler echocardiography, using the STE method can determine RV dysfunction in the subclinical phase.

Relation of Neutrophil-to-Lymphocyte Ratio With GRACE Risk Score to In-Hospital Cardiac Events in Patients With ST-Segment Elevated Myocardial Infarction

In this study, we aimed to investigate the association of the neutrophil-to-lymphocyte ratio (NLR) with Global Registry of Acute Coronary Events (GRACE) risk score in patients with ST-segment elevated myocardial infarction (STEMI). We analyzed 101 consecutive patients with STEMI. Patients were divided into 3 groups by use of GRACE risk score. The association between NLR and GRACE risk score was assessed. The NLR showed a proportional increase correlated with GRACE risk score (P < .001). The occurrence of in-hospital cardiac death, reinfarction, or new-onset heart failure was significantly related to NLR at admission (P < .001). Likewise, NLR and GRACE risk score showed a significant positive correlation (r = .803, P < .001). In multivariate analysis, NLR resulted as a predictor of worse in-hospital outcomes independent of GRACE risk score. Our study suggests that the NLR is significantly associated with adverse in-hospital outcomes, independent of GRACE risk score in patients with STEMI.

Assessment of subclinical left ventricular dysfunction in obstructive sleep apnea patients with speckle tracking echocardiography

In this study, our aim was to evaluate the LV (left ventricle) subclinical myocardial dysfunction using the two-dimensional speckle tracking echocardiography (2D-STE) method on obstructive sleep apnea (OSA) patients with preserved left ventricular ejection fraction (LVEF) and without any confounding disease that may result myocardial dysfunction. Twenty-one healthy individuals and 58 OSA patients were enrolled in the study. The patients were categorized into mild, moderate and severe OSA groups according to the apnea-hypopnea index (AHI). Conventional- and tissue Doppler echocardiography imagings were performed in all the individuals besides the 2D-STE. The longitudinal strain (S) and systolic strain rate (SRS) values decreased as the severity of disease increased from moderate towards severe OSA. The circumferential S and SRS values were observed to be lower in the severe OSA patients. Despite the increase in the radial S and SRS in moderate and mild OSA patients, these measurements decreased in those with severe OSA. Although the longitudinal, circumferential and radial early diastolic strain rates (SRE) decreased as the severity of disease increased form moderate to severe, the late diastolic strain rates (SRA) were observed to increase. In the early stages of OSA, longitudinal systolic LV dysfunction is detected in addition to the diastolic dysfunction. The circumferential mechanics of the LV deteriorate in the later stages of the OSA. Despite a compensatory increase in the radial LV function in the early stages of OSA, in later stages, the LV radial function also deteriorates. The assessment of the myocardial functions using the STE method in patients with OSA with preserved LVEF has the potential to detect the subclinical LV dysfunction and might provide useful information for risk stratification.

Associations of isoprostanes-related oxidative stress with surrogate subclinical indices and angiographic measures of atherosclerosis.

ObjectivesCardiovascular diseases are the most common cause of death in the world. Oxidative stress has been proved to play a role in atherosclerotic diseases and 8-isoprostane is one of the most valid markers of in-vivo oxidative stress. We aimed to investigate the 8-isoprostane levels in relation to surrogate and direct angiographic indexes of atherosclerosis. MethodsUrinary 8-isoprostane levels were measured and a B-mode carotid ultrasound examination was performed in 100 consecutive patients scheduled for coronary angiography. ResultsIn patients with angiographic coronary artery disease (CAD) urinary 8-isoprostane levels were significantly (P<0.001) higher than in patients without CAD (68.75±5.5 vs. 38.27±3.7 pg/ml). Moreover, 8-isoprostane levels of patients with increased carotid intima media thickness (CIMT) were higher (P<0.001) than in patients with normal CIMT values (75.12±6.4 vs. 38.72±2.7 pg/ml). Moreover log(8-isoprostane) levels were significantly correlated with maximum and mean CIMT values (P<0.001) and across univessel and multivessel CAD groups levels of log(8-isoprostane) showed a significantly (P<0.001) increasing trend. Logistic regression analysis revealed that 8-isoprostane levels were an independent predictor for both intima-media thickening and angiographic CAD. ConclusionThese findings indicate that elevated urinary levels of 8-isoprostane are associated with both subclinical atherosclerosis and manifest CAD. The results therefore support the hypothesis that isoprostanes-related oxidative stress is involved in the whole atherosclerotic process.

