Sinan Akıncı

Dual coronary artery–pulmonary artery fistulas

A 62-year-old man presented with exertional angina. His physical examination and electrocardiogram were normal. Myocardial perfusion scintigraphy showed ischemia of the anterior wall of the left ventricle. The patient’s echocardiographic examination was normal. Coronary angiography revealed dual coronary artery fistulas originating from the first diagonal and conus branches of the right coronary artery and opening into the main pulmonary artery (Figures 1 and ​and2).2). Coil occlusion of the fistulas was recommended to the patient. Figure 1) Coronary angiography (90° left anterior oblique, 0° caudal projection) Figure 2) Coronary angiography (46° left anterior oblique, 0° caudal projection)

Traditional Risk Factors Are Predictive on Segmental Localization of Coronary Artery Disease

The aim of this study was to investigate the relationship between established risk factors and segmental localization of coronary artery disease. A total of 2760 patients who underwent coronary angiography were enrolled into the study. Coronary angiographic segmental evaluation was performed according to the scheme of American Heart Association. Patients were classified into 2 groups (group 1: normal coronary artery segments, group 2: coronary artery segments with coronary artery disease). Smoking was highly related with left main coronary artery disease (odds ratio = 7.5; P = .005). Diabetes mellitus and male sex increased the risk of atherosclerosis in all coronary vasculature (odds ratio = 2.7-2.2; P < .001-P < .001). Hypertension was correlated with distal coronary artery (odds ratio = 1.4; P < .001) and family history with distal circumflex lesions (odds ratio = 4.5; P = .005) High triglyceride levels were associated with right coronary artery lesions (odds ratio = 1.00; P =.03). The effect of advanced age was small (odds ratio = 1.08; P < .001). Risk factors may be predictive for segmental localization.

Relief of angina pectoris when carrying heavy loads with the left hand in a patient with previous coronary artery bypass graft operation who has severe exercise angina: a case report.

In patients with known coronary artery disease and/or a history of revascularization, angina pectoris or unstable coronary syndromes are usually attributed to the progression of atherosclerotic lesions rather than an unrecognized great vessel disease. However, for patients with a previous coronary artery bypass graft operation (CABG), during which a left internal mammary artery (LIMA) conduit has been used, great vessel disease, especially subclavian artery stenosis should also be suspected. We present a case of a patient with a LIMA conduit who has angina pectoris on exertion, but interestingly the pain is relieved when he carries heavy loads with his left hand, which can be due to increased blood flow to the LIMA conduit during heavy lifting because of increased peripheral resistance. Copyright

Effect of dobutamine stress echocardiography on serum heart fatty acid binding protein levels

Objective Heart fatty acid binding protein (HFABP) is a low-molecular-weight free protein that is abundant in the intracytoplasmic space of myocytes. Due to its unique features, serum HFABP levels may increase in myocardial ischaemia. The aim of this study was to evaluate the effect of myocardial ischaemia induced by dobutamine stress echocardiography (DSE) on serum HFABP levels. Methods and results A total of 30 consecutive patients with suspected myocardial ischaemia underwent DSE examination. HFABP levels were measured immediately before and 1 hour after DSE. HFABP rose significantly in individuals in the DSE positive group (1.66 ± 1.18 ng/ml vs 2.65 ± 1.34 ng/ml, P = 0.004), but remained unchanged in the DSE negative group (1.61 ± 0.77 ng/ml vs 1.85 ± 0.76 ng/ml, P = 0.066). Conclusion Serum HFABP levels increased significantly at 1 hour in the presence of ischaemia induced by DSE in patients with stable clinical coronary syndromes. No such increase was evident in the absence of ischaemia.

Cardiac autonomic nervous dysfunction detected by both heart rate variability and heart rate turbulence in prediabetic patients with isolated impaired fasting glucose

Objective: Cardiac autonomic nervous dysfunction (CAND), a severe complication of diabetes, has also been shown to affect prediabetic patients. The role of isolated impaired fasting plasma glucose (IFG), a subtype of prediabetes, is not clear in the pathogenesis of CAND. The aim of this study was to examine the relationship between isolated IFG and cardiac autonomic function using heart rate variability (HRV) and heart rate turbulence (HRT) indices derived from 24-h Holter–electrocardiogram recordings. Methods: This observational, prospective, cross-sectional study examined 400 consecutive subjects divided into three groups according to oral glucose tolerance test results: the control group [Group I, fasting plasma glucose (FPG) <100 mg/dL and normal glucose tolerance, n=193], the isolated IFG group (Group II, FPG ≥100 and <126 mg/dL, n=134), and the isolated impaired glucose tolerance (IGT), both IFG and IGT, or newly diagnosed diabetes’ group (Group III, n=73). Patients with non-sinus rhythm, known diabetes mellitus, coronary artery disease, heart failure, severe valvular disease, or receiving medical therapy that may affect HRV and HRT indices were excluded. Time domain HRV parameters, turbulence onset (TO), turbulence slope (TS), and HRT category were examined. Chi-square, one-way analysis of variance, Kruskal–Wallis H, and Mann–Whitney U tests were used to compare variables where appropriate. The correlation between Holter data and FPG levels was analyzed using the Spearman’s test. Multiple linear regression analysis was performed to identify independent predictors of the HRV and HRT parameters. Results: Median (interquartile range 25–75) FPG levels in Groups I, II, and III were 89 (83/93) mg/dL, 109 (104/116) mg/dL, and 174 (150.5/197) mg/dL, respectively. There were significant differences in HRV and HRT parameters between and among all groups. While HRV parameters and TS decreased from Group I to Group III, TO and HRT category gradually increased. Additionally, FPG level was significantly correlated with SDNN, r=–0.220; SDNN index, r=–0.192; SDANN, r=–0.207; RMSSD, r=–0.228; pNN50, r=–0.226; TO, r=0.354; and TS, r=–0.331 (all p<0.001). Conclusion: CAND, as detected by both HRV and HRT, appear to be present in the isolated IFG subtype of prediabetes.

