Serdar Kucukoglu

Carotid artery intima media thickness, plaque and framingham cardiovascular score in Asia, Africa/Middle East and Latin America: the PARC-AALA Study

ObjectiveThe PARC-AALA (Paroi artérielle et Risque Cardiovasculaire in Asia Africa/ Middle East and Latin America) study was designed to evaluate the correlation between intima-media thickness of the common carotid artery (CCAIMT), carotid plaque and absolute cardiovascular risk in a multi-ethnic population.MethodsAn international, cross-sectional, study including 79 centres from 21 countries in Asia, Africa, the Middle East and Latin America. Two thousand three hundred and twenty-eight subjects, meeting all inclusion criteria, were stratified by risk factors groups (no modifiable factor or at least both uncontrolled hypertension and hypercholesterolemia). CCAIMT, presence of plaque and cardiovascular risk factors were assessed for each individual.ResultsSome intergeographical characteristics in demographics, and risk factors were found accompanying early atherosclerosis marker differences. In Asia where the subjects were at lower risk, the mean CCAIMT was 4% lower than in Africa/Middle East and Latin America. On multiple linear regression analysis CCAIMT and carotid plaque were independently associated with increased Framingham cardiovascular score (FCS) without heterogeneity across geographic regions. CCAIMT and carotid plaque explained roughly 20% of the FCS in both genders.ConclusionThe PARC-AALA study confirms the correlation between CCAIMT and FCS in three different populations. Intima-media thickness (IMT) and plaque evaluation may represent a complementary predictive tool for detection of cardiovascular disease in individuals.

Procalcitonin and C-Reactive Protein in Infective Endocarditis: Correlation with Etiology and Prognosis

Background: The aim of this study was to investigate the diagnostic values of serum procalcitonin (PCT) and C-reactive protein (CRP) levels in infective endocarditis (IE) and to correlate them with the etiology of the disease and the prognosis of the patients. Methods: Fifty patients who were diagnosed as having IE based on Duke criteria (major and/or minor) were included in the study at the Istanbul University Cardiology Institute and Florence Nightingale Hospital. Forty patients with bacteremia (non-IE) and 50 healthy blood donors were also included in the study as the control group. During the 45 days of medical follow-up, in those patients who had a response to medical therapy based on the results of left ventricular function tests, transesophageal echocardiography (TEE) and culture, among other factors, PCT and CRP levels were measured in 5-cm3 blood samples obtained without anticoagulant when they were first admitted (day 0), as well as 24 h and 15, 30 and 45 days after admission. In the patients who had valve replacement, 5-cm3 blood samples without anticoagulant were similarly obtained on the day of admission, after 24 h and/or on the 15th day, and 1 day before and on the 2nd and 5th days after the operation. Results: In this study, a significant difference (p < 0.001) was found between the IE group and the healthy control group with respect to their serum PCT and CRP levels at the time of admission. No significant difference was found between IE and non-IE groups (p > 0.05). The sensitivity of PCT in comparison to CRP was found to be lower (84 vs. 100%); however, its specificity was determined to be higher (88 vs. 72%). The median values of serum PCT in the nonoperated and operated cases at the time of admission, after 24 h and on the 15th day were 3.71, 5.35 and 0.44, and 2.45, 4.28 and 4.22 ng/ml, respectively, and those of CRP were 9.30, 10.95 and 10.65, and 9.5, 10.9 and 10.2 mg/dl, respectively. The median values of serum PCT were found to be higher in cases with IE and non-IE related to gram-negative bacteria than those related to gram-positive bacteria (p < 0.02). This was found to be insignificant for CRP (p > 0.05). Conclusions: As a result, this study suggests that in the diagnosis of IE, it would be beneficial to use PCT, besides TEE, culture and other clinical criteria, for its high specificity and positive predictive value in comparison to CRP. This study also suggests that in determining the response to medical treatment in the follow-up period, PCT could be a more valuable parameter than CRP, as PCT has a high prognostic value and is a good indicator for valve replacement in addition to the major criteria. Furthermore, serum PCT levels may help the physician to decide on the antimicrobial therapy combination before obtaining the culture results, or in situations in which the agent could not be isolated yet.

Ruptured Aneurysm of the Sinus of Valsalva into the Left Ventricle: A Case Report and Review of the Literature

This report describes a case of right coronary sinus of Valsalva aneurysm which ruptured into the left ventricle. The diagnosis was made with two-dimensional transthoracic echocardiography which showed an abnormal structure extending from the aortic root into the left ventricle adjacent to the interventricular septum. Subsequent examinations with transesophageal echocardiography and aortic root angiography and surgical findings confirmed the diagnosis of transthoracic echocardiography. The patient underwent aortic valve replacement. At follow-up 12 months later, the patient was without symptoms and repeated echocardiographic examinations showed no recurrence.