The significance of the left atrial volume index in cardioversion success and its relationship with recurrence in patients with non-valvular atrial fibrillation subjected to electrical cardioversion: a study on diagnostic accuracy

OBJECTIVE The aim of this study was to assess the predictive value of the left atrial volume index (LAVI) in electrical cardioversion (ECV) and observe the recurrence rate of atrial fibrillation (AF) after a successful ECV in patients with non-valvular atrial fibrillation. METHOD This study was designed as a diagnostic accuracy and prospective cohort study. Eighty patients (mean age 62±12 years; 52.5% female) were enrolled in study. LAVI was measured using the area-length method and the indexed body surface area. Patients in whom the sinus rhythm (SR) was established following the ECV were assessed according to the clinical and electrocardiography (ECG) findings at the first month and grouped as those with continued SR or recurrent AF. The Students t, Mann-Whitney U, Fishers exact, Chi-square tests, ROC and logistic regression analyses were used for statistical analysis. RESULTS Subsequent to the ECV, SR was achieved in 62.5% (n=50) of the patients. In those where SR was established, the AP-Lad (4.32±0.62 vs. 4.77±0.4 cm/p=0.002) and LAVI (35.3±11.5 vs. 53.1±10.1 mL/m2/p<0.001) values were observed to be lower. ECV success was found to be associated only with the LAVI (OR:1.122, 95%CI: 1.058-1.191, p<0.001). The AUC was found as 0.892±0.041 for the LAVI (95% CI:0.075-0.285, p<0.001). During the controls at the end of the 1st month, SR was maintained in 72% (n=36) of the successful ECV group. Among the patients with maintained SR, the antero-posterior left atrial dimension (4.17±0.62 vs. 4.72±0.5 cm/p=0.004) and LAVI (30.8±6.2 vs. 46.8±13.9 mL/m2/p<0.001) values were also observed to be lower. Only the LAVI was found to be associated with the recurrence of the AF (OR:1.355, 95% CI: 1.154-1.591, p<0.001). The AUC was found as 0.950±0.029 for the LAVI (95% CI:0.063-0.313, p=0.003) CONCLUSION Lower LAVI values before the ECV are strong and independent predictors of the success of the ECV and the maintenance of SR after a successful ECV.

Red cell distribution width and neutrophil-to-lymphocyte ratio predict left ventricular dysfunction in acute anterior ST-segment elevation myocardial infarction

Objectives Red cell distribution width (RDW) and neutrophil-to-lymphocyte ratio (NLR) are the two markers used to determine risk of mortality and adverse cardiovascular outcomes in patients with acute myocardial infarction. The relationship between RDW, NLR, and left ventricular (LV) systolic functions has not been reported. In this report, we aimed to investigate the relationship between RDW, NLR, and LV systolic function in anterior ST-segment elevation myocardial infarction (STEMI) patients who underwent primary percutaneous coronary intervention (PCI). Methods RDW and NLR were measured on admission in 106 STEMI patients treated with primary PCI. Patients were divided into two groups according to left ventricular ejection fraction (LVEF), as Group I (systolic dysfunction, LVEF <50%) and Group II (preserved global left ventricle systolic function, LVEF ⩾50%). The first group included 47 patients and the second group included 59 patients. Results Mean RDW and NLR were significantly higher in Group I compared to Group II [13.7 ± 0.9% vs. 13.4 ± 0.7%, p = 0.03 and 5.86 (range, 0.66–40.50) vs. 2.75 (range, 0.51–39.39), p = 0.013, respectively]. Conclusion Increased RDW and NLR on admission, in anterior STEMI patients treated with primary PCI are associated with LV systolic dysfunction.

Urinary 8-isoprostane levels can indicate the presence, severity and extent of angiographic coronary artery disease.

