Serdar Sevimli

Remarkable anatomic anomalies of coronary arteries and their clinical importance: a multidetector computed tomography angiographic study.

Objective: An anomalous origin and course of the coronary arteries can be benign or life threatening. Recently, because of new advances in computed tomography technology, radiologists have begun to interpret the diseases of coronary arteries. We aimed to demonstrate some remarkable anomalies of coronary arteries, some of which were not shown by multidetector computed tomography (MDCT) coronary angiography previously, and to discuss the clinical importance of these anomalies. Materials and Methods: Seven hundred twenty-five consequent patients referred to Florence Nightingale Hospital and Atatürk University Hospital for MDCT coronary angiography were included in this study. The patients were between the ages of 33 and 78 years (mean ± SD, 59 ± 13.86 years). Four hundred ninety-seven patients (68.6%) were men, and 228 (31.4%) were women. All the examinations were evaluated by both a radiologist and a cardiologist. Results: The incidence of anomalous anatomical origin and course of the coronaries found in our study group was 5.79% (n = 42). The anomalies found in our study are absence of the right coronary artery (RCA; n = 1, 0.13%), ectopic origin of RCA from the left anterior descending (LAD) artery (n = 1, 0.13%), absence of the left main coronary artery (n = 4, 0.52%), ectopic origin of the left main coronary artery from the right sinus of Valsalva (n = 1, 0.13%), double LAD and ectopic origin of LAD from RCA (n = 1, 0.13%), ectopic origin of the left circumflex artery from the right sinus of Valsalva (n = 3, 0.39%), ectopic origin of the left circumflex artery from RCA (n = 2, 0.26%), and myocardial bridging (n = 29, 4%). Conclusions: An anomalous origin of the coronary anatomy must be present in the interpretations because of its importance for patients, cardiologists, and surgeons. As a conclusion, our study showed that MDCT, especially volume rendering and maximum intensity projection techniques, may be useful for assessment of complex variations, when the conventional angiography may not be sufficient.

The relation of serum gamma-glutamyl transferase levels with coronary lesion complexity and long-term outcome in patients with stable coronary artery disease

BACKGROUND Relation of serum gamma-glutamyl transferase (GGT) levels with extent, severity, and complexity of coronary artery disease has not been adequately studied. Therefore, we evaluated the relationship between GGT levels and coronary complexity, severity and extent assessed by SYNTAX score and long-term adverse events. METHODS We enrolled 442 consecutive patients with stable angina pectoris who underwent coronary angiography. Baseline serum GGT levels were measured and SYNTAX score was calculated from the study population. Median follow-up duration was 363 days. Endpoints were all cause mortality and any revascularization. RESULTS GGT levels demonstrated an increase from low SYNTAX tertile to high tertile. In multivariate analysis serum GGT, diabetes mellitus, HDL-cholesterol, eGFR and ejection fraction were found to be independent predictors of high SYNTAX score. The survival analysis showed that long-term revascularization rates were comparable between the GGT groups (for 36 U/l cut point) of the overall population (7.7% vs 8.6% logrank, p = 0.577), whereas long-term all cause mortality rate was higher in the GGT ≥ 36 U/l group (3.6% vs 11.6% logrank, p = 0.001). In Cox proportional hazards regression model, GGT ≥ 36 U/l group was found to be an independent predictor of long-term all cause mortality in the unadjusted (HR 2.54, 95% CI 1.17-5.48, p = 0.018) and age- and gender-adjusted (HR 2.58, 95% CI 1.19-5.58, p = 0.016) models. CONCLUSION Serum GGT level was independently associated with coronary complexity and long-term mortality in patients with stable coronary artery disease.

Pulsed Doppler tissue imaging can help to identify patients with right ventricular infarction.

This study was planned to assess whether tissue Doppler imaging is a useful method for the detection of the right ventricular myocardial infarction. Forty-eight patients with acute inferior myocardial infarction and 24 age- and sex-matched healthy controls were included in this study. Twenty-four patients had electrocardiographic signs of inferior myocardial infarction without right ventricular infarction (group I), and the other 24 patients had electrocardiographic signs of inferior myocardial infarction with right ventricular infarction (group II). From the echocardiographic apical four-chamber view, peak systolic, early diastolic, and late diastolic velocities of the tricuspid annulus at the right ventricular free wall were recorded with the use of pulsed-wave Doppler tissue imaging. The tricuspid annular peak tissue Doppler imaging systolic velocity was significantly lower in group I (14.03 ± 2.57 cm/s, P ≪ 0.005) and in group II (8.50 ± 0.84 cm/s, P ≪ 0.005) than in controls (16.63 ± 2.31 cm/s). The tricuspid annular peak systolic (8.50 ± 0.84 cm/s vs 16.63 ± 2.31 cm/s) and peak early diastolic (10.99 ± 3.28 cm/s vs 19.39 ± 4.3 cm/s) velocities were significantly lower in group II than in group I, as compared with controls (P ≪ 0.001). Peak early diastolic velocity of tricuspid annulus (10.99 ± 3.28 cm/s vs 19.39 ± 4.3 cm/s) was significantly lower in group I than in controls (P ≪ 0.001); however, late diastolic velocity was significantly lower in group II (15.98 ± 5.08 cm/s, P ≪ 0.05) than in group I (18.21 ± 2.63 cm/s, P ≪ 0.05) and in controls (19.02 ± 5.29 cm/s). The results of this study indicate that tricuspid annular peak systolic and early diastolic velocities are reduced in patients with right ventricular infarction. The velocity of the tricuspid annulus by tissue Doppler imaging is simple and can be used to distinguish whether patients with inferior myocardial infarction have right ventricular infarction.

