Ş. Balta

Asymmetric Dimethylarginine and Augmentation Index in Newly Diagnosed Patients With Hypertension

Pulse wave velocity (PWV), augmentation index (Aix), and central aortic pressure (CAP) are arterial stiffness markers of endothelial dysfunction (ED). We investigated the relationship between arterial stiffness parameters and asymmetric dimethylarginine (ADMA; a marker of ED), in newly diagnosed patients with hypertension (n = 101; 61 females). These patients were investigated in accordance with the recommendations of hypertension guidelines. Arterial stiffness was measured, and serum ADMA and C-reactive protein (CRP; a marker of inflammation) levels were determined. In both women and men, there was no difference in terms of age, body mass index, systolic and diastolic blood pressures, PWV, CAP and the levels of ADMA, while Aix and CRP levels were significantly higher in women (P = .004, P = .046, respectively). In the whole group, ADMA levels correlated with Aix (Pearson r = .237, P = .024). Our findings provide further evidence of a link between arterial stiffness and ED in newly diagnosed patients with hypertension.

Arterial stiffness and endothelial inflammation in prediabetes and newly diagnosed diabetes patients

OBJECTIVE There is a growing body of data supporting the association between diabetes and microcirculatory disfunction. We aimed to study e-selectin levels, and their associations with serum markers of inflammation and arterial stiffness in prediabetes and newly diagnosed diabetes patients in this study. SUBJECTS AND METHODS Sixty patients (25 females) with a newly established elevated fasting serum glucose [20 impaired fasting glucose (IFG), 20 impaired glucose tolerance (IGT), 20 newly diagnosed diabetes (T2DM)] and 17 healthy controls (13 females) were included in the study. Serum e-selectin and hs-CRP levels, and arterial stiffness parameters of the patients were studied. RESULTS Fasting serum glucose was the most important predictor of serum e-selectin levels. Pulse wave velocity and central aortic pressures were significantly higher in IFG, IGT and T2DM groups, compared to controls (p = 0.001, < 0.001, 0.013 and 0.015, 0.002, 0.009, respectively). The mean arterial pressure did not show any significant association with serum e-selectin and hs-CRP levels (β coefficient: 0.092, p = 0.358; and β coefficient: 0.189, p = 0.362, respectively). CONCLUSION Prediabetes patients have increasing e-selectin levels through the diagnosis of T2DM. E-selectin is associated with serum glucose levels. Prediabetic and newly diagnosed diabetics have higher arterial stiffness measurements. Serum e-selectin may be a good marker of endothelial inflammation and dysfunction increasing in parallel with serum glucose levels, predicting future cardiovascular events.

Peripheral Arterial Disease Assessment With Photoplethysmography and Continuous-Wave Doppler Ultrasound in Addition to Ankle-Brachial Index May Loss Time and Funds

We read the article ‘‘Photoplethysmography and ContinuousWave Doppler Ultrasound as a Complementary Test to Ankle Brachial Index in Detection of Stenotic Peripheral Arterial Disease’’ by Du Hyun Ro with interest. They concluded that ankle-brachial index (ABI) showed a significantly decreased sensitivity in detection of anatomically stenotic peripheral arterial disease (PAD), especially in stenosis below trifurcation level and both photoplethysmography (PPG) and continuouswave Doppler ultrasound (CWD) were complementary to ABI in these patients. Measurement of ABI manually by Doppler is a well-established method to screen for PAD and to predict the cardiovascular risk of patients. In this study, measuring PPG and CWD in addition to ABI measurement in patients with probable PAD was suggested as the ABI has a sensitivity of 69.3% and a specificity of 99.6% and it may miss a diagnosis of PAD. But in real life, a measurement of ABI as well as these additional methods may consume more time and lead to higher costs. Further studies are needed to answer these questions. A second challenge in the study is that the authors discussed ABI measurements but we do not know the real-time aortic or brachial blood pressure of these patients. It would be better if they provided enough data and the blood pressure measurements were standardized.