Report of a Case with Polymicrobial Endocarditis Related to Multiresistant Strains

We present a patient with polymicrobial endocarditis who had been operated on previously for a mycotic aneurysm and was seen at the cardiology clinic because of palpitations related to effort. A transesophageal echocardiogram revealed a 15-mm vegetation on his aortic valve. Staphylococcus epidermidis and Corynebacterium striatum were isolated from the blood cultures. Both strains were multiresistant (susceptible to 3 antibiotics at most) against chemotherapy in vitro. Microbiological eradication was not achieved from blood cultures even after applying antimicrobial therapy with effective antibiotics as determined with an antibiotic susceptibility test. For this reason, the patient underwent valve replacement. He was discharged from hospital in fairly good health.

Clinical and Echocardiographic Risk Factors for Embolization in the Presence of Left Atrial Thrombus

Aims: The aim of our study was to evaluate the factors leading to embolization in patients with left atrial thrombi (LAT). With this purpose, we retrospectively analyzed clinical, transthoracic, transesophageal echocardiographic data of patients with LAT in the transesophageal echocardiographic evaluation. Methods and Results: One hundred ninety‐two patients with LAT not on anticoagulant therapy were divided into two groups according to the presence of prior ischemic stroke. The group with ischemic stroke included more patients with sinus rhythm and less patients with mitral stenosis. They had smaller left atrial diameter, more left atrial appendage spontaneous echo‐contrast, higher appendage ejection fraction, and emptying velocity. Conclusion: Once the thrombus has been formed, cerebral embolization seems to be higher in patients with relatively preserved appendage ejection fraction and emptying velocity. Presence of atrial appendage spontaneous echo‐contrast also favor embolization. Factors leading to embolization seem to differ in some respects from the causes of thrombus formation.

Abiotrophia defectiva: A rare cause of infective endocarditis

A case of Abiotrophia defectiva-caused infective endocarditis is described. The patient was successfully treated with penicillin combined with gentamicin. Due to the fastidious nature of the agent, there is a need for special media for isolation and moreover, there is a need for a future development of susceptibility assays applicable to the organism.

Single-institutional 22 years experience on cardiac myxomas.

Myxomas are the most common benign tumors of the heart. This study presents single-institutional 22 years experience on cardiac myxomas. The records of 9756 consecutive cases of open heart surgery between 1985 and 2007 revealed 0.23% myxoma. Age ranged between 12 and 77 years and male to female ratio was 7:17. Myxomas originated from the left atrium (15 patients), mitral valve (3 patients), right atrium (2 patients), right atrium and right ventricle (2 patients), right ventricle (1 patient), and left ventricle (1 patient). Three patients were operated for multiple myxomas. Myxomas were resected through right atriotomy, right atriotomy and pulmonary arteriotomy, left atriotomy, biatrial approach, or left ventriculotomy depending on the tumor location. Mean follow-up time was 11.5 years. Mortality occurred in 6 patients (1 early, 5 late deaths). No myxoma recurrence was detected. Myxomas should be resected leaving no remnant mass, without delay when they are diagnosed.

The estimated pulmonary artery pressure can be elevated in Behçet’s syndrome

OBJECTIVES To determine the frequency of elevated systolic pulmonary artery pressure (sPAP) estimated by echocardiography in Behçets syndrome (BS) patients with pulmonary artery involvement (PAI), in healthy controls and in diseased controls with systemic sclerosis (SSc), as well as in BS patients without PAI. METHODS We studied 3 groups of patients with BS (patients with PAI: n = 30, with vascular disease but without PAI: n = 26 and without vascular disease: n = 21), patients with SSc (n = 23) and healthy controls (n = 22). Systolic pulmonary artery pressure (sPAP) was estimated by echocardiography. The upper limit for a normal sPAP was arbitrarily set at 35 mmHg. We also evaluated cardiac function by echocardiography. Pulmonary function tests, a six-minute walking test (six-MWT) and several serum biomarkers were also studied. RESULTS The frequency of patients with an elevated sPAP was significantly higher only among BS patients with PAI (17%) and among patients with SSc (26%). In addition, DL(CO) was decreased and pro-BNP levels were increased in BS patients with PAI, which are similar to the results in patients with SSc. Furthermore, BS patients with PAI also had mild RV diastolic dysfunction. CONCLUSIONS When BS involves the pulmonary arteries, it can cause mild elevations in the estimated sPAP, decrease in DL(CO), mild cardiac dysfunction and increase in pro-BNP levels. These findings suggest that BS can also affect the small/micro vessels of the heart and the lungs in addition to the well-recognized large vessel disease.