Successful treatment of massive pulmonary embolism with reteplase

Unexpected and unexplained out-of-hospital cardiac arrests have a poor prognosis. Difficulties encountered during the differential diagnosis phase may delay the administration of specific treatment for treatable and reversible causes of cardiac arrest. Massive pulmonary embolism is a reversible cause of cardiac arrest, but without proper management it has a high mortality rate. Presently described is the case of a 53-year-old female patient with a massive pulmonary embolism.

Renal artery stenting of chronic kidney disease patient with resistant hypertension.

Resistant hypertension is a clinical entity presenting with uncontrolled blood pressure (BP) despite use of 3 or more antihypertensive drugs, including diuretic. Reno vascular hypertension related to renal artery stenosis (RAS) occurs in etiology of hypertension and affects up to 5% of all hypertensive patients (1). Fifty-five-year-old male patient was admitted to our clinic with uncontrolled BP. He was using several antihypertensive drugs, including diuretic. He had history of chronic kidney disease and untreated renal artery stenosis. He had residual amount of 500 mL daily urine output. We wanted to evaluate his residual renal function with diuretic administration. We increased daily urine output up to 1500 mL with furosemide and this encouraged us to pursue renal artery intervention. Renal angiography revealed moderate stenosis of right renal artery and severe stenosis of left renal artery. We implanted a 4.0x15 mm bare metal stent in left renal artery. BP responded immediately after intervention and we were able to discontinue antihypertensive drugs. Daily urine output increased up to 1000 mL without diuretic. Hemodialysis sessions were decreased to 2 days per week. RAS primarily causes significant reduction in renal blood flow and is notable factor in development of progressive kidney failure. Atherosclerotic RAS patients present with persistent and progressive reduction in glomerular filtration rate, treatment resistant severe hypertension, and recurrent episodes of flash pulmonary edema. Pathogenesis of chronic kidney disease progression due to RAS is assumed to be more complex than just arterial narrowing. Different cytokines and chemokines related to stimulation of Anatol J Cardiol 2016; 16: 889-96 Letters to the Editor 894

[A rare complication of percutaneous coronary intervention: aortic pseudoaneurysm].

On gün önce perkütan koroner girişim (PKG) uygulanmış 74 yaşındaki kadın hasta akut koroner sendrom tanısı ile hastaneye yatırılarak subakut stent trombozuna perkütan balon anjiyoplasti yapıldı. İşlemden birkaç saat sonra sırtından sol omzuna yayılan şiddetli künt ağrı tanımlayan hastanın suprasternal ekokardiyografik incelemesinde inen aort proksimalinde düzensiz sınırlı bir genişleme mevcuttu. Çekilen toraks bilgisayarlı tomografide arkus aorta ile inen aort birleşim yerinde 3 cm çapında ve üst duvarında 1 cm kalınlığa ulaşan trombüs materyalinin izlendiği psödoanevrizmatik genişleme görüldü (Şekil A ve B). Psödoanevrizmanın sol subklavya arterine komşuluğu nedeniyle (Şekil C) endovasküler girişime uygun olmadığına karar verilerek hastaya cerrahi onarım önerildi ancak hasta onam vermediği için yapılamadı. Hastane içi dönemde önemli bir kardiyak ve serebrovasküler istenmeyen olay yaşanmadı. Aort psödoanevrizması intima, medya ve adventisya tabakalarının hasarlanması sonucu oluşan trombüsün aort çevresi bağ dokusu tarafından çevrelendiği aort genişlemesidir. Genellikle künt toraks travmalarına ikincil gelişse de yatrojenik nedenleri arasında kateter aracılı tedaviler de yer alır. Rüptür nedeniyle ani ölüm, fistül oluşumu, çevre dokulara bası ve erozyon gibi hayatı tehdit eden olaylara yol açabilir. Anatomik olarak uygunsa endovasküler ya da cerrahi girişim psödoanevrizmanın boyutundan bağımsız olarak her zaman endikedir. Olgumuzun semptomlarının kateterizasyonundan sonra başlaması ve psödoanevrizmanın lokalizasyonu bu durumun PKG sırasında kılavuz tel ya da kateter travmasına ikincil geliştiğini düşündürmektedir. Zeminde var olabilecek azalmış aort esnekliği, aort enfeksiyonları ya da penetran ülserler kateter aracılı travmayı kolaylaştırmış olabilir. 90