Percutaneous transcatheter closure of atrial and ventricular septal defect in the same session

A 23-year-old man was admitted to our outpatient clinic with the complaint of exertional dyspnea and palpitation. His medical history was unremarkable. Electrocardiography showed a sinus rhythm with a complete right bundle branch block. Two-dimensional transthoracic echocardiography revealed moderately dilated right heart chambers and defects at the interatrial and interventricular septum. The calculated Qp/Qs was 2.5. Two-dimensional transesophageal echocardiography (2D TEE) midesophageal four-chamber view confirmed secundum atrial septal defect (ASD) and ventricular septal defect (VSD) (Figure A, B, Video 1*). For further evaluation of this pathology, we applied three-dimensional transesophageal echocardiography (3D TEE). 3D color Doppler TEE demonstrated the defect at the interventricular septum (Figure C). We decided to close these defects percutaneously because he was symptomatic, and Qp/Qs was higher than normal values. We firstly closed the ASD with a septal occluder device. Then, we performed left ventriculography, which showed the tunnel-like VSD (Figure D, thin arrow), and closed the VSD with a septal occluder device (Figure E). 2D TEE midesophageal four-chamber view (Figure F and Video 2*) and 3D full-volume modality after cropping (Figure G and Video 3*) revealed the ASD and VSD devices. 2D TEE can provide useful information by monitoring transcatheter closure, while 3D TEE enhanced our ability to better define the atrial and ventricular septal anatomy and to assess the true size and morphology of the defect, enabling easier catheter closure. We herein report percutaneous transcatheter closure of ASD and VSD in the same session using multimodality imaging. To the best of our knowledge, this is the first such case in the literature. 314

OP-106 THE COMPARATIVE EFFECTS OF VALSARTAN AND AMLODIPINE ON VWF LEVELS AND N/L RATIO IN PATIENTS WITH NEWLY DIAGNOSED HYPERTENSION

Background: Hypertension is a major global health problem. An estimated 25–30% of the adult population in the world suffer from this condition. Resistant hypertension is defined as when a treatment that has included attention to lifestyle measures and the prescription of at least three drugs (including a diuretic) in adequate doses has failed to lower systolic and diastolic blood pressure to goal. Prevalence of resistant hypertension is nearly 10%. Percutaneous renal sympathetic denervation is a novel approach for resistant hypertension treatment. Method: Renal sympathetic denervation was performed for three patients who had resistant hypertension. For renal denervation first of all renal arteries canulate with 6F guidewire (RDC-I, Vista britetip, Cordis, FL, USA), then we performed renal angiography and showed that renal arteries size (diameter >4mm, length >30mm). We performed renal denervation with renal denervation catheter (RDN 006, Symplicity Catheter, Ardian, Inc, USA). The third patient had double left renal artery (Figure 1); we performed renal denervation for both left renal artery. At the end of the denervation we performed renal angiography and showed the denervation points. Results: Patients characteristics, treatment, procedural characteristics, plasma renin activity and norepinephrine values are shown in Table 1. Three patients were followed in terms of blood pressure and complications for 6 months and we achieved target blood pressure for the first and second patients and the number of antihypertensive drugs were reduced (the antihypertensive drug number reduced from 6 to 3 for the first patient and reduced from 6 to 4 for the second patient) (Table 1). We have not achieved target blood pressure for the third patient yet. Conclusion: Renal denervation was performed successfuly and blood pressure was significantly decreased in patients with resistance hypertension. More data are needed to investigate the usefulness of renal denervation procedure in the management of the double renal artery.

Ambulatory Blood Pressure Monitoring and Body Mass Index: Good but Not Standardized!

