Tuna Tezel

Echocardiographic prediction of long-term response to biventricular pacemaker in severe heart failure

Biventricular pacing substantially improves LV systolic function and symptom status in some patients with dilated cardiomyopathy.

The outcome of primary percutaneous coronary intervention for stent thrombosis causing ST-elevation myocardial infarction.

BACKGROUND There are very few scientific data about the effectiveness of primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) due to stent thrombosis (ST). The purpose of the present study is to investigate the efficacy and outcome of primary PCI for STEMI due to ST in the largest consecutive patient population with ST reported to date. METHODS A total of 2,644 consecutive STEMI patients undergoing primary PCI were retrospectively enrolled into the present study. The primary end point of this study was successful angiographic reperfusion defined as postprocedural Thrombolysis In Myocardial Infarction grade III flow. The secondary end points were cardiovascular death and reinfarction. RESULTS Stent thrombosis was the cause of STEMI in 118 patients (4.4%). In patients with ST, angiographic success (postprocedural Thrombolysis In Myocardial Infarction grade III flow) was worse than in patients with de novo STEMI (76.3% vs 84.8%, P = .01). Patients with ST had significantly higher incidence of in-hospital cardiovascular mortality than patients with de novo STEMI (10.2% vs 5.3%, P = .02). In-hospital reinfarction rate was similar in both groups. In addition, long-term (mean 22 months) cardiovascular mortality and reinfarction rates were significantly higher in patients with ST compared with those without (17.4% vs 10.5%, P = .02 and 15.6% vs 9.5%, P = .03, respectively). CONCLUSIONS Primary PCI for treatment of ST is less effective, and these patients are at increased risk for in-hospital and long-term mortality compared with patients undergoing primary PCI due to de novo STEMI.

A case of coronary spasm induced by 5-fluorouracil.

Cardiotoxicity is an uncommon adverse effect of 5-fluorouracil (5-FU). Coronary artery spasm has been postulated to be involved in the mechanism of this incident. Patients may present with angina, myocardial infarction, arrhythmias and/or even sudden death.When the drug is readministered, there is a high risk of relapse. The underlying mechanisms of cardiotoxicity are not yet fully understood, although coronary vasospasm may be responsible.We report one woman receiving 5-fluorouracil therapy with typical chest pain and electrocardiographic changes consistent with acute coronary syndrome. A resolving pain and normalisation of ECG changes with nitrate therapy and normal coronary arteries indicate that this incident was about a coronary spasm caused by 5-FU.

Comparison of outcomes in young versus nonyoung patients with ST elevation myocardial infarction treated by primary angioplasty.

ObjectivesWe sought to determine in-hospital and intermediate-term outcomes of primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) in young adults. MethodsWe reviewed 2424 consecutive patients treated with primary angioplasty for acute MI; 465 were aged 45 or less (young group) and 1959 were 46–74 years of age (nonyoung group). Clinical characteristics, in-hospital and intermediate-term outcomes of primary PCI were analyzed. ResultsCompared with nonyoung patients, the young patients had significantly lower in-hospital and intermediate-term mortality (for in-hospital mortaliy: 5.4 vs. 1.2%, P<0.001; for intermediate-term mortality: 5 vs. 1.3%, P<0.001). By multivariate Cox regression analysis in all 2424 patients; cardiogenic shock, diabetes mellitus, anterior MI and unsuccessful procedure were independent predictors of both in-hospital and intermediate-term mortality whereas age [odds ratio (OR): 1.07, P<0.001], female sex (OR: 1.88, P = 0.04), MI history (OR: 3.05, P = 0.001) and multivessel disease (OR: 2.15, P = 0.01) were independent predictors of only intermediate-term mortality. The young group had lower unsuccessful procedure rates of primary PCI for STEMI (4.9 vs. 10.1%, P = 0.001). ConclusionThese results suggest that young adults who underwent primary PCI have favorable in-hospital and intermediate-term outcomes. Moreover, primary PCI for young adults with STEMI is safer, more feasible and effective than for a relatively older population.

The effects of hormonal therapy on aortic stiffness and left ventricular diastolic function.

