Serkan Yuksel

Atrial tachyarrhythmias late after Fontan operation are related to increase in mortality and hospitalization

BACKGROUND Atrial tachyarrhythmias are a known complication late after Fontan operation. Limited information is available on their prognostic value. METHODS All patients with previous Fontan operation followed at our institution since 1999 were identified from the electronic database and included in this study. Demographic and clinical characteristics including history of atrial tachyarrhythmias were recorded at the earliest full clinical assessment and patients were followed thereafter for all-cause mortality and hospitalization. RESULTS A total of 98 patients, mean age 31.5 ± 8.9 years, 43.8% male, 31.6% with a total cavopulmonary connection (TCPC) were identified. A history of atrial tachyarrhythmia was present at baseline in 60.2% of patients who were older (33.0 ± 8.3 vs 29.1 ± 9.4 years, p=0.002), less likely to have a TCPC (13.5% vs 58.9%, p<0.001), and more symptomatic in terms of NYHA class (51.9% vs 26.7%, p=0.007) compared to arrhythmia-free patients. During a median follow-up of 6.7 years 18 patients died and 64 patients were hospitalized. Even after adjustment for baseline clinical characteristics, atrial tachyarrhythmia was an independent predictor of death (propensity score adjusted HR 9.35, 95% CI: 1.10-79.18, p=0.04, c-statistic 0.88) and composite of death or hospitalization (propensity score adjusted HR 5.00, 95% CI: 2.47-10.09, p<0.0001). CONCLUSIONS In adult patients with a Fontan-type operation, the presence of atrial tachyarrhythmias is associated with higher morbidity and mortality at mid-term follow-up. Whether early arrhythmia targeting intervention may improve clinical outcome needs to be studied in a prospective manner.

The relationship of coronary flow to neutrophil/lymphocyte ratio in patients undergoing primary percutaneous coronary intervention

PURPOSE It has been known that inflammatory mechanisms play an important role in the coronary artery disease. Our aim in this study was to investigate the relationship between the neutrophil/lymphocyte (N/L) ratio and coronary flow velocity after primary percutaneous coronary intervention (PCI) in patients presenting with ST-segment elevation myocardial infarction (STEMI). METHODS Two hundred and ten patients who had undergone primary PCI were included. The coronary flow velocities were evaluated using the recorded PCI procedures by Thrombolysis in Myocardial Infarction (TIMI) flow grades and corrected TIMI frame counts (cTFC) values. A value of >40 for the final cTFC was accepted as an index of insufficient coronary blood flow. The white blood cell subtypes and counts were determined in the blood samples obtained at the clinics. RESULTS In 165 (78%) of the investigated patients, reperfusion was found to be sufficient (Group I) while in 45 (22%) of them (Group II) insufficient reperfusion was observed (Group II). In-hospital mortality was 7.2% (n=12) in Group I, whereas it was 17.7% (n=8) in Group II (P=0.033). Similarly, one-year mortality was higher in Group II (26.6%, n=12) than in Group I (13.3%, n=22) (P=0.031). N/L ratio was determined to be higher in Group I than in Group II (8.3±6.1 vs. 6.2±5.0; P=0.034). Also, N/L ratio was found as an independent predictor of severe no-reflow development (TIMI 0-1) and of one-year mortality (P=0.01 and P=0.047, respectively). CONCLUSIONS N/L ratio has been found to be an independent indicator for no-reflow development in patients who have undergone PCI for acute STEMI. This simple and low-cost parameter can provide useful information for the relevant risk evaluation in these patients.

Evaluation of the Relationship Between Arterial Blood Pressure, Aortic Stiffness and Serum Endothelin-1 Levels in Patients with Essential Hypertension

This study has attempted to evaluate the relationship between aortic stiffness, blood pressure (BP) and serum endothelin-1 (ET-1) levels in patients with essential HT. Totally 152 subjects, consisting of 103 patients diagnosed with HT at least 1 year previously and 49 healthy individuals, were enrolled in this study. They were subdivided, on the basis of BP measurements made at home, into three groups as the hypertensives with dysregulated BP (n = 56), the hypertensives with regulated BP (n = 47) and the normotensive controls (n = 49). Statistically significant differences were observed between the three groups with respect to aortic elasticity parameters (p < 0.01 for aortic strain, aortic distensibility and aortic stiffness). Serum ET-1 levels in the three groups were similar (p = 0.101), but a significant correlation was observed between the ET-1 values and the aortic elasticity parameters (p = 0.004). Alteration of the aortic elasticity parameters in patients with HT not only correlates with the serum ET-1 levels indicating endothelial dysfunction but also gives direct clues about status of BP regulation.

