Selim Yalçinkaya

Determination of the site of metabolism of total, free, and complexed prostate-specific antigen

OBJECTIVES To determine the site of metabolism of total prostate-specific antigen (tPSA), free PSA (fPSA), and complexed PSA (cPSA). METHODS A total of 20 male patients, 50 years old or older, having a clinical indication for left and right heart catheterization were enrolled in this study. Selective blood samples were obtained from the infrarenal, infrahepatic, and suprahepatic inferior vena cava, renal vein, hepatic vein, superior vena cava, pulmonary artery, and femoral artery. cPSA concentration was accepted as the difference between tPSA and fPSA concentrations. RESULTS We found that tPSA and fPSA concentrations in the infrarenal inferior vena cava were significantly higher than in the systemic artery. There was no significant difference between the systemic artery and the infrarenal inferior vena cava for cPSA concentration. Although fPSA concentration decreased significantly across the renal circulation, the decreases in cPSA and tPSA concentrations were statistically insignificant. In the hepatic circulation, we found that tPSA, fPSA, and cPSA concentrations were significantly decreased. No decrease in tPSA, fPSA, and cPSA concentrations were noted across the pulmonary circulation. CONCLUSIONS Our results indicate that fPSA and tPSA are released into serum from the prostate but the prostate may not have a significant role in complex formation of PSA. In addition, the liver has a significant role in the elimination of tPSA, fPSA, and cPSA. By contrast, the kidneys have a significant role only in the elimination of fPSA. We also found that the lungs did not have a significant role in the elimination of tPSA, fPSA, or cPSA.

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.

Late results of combined percutaneous balloon valvuloplasty of mitral and tricuspid valves

Although combined mitral and tricuspid stenosis are rarely seen in patients with rheumatic heart disease, when both exist together, combined percutaneous balloon valvuloplasty can be an alternative to surgical treatment in suitable cases. We present the immediate and late follow up results of 12 patients with rheumatic tricuspid and mitral stenosis treated with combined percutaneous balloon valvuloplasty. Twelve patients (11 female, 91.7%; 1 male, 8.3%) with a mean age of 35.3 +/- 6.4 years were enrolled in the study. The patients were followed up for 38.8 +/- 12.6 months. The mitral valve area increased from 1.2 +/- 0.2 cm2 to 2.3 +/- 0.2 cm2 (P < 0.01) and on follow up the mitral valve area did not differ significantly (2.2 +/- 0.2 cm2; P > 0.05). The tricuspid valve area increased from 1.6 +/- 0.3 cm2 to 3.2 +/- 0.2 cm2 (P < 0.01) and on follow up the tricuspid valve area did not differ significantly (3.1 +/- 0.2 cm2; P > 0.05). Two patients (16.6%) had tricuspid restenosis and tricuspid re-valvuloplasty. One other patient (8.3%) was referred to surgery 14 months after the procedure secondary to severe tricuspid regurgitation. In conclusion, this study demonstrates a sustained benefit on late follow up after combined percutaneous balloon valvuloplasty of mitral and tricuspid valves and confirms the efficacy and safety of the procedure as an alternative to surgery in selected cases of combined mitral and tricuspid stenosis.

Mechanical complications of intra-aortic balloon counterpulsation

Intra-aortic balloon counterpulsation (IABP) related complications in a heterogeneous group of patients who received an IABP before or after thrombolytic therapy and mechanical revascularization or in the management of refractory unstable angina and myocardial infarction related mechanical complications were evaluated prospectively. Ninety-one patients were enrolled to the study. Mean IABP duration was 4.3+/-2.4 days. While the IABP was in place, three patients (3.3%) had femoral artery emboli, four patients (4.4%) had lower extremity ischemia that resolved after the removal of the balloon, eight patients (8.8%) had groin hematoma requiring blood transfusion (< or =2 units) and four patients (4.4%) had intra-aortic balloon rupture. The relation of several risk factors to groin hematoma requiring < or =2 units blood transfusion, emboli, lower extremity ischemia and to total complications was evaluated. A chi-squared analysis showed that nadroparine use was more often complicated with emboli (P = 0.00005) and ischemic events (emboli and/or lower extremity ischemia) (three patients; 30% of nadroparine group vs. four patients; 4.9% of heparin group, P = 0.005) and hypercholesterolemia (>200 mg/dl) was more often complicated with lower extremity ischemia (P = 0.017). Forward conditional logistic regression analysis did not show any relation between the risk factors identified and emboli, lower extremity ischemia, ischemic events and groin hematoma (P>0.05), but an inverse relation was found between IABP duration and total complications (P = 0.0198). In conclusion, IABP related complications were found to remain unchanged but were not life-threatening and were inversely related to IABP duration and this suggests shorter periods of IABP use whenever possible and one must be cautious to use low molecular weight heparin in patients with an IABP in place.

