Seçkin Pehlivanoğlu

Creatinine kinase isoenzyme–MB: A simple prognostic biomarker in patients with pulmonary embolism treated with thrombolytic therapy

BACKGROUND Creatinine kinase isoenzyme-MB (CK-MB) is a biomarker for detecting myocardial injury. The aim of this study was to evaluate the association between admission CK-MB levels and in-hospital and long-term clinical outcomes in pulmonary embolism (PE) patients treated with thrombolytic tissue-plasminogen activator. METHODS A total of 148 acute PE patients treated with tissue-plasminogen activator enrolled in the study. The study population was divided into 2 tertiles, based on admission CK-MB levels. The high CK-MB group (n=35) was defined as having a CK-MB level in the third tertile (>31.5 U/L), and the low group (n=113) was defined as having a level in the lower 2 tertiles (≤31.5 U/L). RESULTS High CK-MB group had a higher incidence of in-hospital mortality (37.1% vs 1.7%, P<.001). Admission systolic blood pressure and tricuspid annular plane systolic excursion were lower in the high CK-MB group. In the receiver-operating characteristic curve analysis, a CK-MB value of more than 31.5 U/L yielded a sensitivity of 86.7% and specificity of 83.5% for predicting in-hospital mortality. During long-term follow-up, recurrent PE, major and minor bleeding, and mortality rates were similar in both groups. CONCLUSION Creatinine kinase isoenzyme-MB is a simple, widely available, and useful biomarker for predicting adverse in-hospital clinical outcomes in PE.

Early Changes in Atrial Electromechanical Coupling in Patients with Hypertension: Assessment by Tissue Doppler Imaging.

Background:Hypertension (HT) is associated with atrial electrophysiological abnormalities. Echocardiographic pulsed wave tissue Doppler imaging (TDI) is one of the noninvasive methods for evaluation of atrial electromechanical properties. The aims of our study were to investigate the early changes in atrial electromechanical conduction in patients with HT and to assess the parameters that affect atrial electromechanical conduction. Methods:Seventy-six patients with HT (41 males, mean age 52.6 ± 9.0 years) and 41 controls (22 males, mean age 49.8 ± 7.9 years) were included in the study. Atrial electromechanical coupling at the right (PRA), left (PLA), interatrial septum (PIS) were measured with TDI. Intra- (right: PIS-PRA, left: PLA-PIS) and inter-atrial (PLA-PRA) electromechanical delays were calculated. Maximum P-wave duration (Pmax) was calculated from 12-lead electrocardiogram. Results:Atrial electromechanical coupling at PLA (76.6 ± 14.1 ms vs. 82.9 ± 15.8 ms, P = 0.036), left intra-atrial (10.9 ± 5.0 ms vs. 14.0 ± 9.7 ms, P = 0.023), right intra-atrial (10.6 ± 7.8 ms vs. 14.5 ± 10.1 ms, P = 0.035), and interatrial electromechanical (21.4 ± 9.8 ms vs. 28.3 ± 12.7 ms, P = 0.003) delays were significantly longer in patients with HT. The linear regression analysis showed that left ventricular (LV) mass index and Pmax were significantly associated with PLA (P = 0.001 and P = 0.002, respectively), and the LV mass index was the only related factor for interatrial delay (P = 0.001). Conclusions:Intra- and interatrial electromechanical delay, PLA were significantly prolonged in hypertensive patients. LV mass index and Pmax were significantly associated with PLA, and the LV mass index was the only related factor for interatrial delay. The atrial TDI can be a valuable method to assess the early changes of atrial electromechanical conduction properties in those patients.

Predictive value of SYNTAX score II for clinical outcomes in cardiogenic shock underwent primary percutaneous coronary intervention; a pilot study

SYNTAX Score II (SSII) connects clinical variables with coronary anatomy. We investigated the prognostic value of SSII in patients with ST segment elevated myocardial infarction (STEMI) complicated with cardiogenic shock treated with primary percutaneous coronary intervention (PPCI). In this retrospective analysis, we evaluated the in-hospital prognostic impact of SSII on 492 patients with STEMI complicated with cardiogenic shock treated with PPCI. Patients were stratified by tertiles of SSII, in-hospital clinical outcomes were compared between those groups. In-hospital univariate analysis revealed higher rates of in-hospital death for patients with SSII in tertile 3, as compared to patients with SSII in tertile 1 (OR 17.4, 95% CI 10.0–30.2, p < 0.001). After adjustment for confounding baseline variables, SSII in tertile 3 was associated with 6.2-fold hazard of in-hospital death (OR 6.2, 95% CI 2.6–14.1, p < 0.001). SSII in patients with STEMI complicated with cardiogenic shock treated with PPCI provide an independent prognostic marker of in-hospital outcomes. Our data suggests SSII to be a simple, feasible and clinically applicable tool for rapid risk stratification in patients with STEMI complicated with cardiogenic shock treated with PPCI.