Neutrophil-to-lymphocyte ratio for the assessment of hospital mortality in patients with acute pulmonary embolism.

Introduction Neutrophil-to-lymphocyte ratio (NLR), which is an essential marker of inflammation, has been shown to be associated with adverse outcomes in various cardiovascular diseases in the literature. In this study we sought to evaluate the association between NLR and prognosis of acute pulmonary embolism (APE). Material and methods We retrospectively evaluated blood counts and clinical data of 142 patients with the diagnosis of pulmonary embolism (PE) from Ondokuz Mayis University Hospital between January 2006 and December 2012. The patients were divided into two groups according to NLR: NLR < 4.4 (low NLR group, n = 71) and NLR ≥ 4.4 (high NLR group, n = 71). Results Massive embolism (66.2% vs. 36.6%, p < 0.001) and in-hospital mortality (21.1%, 1.4%, p < 0.001) were higher in the high NLR group. In multivariate regression analysis NLR ≥ 5.7, systolic blood pressure (BP) < 90 mm Hg, serum glucose > 126 mg/dl, heart rate > 110 beats/min, and PCO2 < 35 or > 50 mm Hg were predictors of in-hospital mortality. The optimal NLR cutoff value was 5.7 for mortality in receiver operating characteristic (ROC) analysis. Having an NLR value above 5.7 was found to be associated with a 10.8 times higher mortality rate than an NLR value below 5.7. Conclusions In patients presenting with APE, NLR value is an independent predictor of in-hospital mortality and may be used for clinical risk classification.

Evaluation of plasma chemerin levels in patients with non-dipper blood pressure patterns

Background Chemerin is a novel adipokine that plays a role in inflammation and atherosclerosis. Although there are several correlations between hypertension and the inflammatory system, there is still insufficient information about the relationship between blood pressure variability and inflammatory markers. In this study, we aimed to determine whether chemerin levels are elevated in non-dipper patients compared with dippers and healthy controls. Material/Methods This study was composed of a group of 90 patients: 60 hypertensive patients and 30 healthy control subjects (12 males, mean age 53.2±15.4 years). Ambulatory blood pressure monitoring devices (ABPM) were connected to all patients. Using data from the ABPM, hypertensive patients were divided into 2 groups: 30 dipper patients (12 males, mean age 52.5±15.1 years) and 30 non-dipper patients (11 males, mean age 54.6±13.0 years). Complete blood count and biochemistry were measured by standard methods and plasma chemerin concentrations were quantified by ELISA. Results Non-dipper patients demonstrated higher chemerin levels compared to dippers and normotensives (219.7±16.3 vs. 182.4±21.4 ng/ml; 219.7±16.3 vs. 85.4±38.1 ng/ml, respectively, p<0.001 for both comparisons). A receiver operating characteristic curve analysis revealed that the optimal cut-off value for chemerin to predict a non-dipping pattern was 201.4, with 90% sensitivity and 90% specificity. There was a positive correlation between chemerin levels and all ambulatory blood pressure values in all hypertensive patients. Conclusions Chemerin, which plays a role in inflammation and atherosclerosis, was higher in non-dippers compared to dippers and normotensives. Additionally, chemerin shows positive correlations with blood pressure.

A Forgotten Guidewire Causing Intracardiac Multiple Thrombi With Paradoxical and Pulmonary Embolism

A woman aged 70 years was transferred from another medical centre to our hospital because of shortness of breath, hemoptysis, and ischemic changes in the right foot (Fig. 1A). She had chronic renal failure and had been enrolled in a hemodialysis treatment program for 6 years. Transesophageal echocardiography showed a guidewire in the right atrium and right ventricle, with multiple mobile thrombi attached to it. The guidewire entered the right atrium through the superior vena cava, passed into the right ventricle through the lateral tricuspid valve annulus, and then looped in the right ventricle. One of the thrombi was entrapped within a patent foramen ovale and oscillated between right and left atria (Fig. 1B; Video 1 ; view video online). Pulmonary computed tomography angiography showed emboli in the segmental artery of the right lower lobe and a subsegmental artery of the left lower lobe. Because of the precarious state of the patient and the risk of further emboli, it was decided to take the patient for emergency cardiac surgery. The intracardiac guidewire and multiple thrombi were removed successfully (Fig. 1C). Unfortunately, because of multiple comorbidities, hemodynamic instability, and profound acidosis, she died on the second postoperative day. Vascular interventional procedures are widely used, resulting in increased complication rates. Guidewire loss may lead to thrombosis, embolism, sepsis, arrhythmia, or perforation. Loss of a complete guidewire is a rarely reported complication. Percutaneous retrieval is the preferred treatment, with low complication and high success rates. Various devices and techniques, such as loop snares, 2-wire or triplewire technique, basket retrievers, special catheters, grasping