Right ventricular strain and strain rate properties in patients with right ventricular myocardial infarction.

Background: This study was planned to assess strain and strain rate properties of right ventricle in patients with RV myocardial infarction. Material and Method: Thirty patients with acute inferior myocardial infarction were included in this study. The presence of right ventricular infarction in association with an inferior myocardial infarction was defined by an ST‐segment elevation 0.1 mV in lead V4 R. According to this definition, 15 patients had electrocardiographic signs of inferior myocardial infarction without right ventricular infarction (group I), and 15 patients had electrocardiographic signs of inferior myocardial infarction with right ventricular infarction (group II). Echocardiography was performed using a Vivid 5 System (GE Ultrasound; Horten, Norway) and a 2.5‐MHz transducer. 2‐dimensional color doppler myocardial imaging (CDMI) data for longitudinal function were recorded from the RV free wall using standard apical view. Offline analysis of the myocardial color Doppler data for regional velocity (V), strain rate (Sr), and strain (S) curves was performed using a special software program (EchoPac 6.4 Vingmed, Horten, Norway). They were assessed in basal, middle and apical segments of the RV. The differences between different groups were assessed with the Mann‐Whitney U‐test. A value of P < 0.05 was considered statistically significant. Results: Systolic tissue velocity, strain, strain rate of basal (4.8 ± 0.8 cm/s vs 6.5 ± 1.2 cm/s, −12 ± 3% vs −24 ± 5%, 1.28 ± 0.3/s vs −1.9 ± 0.4/s; P < 0.001, <0.001, <0.001, respectively) and mid (4.2 ± 0.5 cm/s vs 5.4 ± 0.5 cm/s, −16 ±3% vs −26 ± 4%, −1.2 ± 0.3/s vs −2.1 ± 0.3/s; P < 0.001, <0.001, <0.001, respectively) segments of right ventricle were significantly lower in patients with RV infarction than in patients without RV infarction. There were no differences between groups for apical strain, strain rate, and systolic tissue velocity. Conclusion: This study demonstrates that right ventricular strain and strain rate were lower in patients with left ventricular inferior wall myocardial infarction with, compared to without, right ventricular infarction.

The Role of the Nonspecific Inflammatory Markers in Determining the Anatomic Extent of Venous Thromboembolism

We aimed to investigate the relationship between the extent of venous thromboembolism (VTE) and nonspecific inflammatory markers such as neutrophil to lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hs-CRP). We retrospectively enrolled 77 patients with VTE (distal deep vein thrombosis [DVT], n = 19; proximal DVT, n = 32; and pulmonary thromboembolism [PTE], n = 26) and 34 healthy controls. In the performed analysis of variance, the levels of white blood cell, NLR, and hs-CRP were clearly different among the groups (control, distal and proximal DVT, and PTE) (P < .001). Especially, a significant increase from the control group to the DVT and PTE was observed in the analysis made for NLR. In the performed receiver–operating characteristic curve analysis, area under curve (AUC) = 0.849 and P < .001 were detected for NLR > 1.84. For this value, the sensitivity and specificity were determined as 88.2% and 67.6%, respectively. The NLR is an inexpensive and a readily available marker that may be effective in determining the extent of VTE, and it is useful for risk stratification in patients with VTE.

Relation of Neutrophil to Lymphocyte Ratio With the Presence and Severity of Stable Coronary Artery Disease

Objectives: We examined the association between neutrophil to lymphocyte ratio (NLR) and the complexity of coronary artery disease assessed by SYNTAX score (SS). Methods: The study population included patients with chest pain who had undergone coronary angiography for stable angina pectoris. Patients were classified depending on whether the SS was 0 or SS > 0. Results: Left ventricular ejection fraction, estimated glomerular filtration rate, and NLR were found to be the independent predictors of high SS in multivariate analysis. The area under the receiver–operating curve of NLR was 0.72 (0.65-0.80, P < .001) for predicting high SS. The optimal cutoff value of NLR to predict high SS was 2.7 (sensitivity of 72% and a specificity of 61%). There was a significant correlation between NLR ratio and continuous SS (r = .552, P < .001). Conclusion: The NLR is a readily measurable systemic inflammatory marker and is associated with both the presence and the complexity of coronary artery disease.

Rosuvastatin versus atorvastatin to prevent contrast induced nephropathy in patients undergoing primary percutaneous coronary intervention (ROSA-cIN trial).