Successful thrombolysis of a subacute prosthetic valve thrombosis with modified ultra-slow thrombolytic therapy

Prosthetic valve thrombosis is a serious complication of heart valve surgery. According to the recent studies, thrombolytic therapy is an important alternative therapy to the open heart surgery with successful outcomes. We present a case of a prosthetic mitral valve thrombosis who was successfully treated with modified ultra‐slow thrombolytic therapy.

Acute myocardial infarction with concomitant pulmonary embolism as a result of patent foramen ovale

Acute myocardial infarction (MI) and pulmonary embolism canal one lead to life-threatening conditions such as sudden cardiac death and congestive heart failure. We discuss a case of a 74-year-old man presented to the emergency department with acute dyspnea and chest pain. Acute anterior MI and pulmonary embolism concomitantly were diagnosed. Primary percutaneous coronary intervention performed because of preliminary acute anterior MI diagnosis. Transthoracic echocardiography was performed to determine further complications caused by acute MI because patient had a continuous tachycardia and dyspnea although hemodynamically stable. Transthoracic echocardiography revealed a thrombus that was stuck into the patent foramen ovale with parts in right and left atria. Anticoagulation therapy was started; neither fibrinolytic therapy nor operation was performed because of low survey expectations of the patients recently diagnosed primary disease stage IV lung cancer. Patient was discharged on his 20th day with oral anticoagulation and antiagregant therapy.

Acute Renal Failure in Patients with Massive Pericardial Effusion or Cardiac Tamponade

GİRİŞ ve AMAÇ: Akut böbrek yetmezliği (ABY) yoğun bakım ünitelerinde özellikle kritik hastalarda sık karşılaşılan bir durumdur. Akut böbrek yetmezliği prevalansı 3-25% arasında değişmektedir. Koroner yoğun bakım ünitelerindeki (KYBÜ) hastalarda gelişen ABY ile ilgili literatürde yeterli very bulunmamaktadır. Özelllikle massif perikardiyal effüzyon ve kardiyak tamponad bulunan hastalardaki ABY gelişimi için prediktörler bilinmemektedir. Bu çalışmadaki amaç bu hasta grubunda ABY prevalansını ve prediktörlerini belirlemektir.

Reply to the Letter to the Editor: Successful thrombolysis of a subacuteprosthetic valve thrombosis with modified ultra-slow thrombolytic therapy

We would like to thank Dr Guner and his colleagues for their interest in our article which is entitled “Successful thrombolysis of a subacute prosthetic valve thrombosis with modified ultraslow thrombolytic therapy” and for taking time to write their opinions.1 In his letter to the editor, Dr Guner notes potential concerns with simultaneous unfractionated heparin (UFH) infusion during thrombolytic therapy (TT) and switching lone tissue plasminogen activator (tPA) protocol to UFH plus tPA protocol. They pointed out the increased risk of bleeding and adverse events with this protocol. However, simultaneous UFH infusion during TT has been widely used to treat acute myocardial infarction with STsegment elevation, highrisk acute pulmonary embolism, and also prosthetic valve thrombosis; 2017 European Society of Cardiology (ESC) Guidelines for the management of acute myocardial infarction in patients presenting with STsegment elevation recommends concurrent anticoagulation therapy with fibrinolysis.2 Similarly, 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism recommends accelerated TT over 2 hours with UFH and highlights the importance of thrombolytic agent type. According to the guideline, UFH infusion should be stopped during the administration of streptokinase or urokinase; it can be continued during tPA infusion.3 Lastly, ESC Guidelines for the management of valvular heart disease, which is published in 2017, recommends 10 mg bolus tPA plus 90 mg tPA in 90 minutes with UFH in patients with prosthetic valve thrombosis.4 On the other hand, relevant American College of Cardiology/American Heart Association (ACC/AHA) Guidelines exerts quite a different approach for the pharmacological treatment of acute prosthetic valve thrombosis.5,6 ACC/AHA 2014 guideline suggests several days of intravenous UFH, if valve thrombosis persists, fibrinolysis with a tPA dose of a 10 mg bolus followed by 90 mg infused intravenous over 2 hours. In accordance with the author’s opinion, ACC/AHA 2017 guideline promotes “slowinfusion lowdose fibrinolytic therapy” by specifically referring the PROMETEE trial, due to its higher success rates and lower complication rates than prior highdose regimens.7 In summary, according to different guidelines, UFH plus tPA protocol is not a definitely forbidden case. In our case, although we fully support the PROMETEE trial protocol for the treatment of acute prosthetic valve thrombosis, we modified the protocol after first 48 hours by combining UFH infusion with ultraslow tPA infusion to increase early therapeutic success. We think that, in case of failed fibrinolysis after the first 48 hours according to the PROMETEE trial protocol, switching lone tPA protocol to UFH plus tPA protocol may increase early treatment success especially in patients with the low hemorrhagic risk profile and this approach can accelerate treatment process and elicit shorter inhospital stay and lower treatment cost.