Sustained ventricular tachycardia in cardiac hemochromatosis treated with amiodarone

Cardiac hemochromatosis can cause heart failure and cardiac arrhythmias. Among these arrhythmias, ventricular tachycardia may be resistant to treatment. A case of cardiac hemochromatosis complicated with ventricular tachycardia that did not respond to intravenous lidocaine, procainamide or propafenone, nor to DC cardioversion, was successfully treated with amiodarone. Amiodarone, a class III antiarrhythmic drug, may be highly effective in similar cases.

Tricuspid valve thrombus: A case report associated with gonadotropin-releasing hormone analogue therapy and review of the literature

A 35-year-old woman with a previously repaired atrial septal defect was referred for preoperative evaluation before laparoscopic surgery. The patient was asymptomatic, and a transesophageal echocardiographic examination revealed a probable thrombus attached to the tricuspid valve. The patients history included therapy with a gonadotropin-releasing hormone analogue and deep venous thrombosis five months earlier. The tricuspid valve thrombus disappeared after anticoagulant therapy. Warfarin was initiated for prophylaxis. During the follow-up, the patient was event-free during laparoscopic surgery and pregnancy (when warfarin was switched to acetylsalicylic acid) and gave birth to a healthy term baby. Because etiological investigations revealed no reason for the tricuspid valve thrombus, it was considered to be related to the procoagulant state induced by hormonal treatment. The patient was scheduled for close follow-up.

Concomitant Use of Intraaortic Balloon Counterpulsation and Streptokinase in Acute Anterior Myocardial Infarction

Using a prospective, nonrandomized design, the authors sought to determine whether concomitant use of intraaortic balloon counterpulsation (IABP) and streptokinase in acute anterior myocardial infarction (MI) would improve the in-hospital mortality rate and angiographic findings. The study included 45 patients with an acute anterior MI. All patients received intravenous streptokinase. Among these, 25 patients had concomitant IABP while the remaining 20 patients had streptokinase alone. All patients underwent cardiac catheterization. Patients treated with concomitant IABP had a significantly higher frequency of thrombolysis in myocardial infarction (TIMI) grade 3 flow (n: 11; 44% vs n: 1; 5%, p<0.05), and there was a trend toward a lower in-hospital mortality rate in the IABP group (n: 0; 0% vs n: 3; 15%, p=0.08). The angiographic presence of thrombus image and grade ≥2 coronary collateral circulation to the infarct-related coronary artery for the IABP and non-IABP groups did not differ significantly. The preliminary results of this study suggest that concomitant use of IABP and streptokinase in acute anterior MI increases the incidence of TIMI grade 3 flow and may have decreased the in-hospital mortality rate without unacceptable rates of vascular or hemorrhagic complications.

Imminent pulmonary embolism: a fatal mobile right atrial thrombus.

Right sided heart thrombi are infrequent and if they are mobile they may cause serious morbidity and mortality due to massive pulmonary embolism or paradoxical embolism. Malignancies are one of the important etiological factors for right heart thrombi. A patient with operated but recurrent ovarian carcinoma, presented with symptoms of heart failure was admitted to oncology department. Rapidly progressing dyspnea and a pre-syncope attack required consultation of a cardiologist and echocardiography revealed a mobile thrombus in the right atrium. Urgent open heart surgery was decided but imminent massive pulmonary embolism complicated the case leading to irreversible cardiogenic shock. By means of the presented case this paper overviews etiological factors and treatment options for right sided heart thrombi.

Left atrial function as a predictor of haemodynamic response in patients with mitral stenosis: a dobutamine stress echocardiographic study.

