Ümit Yaşar Sinan

Relationship Between Increased Serum Resistin Level and Severity of Coronary Artery Disease

Resistin, which is derived from the gene of RSTN, belongs to a family of cysteine-rich secretory proteins called resistin-like molecules (RELMs). Increased serum resistin levels are associated with coronary artery disease (CAD) and the risk of cardiovascular death. Patients (n = 214) with an initial diagnosis of stable angina pectoris, unstable angina pectoris, and myocardial infarction without ST-segment elevation and referred to catheter laboratory for coronary angiography were enrolled in the study. We aimed to investigate the relationship between increased serum resistin level and CAD. The severity of CAD was calculated by the Gensini scoring system. In conclusion, we established a significant correlation between serum resistin levels and CAD (P = .010). Also, serum resistin levels correlated with the Gensini score that represents the severity of CAD angiographically (P = .010).

Pulmonary Artery Sarcoma Masquerading as Chronic Pulmonary Thromboembolism

We describe the case of a 60-year-old woman who presented with pulmonary artery sarcoma, a very rare tumor of the cardiovascular system. Her tumor was initially misdiagnosed as chronic pulmonary thromboembolism, and she underwent pulmonary endarterectomy. Early diagnosis of primary pulmonary artery sarcoma is crucial. That alternative should always be considered before settling on a diagnosis of pulmonary embolism. Suspicion should be aroused by the failure of anticoagulant treatment to alleviate pulmonary perfusion abnormalities and systemic symptoms. Surgical resection of the tumor-preferably by pulmonary endarterectomy, followed by reconstruction as needed-is currently the most promising treatment for pulmonary artery sarcoma.

Relationship between serum endothelin-1 level and spontaneous reperfusion in patients with acute myocardial infarction.

AimSpontaneous reperfusion (SR) was associated with better clinical outcomes and lower incidence of major adverse cardiovascular events. Endothelin-1 (ET-1) is a potent endothelium-derived vasoconstrictor peptide and elevated systemic ET-1 levels predict a poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). We aimed to investigate the relationship between systemic ET-1 plasma levels and SR in a group of STEMI patients treated with a primary percutaneous coronary intervention (PCI). Methods and resultsWe measured ET-1 levels acutely (within the first 6 h) in 33 STEMI patients with SR and 45 STEMI patients with non-SR presenting with their first STEMI who underwent primary PCI. Blood samples for ET-1 plasma level measurement were drawn after vascular puncture before angiography in the catheterization laboratory from the peripheral vein.The mean age of the patients was 56.1±13.3 years in the SR group and 57.4±11.4 years in the non-SR group. The circulating level of ET-1 was considerably higher in the non-SR patients than in the SR patients (0.81±0.2, 1.0±0.3, P=0.004). On multivariable logistic regression analysis, the ET-1 level was the only significant predictor of SR (P=0.01).The receiver operating characteristic curve analysis showed that the ET-1 level at admission is an indicator of SR, with an area under the curve of 0.62. ConclusionThis study shows that in patients admitted with ST-elevation acute myocardial infarction, ET-1 plasma levels are related to angiographic SR before primary PCI.

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

The effect of oxidative stress related with ischemia-reperfusion damage on the pathogenesis of atrial fibrillation developing after coronary artery bypass graft surgery.