Objective — The main objective of this study is to investigate the effects of oestrogen replacement therapy (ERT) and hormone replacement therapy (HRT) on aortic stiffness and on the left ventricular diastolic function, including tissue Doppler. Methods and results — The two study groups were composed of 20 postmenopausal women having HRT and 22 postmenopausal women having ERT. Each group was evaluated for aortic elasticity properties and the left ventricular diastolic function at both the pre-treatment stage and after 12 weeks of hormonal therapy.There was a significant improvement in beta index (5.2±2.5 vs. 3.2±2.2, p = 0.001), distensibility (5.2±3.7 vs. 6.1±4.1 cm2.dyn-1.10-3, p = 0.036) and mitral E/Em ratio (7.44±3.25 vs. 5.75±.2.34, p = 0.004) with ERT. HRT was observed to improve aortic elasticity properties (for strain 10.7±4.7 vs. 12.8±7.6%, for beta index 4.9±2.1 vs. 3.39±2.4 and for distensibility 4.6±2.1 vs. 5.69±4.1 cm2.dyn-1.10-3) and the mitral E/Em ratio (7.61±3.31 vs. 5.81±2.31, p = 0.003). Conclusion — Both ERT and HRT have an improving effect on aortic elasticity properties, as well as on the diastolic function.

Aortic stiffness in patients with cardiac syndrome X.

Aim — Recently, the close relationship between aortic stiffness and cardiovascular mortality has aroused the interest of investigators in carrying out studies related to aortic stiffness.This study aims to investigate the aortic stiffness parameters in patients with cardiac syndrome X, a disorder that is believed to be a generalized disturbance of the vasodilator function of small arteries. Material and methods — 18 patients with typical chest pain and angiographically normal coronary arteries associated with a positive exercise test were included in the study. The control group consisted of 27 patients with angiographically normal coronary arteries and no ischaemia on exercise testing. Antianginal medication was withheld 4 weeks before the study and transthoracic echocardiography was performed using a Hewlett-Packard Sonos 1500 instrument with a 2.5 MHz phased array transducer. Ascending aorta diameters were measured on the M-mode tracing at a level 3 cm above the aortic valve. Diameter change, pulse pressure, aortic strain and distensibility were measured as aortic stiffness parameters. Results —The aortic diameter change was less in the syndrome X group than in the control group (0.15±0.04 cm/m2 vs. 0.28±0.12 cm/m2, p<0.001). Likewise, aortic strain (9±3% vs. 18±8%, p<0.001) and distensibility (4.01±1.71 cm2.dyn-1.10-3 vs. 9.95±5.08 cm2.dyn-1.10-3, p<0.001) was significantly lower in the syndrome X group than in the control group. Conclusion—The deterioration in aortic elasticity properties in patients with cardiac syndrome X suggests that this disease may be a more generalized disturbance of the vasculature.

Double-orifice mitral valve associated with nonisolated left ventricular noncompaction: A case report

Double-orifice mitral valve is a rare congenital anomaly. Although it is more frequently associated with other cardiac abnormalities, it may occur as an isolated lesion. There are 2 forms of myocardial noncompaction: isolated and nonisolated myocardial noncompaction. Nonisolated myocardial noncompactions are occasionally reported postnatally in association with congenital heart anomalies such as ventricular septal defect, pulmonic stenosis, and atrial septal defect. To our knowledge, this is the first case presentation reporting a double-orifice mitral valve associated with nonisolated myocardial noncompaction.

Patients with anemia on admission who have undergone primary angioplasty for ST elevation myocardial infarction: in-hospital and long-term clinical outcomes.