Predictors of In-Hospital Mortality in Patients With ST-Segment Elevation Myocardial Infarction Complicated With Cardiogenic Shock

BACKGROUND ST-segment elevation myocardial infarction (STEMI) complicated with cardiogenic shock (CS) remains as an unresolved condition causing high morbidity and mortality despite advances in medical treatment and coronary intervention procedures. In the current study, we evaluated the predictors of in-hospital mortality of STEMI complicated with CS. METHODS In this retrospective study, we evaluated the predictive value of baseline characteristics, angiographic, echocardiographic and laboratory parameters on in-hospital mortality of 319 patients with STEMI complicated with CS who were treated with primary percutaneous coronary intervention. Patients were divided into two groups consisting of survivors and non-survivors during their index hospitalisation period. RESULTS The mortality rate was found to be 61.3% in the study population. At multivariate analysis after adjustment for the parameters detected in univariate analysis, chronic renal failure, Thrombolysis In Myocardial Infarction (TIMI) post percutaneous coronary intervention (PCI) ≤2, plasma glucose and lactate level, blood urea nitrogen level, Tricuspid Annular Plane Systolic Excursion (TAPSE) and ejection fraction were independent predictors of in-hospital mortality. CONCLUSIONS Apart from haemodynamic deterioration, angiographic, echocardiographic and laboratory parameters have an impact on in-hospital mortality in patients with STEMI complicated with CS.

Clinical characteristics and outcomes of acute coronary syndrome patients with intra-aortic balloon pump inserted in intensive cardiac care unit of a tertiary clinic

OBJECTIVE An intra-aortic balloon pump (IABP) is a mechanical support device that is used in addition to pharmacological treatment of the failing heart in intensive cardiac care unit (ICCU) patients. In the literature, there are limited data regarding the clinical characteristics and in-hospital outcomes of acute coronary syndrome patients in Turkey who had an IABP inserted during their ICCU stay. This study is an analysis of the clinical characteristics and outcomes of these acute coronary syndrome patients. METHODS The data of patients who were admitted to the ICCU between September 2014 and March 2017 were analyzed retrospectively. The data were retrieved from the ICCU electronic database of the clinic. A total of 142 patients treated with IABP were evaluated in the study. All of the patients were in cardiogenic shock following percutaneous coronary intervention, at the time of IABP insertion. RESULTS The mean age of the patients was 63.0±9.7 years and 66.2% were male. In-hospital mortality rate of the study population was 54.9%. The patients were divided into 2 groups, consisting of survivors and non-survivors of their hospitalization period. Multivariate analysis after adjustment for the parameters in univariate analysis revealed that ejection fraction, Thrombolysis in Myocardial Infarction flow score of ≤2 after the intervention, chronic renal failure, and serum lactate and glucose levels were independent predictors of in-hospital mortality. CONCLUSION The mortality rate remains high despite IABP support in patients with acute coronary syndrome. Patients who are identified as having a greater risk of mortality according to admission parameters should be further treated with other mechanical circulatory support devices.

Hypertensive emergency due to pheochromocytoma crisis complicated with refractory hemodynamic collapse.

Hypertensive emergency usually appears in older patients with previous recurrent episodes, and is among the most frequent admissions to emergency departments. A 29-year-old woman was referred to our clinic with the diagnosis of hypertensive emergency. The patient complained of severe headache, dyspnea, palpitation, diaphoresis, and confusion due to hypertensive encephalopathy. Her blood pressure was 250/150 mmHg on admission. At the referral hospital, the patient had undergone cranial CT because of her confused state and this excluded acute cerebral hemorrhage. Also at that hospital, thoracoabdominal CT for differential diagnosis depicted an adrenal mass with a necrotic core. After admission to our clinic, initial control of excessive blood pressure was not achieved despite high dose intravenous nitrate therapy. Thereafter intravenous esmolol treatment was initiated simultaneously with oral alpha blocker therapy in order to counterbalance the unopposed alpha adrenergic activity with beta blocker therapy. After 12 hours, sudden onset of hypotension developed and deepened despite IV saline, inotropic and vasopressor agents such as IV dopamine, noradrenaline and adrenaline. The patient died at the 24th hour due to hemodynamic collapse as a result of hyperadrenergic state due to possible pheochromocytoma crisis. This case is an exceptional example of hypertensive emergency secondary to fulminant pheochromocytoma crisis failing to respond to intensive antihypertensive treatment, and in which patient death was unavoidable due to uncontrolled excessive adrenergic activity which led to profound cardiogenic shock.