A Cardiac Papillary Fibroelastoma with Chordal Location

Papillary fibroelastomas, which were initially incidental findings at autopsy and surgery, are now being recognized with increasing frequency with the widespread use of echocardiography. Because of their embolic potential, an aggressive treatment approach is generally accepted. We report a papillary fibroelastoma located at the chorda of the anterior mitral leaflet that underwent conservative follow-up for 8 years without any complications. Because most of the cardiac papillary fibroelastoma cases reported are incidental findings, the question of whether symptomless fibroelastomas must be removed or other factors contribute to the embolic nature of the selected cases remains a challenge for the future.

Cardiac amyloidosis cases with relative apical sparing of longitudinal strain.

Amyloidosis is a clinical disorder caused by extracellular deposition of insoluble abnormal fibrils, derived from aggregation of misfolded normally soluble protein. Cardiac amyloidosis (CA) describes clinically significant involvement of the heart by amyloid deposition, which may or may not be associated with involvement of other organs. An echocardiogram demonstrating marked left ventricle (LV) wall thickening particularly in the absence of hypertension, biatrial enlargement, thickened valve leaflets, and a pericardial effusion in the context of reduced voltage of R-waves in electrocardiogram (ECG) is highly persuasive of cardiac amyloid. If either a thickened interatrial septum or a granular highly echogenic myocardium is also present, this makes the diagnosis even more likely. This thickening is often referred to incorrectly as “hypertrophy” because the pathological process is infiltration, not myocyte hypertrophy. The absence of high ECG voltages in advanced disease may be more specific for infiltrative diseases, of which amyloid is the most common. Echocardiography in CA can detect abnormalities in systolic and diastolic function of the myocardium even before ejection fraction (EF) is impaired. Strain (S) and strain rate (SR) has been shown to be superior to tissue Doppler techniques in this respect. Lately, the prognostic value of S and SR was, also, shown. We report 2 cases with similar clinical and echocardiographic features highly suggestive of CA. First patient (patient A) was a 50-year-old male. He had history of familial Mediterranean fever for several years using cholchicum dispert. The second patient (patient B) was also male (48year old). He had type 2 diabetes mellitus controlled with oral antidiabetic drugs. Both had no history of ischemic and hypertensive heart disease and had symptoms and signs of congestive heart failure. Their ECGs were similar presenting low voltage in limb leads. Patient A had also anterior and inferior pseudoinfarct pattern (Fig. 1A, B). Their transthoracic echocardiography (GE Healthcare, Horten, Norway) revealed increased wall thickness and systolic dysfunction in both LV and right ventricle (RV). (LV EF 30%, Tricuspid Annular Plane Systolic Excursion 1.3 cm) with normal chamber size, mild-to-moderate mitral and tricuspid insufficiency, mild pulmonary hypertension, and mild pericardial effusion. (Fig. 2A, B) We also performed twodimensional speckle tracking echocardiography (GE Healthcare). Longitudinal strain (LS) measurements were performed off line using automated software (EchoPAC Version 108.1.2. Advanced Analysis Technologies; GE Healthcare), using 3 standard apical views, the LV endocardium was manually identified and tissue speckles were automatically tracked frame by frame throughout the cardiac cycle. A bull’s-eye plot illustrating segmental LS values was automatically generated. Both the patients had lower global LS. ( 7.5, 4.5). The majority of segments in the basal and mid-ventricular regions had reduced LS, whereas apical segments had normal LS. Apical sparing was consistently seen in both (Fig. 3A, B). Patient A who had a salivary gland biopsy which showed non AA type amyloid deposition died 1 month after the diagnosis of congestive heart failure. Patient B had a rectal biopsy which showed AA type amyloid deposition and is still being followed. Amyloidosis should be considered in any patient older than 40 years who has nephrotic syndrome, congestive heart failure (not on an ischemic basis), idiopathic peripheral neuropathy, or unexplained hepatomegaly. There is an increasing realization that the prevalence of CA may be higher than previously expected and, not uncommonly, that the diagnosis can go unrecognized. Although a tissue biopsy is required to define the type of CA, the clinical challenge Address for correspondence and reprint requests: Cem Bostan, M.D., Department of Cardiology, Istanbul University, Institute of Cardiology, Haseki, Fatih 34350 Istanbul, Turkey. Fax: 90 (216) 469-3796; E-mail: bostancem@yahoo.com