ObjectiveWe investigated the in-hospital and long-term follow-up (mean 21 months) results of patients with and without anemia on admission and who have undergone primary angioplasty for ST elevation myocardial infarction (STEMI). Study designA total of 2509 patients (616 patients with anemia on admission, 1893 patients without anemia on admission), who were treated with primary angioplasty due to STEMI, were included in this study. Demographics and basic clinical features of the patients, outcomes of the primary angioplasty procedures, and clinical course of the patients during and a mean period of 21-month follow-up after hospitalization were retrospectively evaluated. All the parameters were compared between anemic and nonanemic groups. ResultsThe mean age of the patients in anemic group was found to be higher than nonanemic group (61.5±11.4 vs. 54.8±11.4, P<0.001). The rates of death, major cardiac events, and severe cardiac insufficiency were significantly higher in anemic patients during hospitalization period. Moreover, frequency of death was also higher in anemic patients when compared with the nonanemic ones after a mean follow-up period of 21 months (P<0.001). Anemia on admission is an independent predictive factor for mortality in patients with STEMI who were treated with primary angioplasty (odds ratio: 2.2; 95% confidence interval: 1.2–4.0; P<0.009). ConclusionPatients with anemia on admission initially have high-risk profiles regarding their worse clinical outcomes during and 21 months after hospitalization. In accordance with the suggestion of the evidence-based medicine we conclude that etiology of anemia should be meticulously investigated and the oxygenization of the tissue should be provided with the appropriate treatment.

Assessment of the effects of various maneuvers on both atrial pressure changes

The aim of the present study was to determine which maneuver causes the greatest pressure difference between both atria by measuring right and left atrial pressures simultaneously after certain maneuvers. Thirty-two coronary care unit patients, whom a Swan-Ganz catheter was inserted because of acute left ventricular dysfunction, hypotension, sinus tachycardia with unknown cause, were included in this study. The basal values of peak right atrium (RA) pressure and corresponding pulmonary capillary wedge pressure (PCWP) were measured via two separated transducers. Patients were tutored with several trials to perform breath holding, successive three strong coughs, Valsalva maneuver, 20 degrees head down, respectively. In the end of these maneuvers, the peak RA pressure and corresponding PCWP were measured simultaneously. All maneuvers caused an increase in RA pressure. The highest peak RA pressure was obtained by means of the Valsalva maneuver (7.6 +/- 5 versus 20.4 +/- 7.6 mmHg before and after Valsalva, respectively; P<0.001). PCWP (18.8 +/- 5.9 mmHg) increased only with coughing (21.2 +/- 6.7 mmHg, P<0.01) and 20 degrees head down maneuver (20 +/- 5.7 mmHg, P<0.05). The highest increase in pressure gradient between peak RA pressure and corresponding PCWP was observed during Valsalva maneuver (-11 +/- 6.6 vs. 2.3 +/- 5.9 mmHg, P<0.001). The lowest increase was obtained in 20 degrees head down maneuver (-11 +/- 6.6 vs. -8.5 +/- 5.8 mmHg, P<0.001). When measuring the pressure of both atria invasively and simultaneously, Valsalva maneuver was the most effective maneuver consistent with pressure difference in favour of RA among all the other maneuvers.

Prediction of cardiovascular mortality in patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention.

ObjectivesWe analyzed a large patient group to develop a clinical risk score that could be applied to patients after primary percutaneous coronary intervention (PCI). MethodsWe reviewed 2529 consecutive patients treated with primary PCI for ST-elevation myocardial infarction between 2003 and 2008. All clinical, angiographic and follow-up data were retrospectively collected. Independent predictors of in-hospital cardiovascular mortality were determined by multivariate Cox regression analysis in all study patients. ResultsFive variables (Killip class 2/3, unsuccessful procedure, contrast-induced nephropathy, diabetes mellitus, and age >70 years) were selected from the initial multivariate model. Each of them was weighted with 1 point according to their respective odds ratio for in-hospital mortality and then total risk score was calculated for each patient with a range of 0–5 points. For simplicity, four strata of risk were defined (low risk, score 0; intermediate risk, score 1; high risk, score 2 and very high risk, score ≥3). Each risk strata had a strong association with in-hospital cardiovascular mortality (P<0.001 for trend). Moreover, among survivors after an in-hospital period, our risk score continued to be a powerful predictor of long-term mortality (P<0.001 for trend). ConclusionIn patients treated with primary PCI, a risk score, which was developed from five risk factors readily available after intervention, may be useful to predict in-hospital and long-term cardiovascular mortality.