Objective—The mechanisms of the different haemodynamic and clinical responses to dobutamine infusion in mitral stenosis (MS) are not clearly established. The aim of this study was to evaluate the relation between left atrial (LA) function and haemodynamic response in patiens with MS during dobutamine infusion. Methods and results — Forty-two consecutive moderately symptomatic patients (33 women, 9 men; mean age 46±9, range from 26 to 66), NewYork Heart Association (NYHA) class II with MS (mean mitral valve area 1.7±0.1cm2) were evaluated with dobutamine stress echocardiography. Haemodynamic measurements were obtained at rest and during peak dobutamine infusion. LA fractional shortening at rest was used as an index of global LA function. Group I consisting of patients with significantly elevated pulmonary artery pressure (>60 mm Hg) and mean transmitral gradient (>15 mm Hg) at peak dobutamine infusion were defined as haemodynamically serious MS. Group II consisted of the remaining 30 patients whose haemodynamic data were below these levels.While baseline haemodynamic parameters and mitral valve characteristics were not different between the two groups, LA fractional shortening was significantly lower (18.9±2.8 vs. 32.3±5.1%, p<0.0001) and left atrial dimension was significantly larger in group I (49.7±2.3mm vs 43.6±5.3 mm, p<0.0001). Left atrial fractional shortening was negatively correlated with the increase in mean transmitral gradient (r:-0.58, p<0.01). When the patients were divided using a LA fractional shortening level of 25% as the cut-off point, we observed that the patients with low LA fractional shortening had a greater increase in mean transmitral gradient (7.3±3.1 mm Hg vs. 4.6±1.4 mm Hg), p = 0.005) and pulmonary artery pressure (22.4±3.5 mm Hg vs. 16.1±8.5 mm Hg, p = 0.001) compared to the patients with high LA fractional shortening. Based on these haemodynamic results, management was changed in 12 patients (28%): 5 underwent percutaneous mitral balloon commissurotomy and 7 received intensive medical treatment. Conclusions—The present study demonstrates that haemodynamic response during dobutamine stress echocardiography correlates with LA fractional shortening in patients with MS. The evaluation of left atrial function at rest in patients with ambiguous symptoms and mild mitral stenosis may be useful in clinical decision making. Atrial dysfunction at rest may predict the haemodynamic response during stress echo in these patients.

Effect of intraaortic balloon counter-pulsation on QT dispersion in acute anterior myocardial infarction

The present prospective non-randomized study aimed to examine whether intraaortic balloon counter-pulsation (IABP) has a favorable effect on QT dispersion in patients with acute anterior MI. Patients with acute anterior MI who presented within 6 h after the symptom onset were assigned to the IABP + streptokinase or streptokinase (STK) group. The IABP + STK group was consisted of 26 men and two women (mean age 52.9+/-10.2). The STK group was consisted of 19 men and two women (mean age 54.4+/-10.8). In the IABP + STK group, mean QT interval dispersion significantly shortened 6 h after treatment (50.9+/-15.6 ms before STK, and 36+/-13.9 ms 6 h after STK; P = 0.001) and did not significantly change 24 h after STK (35.6+/-11.2 ms). In the STK group, mean QT interval dispersion did not vary significantly before and 6 h after STK (57.14+/-13.2 ms before STK, and 56.07+/-13.3 ms 6 h after STK; P > 0.05) but 24 h after STK it significantly shortened to 40.42+/-10.8 ms (P < 0.001). Before STK, mean QT interval dispersions in the IABP + STK and STK groups were 50.9+/-15.6 ms and 57.14+/-13.2 ms, respectively (P > 0.05), 6 h after STK, mean QT interval dispersions were 36+/-13.9 ms and 56.07+/-13.3 ms, respectively (P = 0.0001) and 24 h after STK, mean QT interval dispersions were 35.6+/-11.2 ms and 40.42+/-10.8 ms, respectively (P > 0.05). In conclusion this study demonstrates that the adjunct of IABP to thrombolytic therapy, in the setting of acute anterior MI, significantly decreases QT interval dispersion at 6 h and this effect might be secondary to accelerated reperfusion and/or other beneficial effects of IABP.