hypertension. Ambulatory BP monitoring is a more accurate method of excluding white coat hypertension in subjects with higher BP measurements in the doctor’s office. Also, it can give more information about all-day BP levels, especially night BP levels. Hence, the study by Tekin at al. [1] provided important information about childhood BP and that obesity could be related to night-time systolic BP. However, some comments are in order. Firstly, in this study, if the authors had excluded some clinical diseases, including secondary hypertension that is usually seen in these study groups, it would have been better. Secondly, the authors did not analyse the distribution of body fat and its impact on ambulatory hypertension as an isolated change in abdominal obesity, without any changes in total obesity (i.e., body mass index) [3] . Finally, ambulatory BP monitoring was used with a fixed schedule according to awake-asleep periods in this study; however, the actual awake and asleep periods could not be determined because they might differ from person to person [4] . In conclusion, although ambulatory BP monitoring is the best method for analysis of BP measurements, and also obesity may be a risk factor for hypertension as presented in a recent study, we suggest that above factors should be kept in mind when clinicians make similar studies. Dear Editor, We have read with interest the article entitled ‘Ambulatory blood pressure parameters in office normotensive obese and nonobese children: relationship with insulin resistance and atherosclerotic markers’ by Tekin et al. [1] . The authors showed that normotensive obese children had higher ambulatory blood pressure (BP) parameters. A high low-density lipoprotein cholesterol to highdensity lipoprotein cholesterol ratio and night-time systolic BP were associated with an increased risk of being obese. High lowdensity lipoprotein cholesterol to high-density lipoprotein cholesterol ratios and total cholesterol to high-density lipoprotein cholesterol levels in children and adolescents may be risk factors for night-time hypertension. Hypertension is a major health problem in the adult population worldwide [2] and has recently also become an important condition in childhood. The prevalence of overweight and obesity in the adolescent population has increased substantially. Childhood obesity is a predictor of an increased rate of death, due primarily to an increased risk of cardiovascular disease and risk factors including Received: October 15, 2014 Accepted: May 14, 2015 Published online: June 25, 2015

Incidentally Detected Pericardial Cyst Adjacent to the Right Atrium

DOI: 10.4328/JCAM.1416 Received: 21.11.2012 Accepted: 10.12.2012 Publihed Online: 10.12.2012 Corresponding Author: Şevket Balta, GATF Kardiyoloji Bilim Dali, Etlik, 06018, Ankara, Turkiye. E-Mail: drsevketb@gmail.com Ozet Perikardial kistler nadir gorulen iyi huylu konjenital lezyonlardir. Cogu perikardiyal kist asemptomatiktir ve buyuk boyutlara ulasmalarina ragmen bulgu vermeyebilirler. Klasik olarak on mediastende kardiofrenik aciya yerlesirler fakat nadiren atipik yerlesim gosterebilirler. Nadir gorulen bu lezyonlarin toplumdaki sikligi yuzbinde bir ve mediastinal kitleler icindeki sikligi %7’dir. Bu hastalarin yaklasik altida biri gogus agrisi sikayeti ile kendini gosterir. Zaman icinde buyuk boyutlara ulastiginda kardiyak kompresyona neden olabilirler. Rutin akciger grafisi ile rahatlikla tani konabilir. Tani ekokardiyografi, tomografi ve manyetik rezonans goruntuleme ile dogrulanmalidir ve tum hastalara mumkun olan en kisa zamanda cerrahi tedavi uygulanmalidir.

A Combination of Persistent Left Superior Vena Cava and Subaortic Discrete Membrane

A persistent left superior vena cava is the most common congenital anomaly in volving the systemic veins. It occurs in approximately 0.5% of the general population and 3% to 10% of patients with other cardiovascular abnormalities including atrial septal defect, ventricular septal defect, bicuspid aortic valve, coarctation of aorta, and cor-triatriatum. A discrete subaortic membrane is a rare cause of subaortic stenosis in adult. It may present as in an isolated form as fibrous or fibromuscular ring below the aortic valve or in association with other congenital anomalies. This is the case of a persistent left vena cava superior associated with a subaortic discrete membrane.

Military jet pilots have higher p-wave dispersions compared to the transport aircraft aircrew.