Aim We aimed to compare the incidence of contrast-induced nephropathy (CIN) between atorvastatin versus rosuvastatin in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary coronary angioplasty. Methods One hundred ninety-two consecutive patients, who underwent primary percutaneous intervention (p-PCI) with the diagnosis of STEMI, were included in the study. The patients were randomized to take atorvastatin 80 mg (n = 98) or rosuvastatin 40 mg (n = 94) before the procedure. Biochemical and complete blood count measurements were done at baseline and at 48 hours following admission. Results The incidence of CIN was 8.9% (n = 17) in the entire groups. The analysis performed between the statin groups revealed no statistical difference in any of the renal dysfunction indicators [baseline creatinine, baseline estimated glomerular fi ltration rate (eGFR), creatinine at 48 h, eGFR at 48 h, diff erence between baseline and 48 h creatinine, the per cent increase in the creatinine at 48 hours relative to basal creatinine]. In STEMI patients undergoing primary PCI, only the amount of the contrast agent administered was determined to be an independent predictor for CIN (OR and 95% CI: 1.08 (1.03- 1.13), P ≤ 0.001). Left ventricular ejection fraction exhibited borderline statistical signifi cance (OR and 95% CI: 0.88 (0.77-1.01), P= 0.07). Conclusion Atorvastatin and rosuvastatin had similar effi cacy in preventing CIN in patients with STEMI undergoing P-PCI.

Severity of Mitral Stenosis and Left Ventricular Mechanics: A Speckle Tracking Study

Background: It has been shown that mitral stenosis (MS) impairs left ventricular (LV) systolic function; however, this issue has not been studied comprehensively. We aimed to evaluate the role of 2D strain in the assessment of subclinical LV systolic dysfunction in patients with MS. Methods: Seventy-two patients with isolated MS (mild, moderate and severe) and 31 healthy control subjects constituted the study population. 2D echocardiography images were obtained from LV apical 4-chamber (4C), long axis (LAX), and 2-chamber (2C) views. Peak longitudinal strain and strain rate (Sr) were obtained from 4C, LAX, and 2C views. Global strain and Sr were calculated by averaging the three apical views. Results: There were no significant differences in LV ejection fraction and LV systolic or diastolic dimensions between the groups. Patients with MS had significantly lower LV longitudinal strain and Sr measurements than the control group. In addition, there were no significant differences in MS subgroups with respect to LV strain and Sr measurements. Conclusion: We demonstrated that patients with MS had lower LV functions using 2D strain imaging, and this is independent of the hemodynamic severity of MS. In the detection of subclinical LV dysfunction in patients with MS, 2D strain imaging appears to be useful.

Relation of Red Cell Distribution Width With Presence and Severity of Coronary Artery Ectasia

Red cell distribution width (RDW) is an index that has been shown to be an independent correlate of adverse outcomes in some cardiac conditions. Isolated coronary artery ectasia (CAE) is an abnormality of the coronary anatomy and can cause ischemia. We hypothesized that increased RDW would be associated with isolated CAE because both are associated with inflammation. In this study, 2345 patients who received coronary angiography were retrospectively evaluated. After exclusion, 75 patients with isolated CAE and 96 consecutive patients with normal coronary were included in the study. The severity of isolated CAE was determined according to the Markis classification. Baseline RDW was measured as part of the automated complete blood count. Red cell distribution width was observed to be an independent predictor of both presence and severity of isolated CAE. In conclusion, RDW is associated with both the presence and severity of isolated CAE.

Increased mean platelet volume associated with extent of slow coronary flow

BACKGROUND Slow coronary flow (SCF) is characterized by delayed opacification of epicardial coronary vessels. SCF can cause ischemia and sudden cardiac death. We investigated the association between presence and extent of SCF, and cardiovascular risk factors and hematologic indices. METHODS In this study, 2467 patients who received coronary angiography for suspected or known ischemic heart disease were retrospectively evaluated between April 2009 and November 2010. Following the application of exclusion criteria, our study population consisted of 57 SCF patients (experimental group) and 90 patients with age- and gender-matched subjects who proved to have normal coronary angiograms (control group). Baseline hematologic indices were measured by the automated complete blood count (CBC) analysis. The groups were evaluated for cardiovascular risk factors and medications. Patients were categorized based on the angiographic findings of vessels with or without SCF. Moreover, patients with SCF were divided into subgroups relative to the extent of SCF. RESULTS Among the 147 patients (mean age 52.7 ± 10.0, 53.7% male), mean platelet volume (MPV) ranged from 6.5 fL to 11.7 fL (median 7.9 fL, mean 8.1 ± 0.8 fL). Diabetes (OR = 3.64, 95% CI 1.15-10.43, p = 0.03), hypercholesterolemia (OR = 4.94, 95% CI 1.99-12.21, p = 0.001), smoking (OR = 3.54, 95% CI 1.43-8.72, p = 0.006), hemoglobin (OR = 1.69, 95% CI 1.22-2.36, p = 0.002), and MPV (OR = 2.52, 95% CI 1.43-4.44, p = 0.001) were found to be the independent correlates of SCF presence. Only MPV (OR = 2.13, 95% CI 1.05-4.33, p = 0.03) was identified as an independent correlate of extent of SCF. CONCLUSIONS Elevated baseline MPV value was found to be an independent predictor of the presence and extent of SCF.