Background — Atherosclerotic coronary artery disease is the leading cause of death worldwide. Oxidative stress is one of the key elements in the pathogenesis of atherosclerosis. Isoprostanes are established markers of oxidative stress. The aim of this study was to investigate the association of urinary 8-isoprostane levels with the presence and severity of coronary artery disease (CAD) assessed by a validated scoring system. Method — Urinary 8-isoprostane levels were measured in 100 consecutive patients scheduled for coronary angiography. Extent and severity of CAD were assessed by modified Gensini scores. Results — In patients with CAD, 8-isoprostane levels were higher (P < 0.001) than in patients without CAD (68.75 ± 5.5 vs. 38.27 ± 3.7 pg/ml). The levels of 8-isoprostane correlated with the number of risk factors (P < 0.001) and significantly increased in relation with the number of diseased vessels (P < 0.001). A significant (P < 0.001) correlation was found between 8-isoprostane levels and Gensini scores (r = 0.496), and a stepwise elevation in 8-isoprostane levels was observed across the increasing tertiles of the Gensini scores (P < 0.001). The multivariate logistic regression analysis revealed that 8-isoprostane was an independent predictor (odds ratio: 7.19 and P = 0.007) associated with angiographic CAD. Conclusion — These results confirm the role of oxidative stress in the atherosclerotic process. Urinary 8-isoprostane levels reflect the extent and severity of CAD and they may provide additional information for risk assessment in patients with suspected CAD.

Evaluation of subclinical left ventricular systolic dysfunction in patients with obstructive sleep apnea by automated function imaging method; an observational study.

OBJECTIVE We aimed to evaluate the subclinical left ventricular (LV) systolic dysfunction with the automated function imaging method (AFI) based on speckle tracking echocardiography (STE) in obstructive sleep apnea patients (OSA) with normal left ventricular ejection fraction (LVEF) and without any confounding disease that can cause myocardial dysfunction. METHODS Twenty-one healthy individuals and 58 OSA patients were included in this observational cross-sectional study. According to the severity of disease, OSA patients were examined in three groups; mild, moderate and severe OSA. Apical 2-, 3- and 4- chamber images were obtained for AFI evaluation. The global systolic longitudinal strain (GLS) values were determined for each view, and averages of these were used in comparison of the patient groups. One-way ANOVA, Kruskal-Wallis, Pearson correlation tests and linear regression analysis were used for statistical analysis. RESULTS The GLS values of the OSA patients were lower than of the healthy individuals and these values were decreased along with the OSA severity (Healthy:-25.58±-2.16%, Mild:-23.93±-3.96%, Moderate:-21.27±-2.60%, Severe:-16.94±-2.66%, respectively). The difference was significant between moderate OSA patients and healthy individuals, and significant between severe OSA patients and all other groups (p<0.03). The apnea-hypopnea index was found to be correlated with the GLS (β=-0.659, 95% CI: 0.09-0.17, p<0.001). CONCLUSION Longitudinal LV mechanics in OSA patients with normal LVEF are deteriorated in the subclinical stage being associated with the severity of disease. AFI can be used as an effective and safe method in the determination of subclinical myocardial dysfunction in OSA patients, because it is semi-automated and easy to use with a short analysis time.

Primer aşırı pıhtılaşma eğilimi olan hastada foramen ovale\'ye tuzaklanmış sağ kalp trombüsü ve pulmoner emboli

Thromboembolic disease is a potentially severe pathology. When its clinical feature implies a massive occlusion of the arterial pulmonary tree and a cardiac failure is ensued, it can be seriously life threatening even for young patients. Less frequent features as right or left atrium thrombosis could increase morbidity and mortality of this disease. We report a case of massive right pulmonary embolism (PE) with entrapped thrombus in patent foramen ovale and right heart failure in a 32- year-old man. Transthoracic echocardiography showed a right atrial thrombus attached to the inter-atrial septum. Following the diagnosis of right heart thrombosis with massive PE, infusion of tissue type plasminogen activator (100 mg in two hours) was administered. Echocardiography performed two days after thrombolysis showed a significant decrease in the right ventricular size and complete lysis of the thrombus in the right heart. By genetic examination, he proved to have factor V ’Leiden’ gene and two thrombophilia genes, all of which were positive in the heterozygous state. He had also a high serum homocysteine.

Early thrombus formation in patient with HeartWare left ventricular assist device presenting with acute heart failure.

Heart failure is one of the leading causes of mortality and morbidity in the world. Heart transplantation is still the gold standard therapy despite emerging treatment options. Due to the limited number of available donors, the use of ventricular assist devices has increased. However, increasing incidences of complications are observed with using these devices. In this article, surgical treatment of a huge mobile thrombus formation in an inflow cannula due to ineffective anticoagulation in a 59 year-old man who received a HeartWare ventricular assist device because of ischemic cardiomyopathy is presented.