OBJECTIVES For the purpose of flight safety military aircrew must be healthy. P-wave dispersion (PWD) is the p-wave length difference in an electrocardiographic (ECG) examination and represents the risk of developing atrial fibrillation. In the study we aimed at investigating PWD in healthy military aircrew who reported for periodical examinations. MATERIAL AND METHODS Seventy-five asymptomatic military aircrew were enrolled in the study. All the subjects underwent physical, radiologic and biochemical examinations, and a 12-lead electrocardiography. P-wave dispersions were calculated. RESULTS The mean age of the study participants was 36.15±8.97 years and the mean p-wave duration was 100.8±12 ms in the whole group. Forty-seven subjects were non-pilot aircrew, and 28 were pilots. Thirteen study subjects were serving in jets, 49 in helicopters, and 13 were transport aircraft pilots. Thirty-six of the helicopter and 11 of the transport aircraft aircrew were non-pilot aircrew. P-wave dispersion was the lowest in the transport aircraft aircrew, and the highest in jet pilots. P-wave dispersions were similar in the pilots and non-pilot aircrew. Twenty-three study subjects were overweight, 19 had thyroiditis, 26 had hepatosteatosis, 4 had hyperbilirubinemia, 2 had hypertension, and 5 had hyperlipidemia. The PWD was significantly associated with thyroid-stimulating hormone (TSH) levels. Serum uric acid levels were associated with p-wave durations. Serum TSH levels were the most important predictor of PWD. CONCLUSIONS When TSH levels were associated with PWD, uric acid levels were associated with p-wave duration in the military aircrew. The jet pilots had higher PWDs. These findings reveal that military jet pilots may have a higher risk of developing atrial fibrillation, and PWD should be recorded during periodical examinations.

Relation between epicardial fat thickness and chronic obstructive pulmonary disease.

We read the article “Relationship between metabolic syndrome and epicardial fat tissue thickness in patients with chronic obstructive pulmonary disease” by Demir et al. (1) with great interest. The authors aimed to evaluate the usefulness of epicardial fat thickness (EFT) to predict metabolic syndrome (MS) in chronic obstructive pulmonary disease (COPD) patients. They concluded that EFT was a non-invasive and easily available parameter, which is valuable in the prediction of increased MS risk in COPD patients. Early diagnosis of patients at risk of MS might help prevent ischemic heart disease in these patients. We thank the authors for their good contribution of the present study, which is successfully designed and well-documented. Cardiovascular diseases are the most important factors that are associated with higher morbidity and mortality rate in COPD patients. At present, epicardial tissue, which is one of the endocrine organ, plays an important role in releasing numerous markers that are related to inflammation, endothelial dysfunction, oxidative stress, and atherosclerosis (2, 3). Over the past years, various studies have investigated the potential importance of epicardial tissue in the risk of cardiovascular diseases (3). In this respect, a previous report showed that the amount of epicardial tissue is importantly correlated to abdominal visceral adiposity, metabolic syndrome, cardiovascular diseases, and proinflammatory activity (3, 4). In clinical practice, EFT is a widely used method that gives information about the amount of epicardial tissue. In addition, EFT has several advantages, including its inexpensiveness, easy accessibility, rapid applicability, and good reproducibility. However, some important conditions should be emphasized. First, EFT was measured using transthoracic echocardiography and was measured on the free wall of the right ventricle at end-diastole in the current study (1). The authors should exclude the mediastinal fat, presenting as an echolucent area above the parietal pericardium, because linear echodense parietal pericardium may be considered to be epicardial fat. Second, because EFT measurements are linearly assessed using transthoracic echocardiography, echocardiographic EFT may not accurately reflect the total epicardial fat volume. Therefore, because of three-dimensional distribution of EFT, the gold standard measurement of EFT is magnetic resonance imaging (MRI) or computed tomography (CT). Concordantly, the lack of MRI and CT use should have been one of the limitations of the present study (5). Third, two-dimensional echocardiography cannot give adequate window of all cardiac segments, especially in obese subjects, and is highly dependent on acoustic windows. With this point of view, interand intraobserver variabilities for EFT measurement should be addressed in future studies (4). Moreover, hypothyroidism, overt or subclinical, has multiple effects on the cardiovascular system. EFT may be a useful marker of subclinical atherosclerosis in patients with hypothyroidism. Also, a recent report emphasized that EFT was increased in patients with psoriasis; EFT may be a possible marker of subclinical atherosclerosis and increased cardiovascular risk in patients with psoriasis. As a conclusion, although EFT values give us important information about patients’ inflammatory status, they may not provide information to clinicians about systemic inflammation without the abovementioned conditions. We believe that these findings will require further studies on EFT in COPD patients.