Serum Neutrophil Gelatinase-Associated Lipocalin Levels and Aortic Stiffness in Noncritical Coronary Artery Disease

Aim: The aim of this study was to establish the degree of aortic stiffness and levels of neutrophil gelatinase-associated lipocalin (NGAL) in patients with stable ischemic heart disease. Materials and Methods: Patients who were found to have stable, noncritical lesions on coronary angiography were included in the study [noncritical coronary artery disease (CAD)]. The control group consisted of those patients who had similar risk profiles and metabolic parameters without atherosclerosis on angiography. Results: A total of 101 patients were included in the study of which 56 had noncritical CAD. Whereas the aortic strain (9.11 ± 3.4 vs. 14.01 ± 4.1%, p < 0.001) and aortic distensibility (3.98 ± 1.9 10-6 cm2/dyn vs. 6.33 ± 2.3 10-6 cm2/dyn, p < 0.001) were lower in the noncritical CAD group, the aortic stiffness index was higher (6.34 ± 3.9 vs. 3.37 ± 2.4, p < 0.001) as compared to controls. Serum NGAL levels were higher in the noncritical CAD group (79.29 ± 38.8 vs. 48.05 ± 21.4 ng/ml, p < 0.001). NGAL levels were negatively correlated with aortic strain (p < 0.01, r = 0.57) and distensibility (p < 0.001, r = 0.62), but positively correlated with the aortic stiffness index (p < 0.001, r = 0.72). Conclusion: We show that in patients with noncritical CAD, the degree of aortic stiffness and NGAL levels are higher. These markers can be used as tools for further risk stratification of patients with noncritical CAD.

Prevalence and Characteristics of Coronary-Cameral Communications in Adult Patients: Coronary Angiographic Analysis of 16,573 Patients

Objective: To analyze the coronary angiograms of patients with symptomatic heart disease in order to determine the frequency and characteristics of coronary-cameral communications (CCCs) in a single center. Subjects and Methods: The coronary angiograms of 16,573 patients with symptomatic heart disease performed from November 2001 to January 2011 were analyzed. The diagnosis of coronary fistula and coronary-cameral microcommunications (CCMCs) was made according to previously defined criteria. Results: Of the 16,573 patients, 15 (0.09%; 8 males and 7 females, mean age 63 ± 12 years) had CCCs, while coronary fistulas were identified in 2 (0.01%). In the first patient, the coronary fistula arose from the branches of the left anterior descending (LAD) artery and the right coronary artery (RCA) and drained into the right ventricle. In the second patient, the fistula originated from branches of the LAD artery, the circumflex (Cx) artery and the RCA and drained into the left ventricle. In 7 patients, the CCMCs originated from the LAD artery. In 3 patients, the Cx artery was the origin. The CCMCs originated from the RCA in 2 patients. In 1 patient the CCMC took its origin from the RCA and the Cx artery, while in 2 patients the CCMCs were associated with intracardiac masses in the left atrium and the right atrium, respectively. Conclusion: The prevalence of CCCs in adult patients was low and that of large coronary fistulas was even lower; coronary fistulas are probably very rare in adult patients because the majority of them are detected and treated during childhood.

Single coronary artery: right coronary artery originated from middle of left anterior descending artery in a patient with severe mitral regurgitation.

The single coronary artery is a benign and very rare coronary artery abnormality. Anomalous origin of the right coronary artery originating from the left anterior descending artery has been reported previously in just a few cases. In this article, we presented a patient with an anomalous origin of the right coronary artery from the midportion of the left anterior descending artery. The anomalous coronary artery was discovered incidentally during a coronary angiography performed prior to mitral valve surgery. Copyright

Huge cardiac cyst hydatid causing cardiac symptoms and electrocardiographic changes

Here we present a huge cardiac cyst hydatid case with wonderful echocardiographic and computed tomographic images, causing cardiac symptoms and electrocardiographic changes.