OBJECTIVES We aimed to investigate the role of oxidative stress related with ischemia- reperfusion damage on the pathogenesis of atrial fibrillation (AF) developing after coronary artery bypass graft (CABG) surgery. STUDY DESIGN In our prospective, single-center study, 118 patients who underwent elective isolated on-pump CABG surgery were included. Patients were divided into two groups according to the development of postoperative atrial fibrillation (POAF) as Group 1: Patients who developed POAF, and Group 2: Patients who remained in sinus rhythm. In addition to preoperative demographic, laboratory, echocardiographic, intraoperative, and postoperative clinical characteristics, levels of plasma total oxidative status (TOS) after placement and removal of aortic cross clamp (ACC) were compared between the two groups. Predictors of POAF were also investigated by multivariate logistic regression analysis. RESULTS A comparison of preoperative demographic, laboratory, echocardiographic, and postoperative clinical characteristics between the two groups showed that patients in Group 1 were significantly older (65.6±7.20 vs. 59.6±9.07, p<0.001), had a lower hematocrit level (37.5±5.16 vs. 39.7±5.28; p=0.034), and an enlarged left atrium diameter (39±0.45 vs. 3.6±0.48; p=0.006). Changes in plasma TOS levels after placement and removal of ACC were statistically significant in Group 1 [13 (8.6-23), 30 (18.1-47.3); p=0.001 vs. 14 (8.8-22.2), 24 (21.4-42.7); p=0.060]. Length of stay in the intensive care unit [3 (2-14) vs. 2 (1-58); p=0.001] and length of stay in hospital [7 (6-85) vs. 7 (5-58); p=0.001] were prolonged in Group 1. In multivariate logistic regression analysis, aging (odds ratio (OR): 1.088, 95% confidence interval (CI): 1.005-1.177; p=0.036), hematocrit level (OR: 0.718, 95% CI: 0.538-0.958; p=0.025), pump temperature (OR: 1.445, 95% CI: 1.059-1.972; p=0.020), and plasma TOS level (OR: 1.040, 95% CI: 1.020-1.050; p=0.040) were found to be independent predictors of POAF. CONCLUSION Ischemia-reperfusion damage related with ACC placement may be an important factor on the pathogenesis of POAF. Minimizing the oxidative stress occurring intraoperatively should be targeted for preventing mortality and morbidity due to POAF.

Impact of continuation of metformin prior to elective coronary angiography on acute contrast nephropathy in patients with normal or mildly impaired renal functions

Objective: Discontinuation of metformin treatment in patients scheduled for elective coronary angiography (CAG) is controversial because of post-procedural risks including acute contrast-induced nephropathy (CIN) and lactic acidosis (LA). This study aims to discuss the safety of continuing metformin treatment in patients undergoing elective CAG with normal or mildly impaired renal functions. Methods: Our study was designed as a single-centered, randomized, and observational study including 268 patients undergoing elective CAG with an estimated glomerular filtration rate of >60 mL/min/1.73 m2. Of these patients, 134 continued metformin treatment during angiography, whereas 134 discontinued it 24 h before the procedure. CIN was defined as either a 25% relative increase in serum creatinine levels from the baseline or a 0.5 mg/dL increase in the absolute value that measured 48 h after CAG. Logistic regression analysis was performed to identify independent predictors of CIN and LA after CAG. Results: Both groups were comparable in terms of demographics and laboratory values. CIN at 48 h was 8% (11/134) in the metformin continued group and 6% (8/134) in the metformin discontinued group (p=0.265). Patients in neither of the groups developed metformin-induced LA. Based on multiple regression analysis, the ejection fraction [p=0.029, OR: 0.760; 95% CI (0.590–0.970)] and contrast volume [p=0.016, OR: 0.022 95% CI (0.010–0.490)] were independent predictors of CIN. Conclusion: Patients scheduled for elective CAG with normal or mildly impaired renal functions and preserved left ventricular ejection fraction (>40%) may safely continue metformin treatment.

Giant thrombus on apical wall of left ventricle due to HIT syndrome after anterior MI

Heparin-induced thrombocytopenia (HIT) is the most important and the most frequent drug-induced, immune-mediated type of thrombocytopenia. It is associated with significant mortality and morbidity if unrecognized. We describe a patient with a giant thrombus on the apical wall of the left ventricle that occurred due to HIT syndrome after anterior myocardial infarction.ZusammenfassungDie heparininduzierte Thrombozytopenie (HIT) ist die wichtigste und häufigste medikamenteninduzierte immunvermittelte Art der Thrombozytopenie. Sie geht mit einer erheblichen Mortalität und Morbidität einher, wenn sie nicht erkannt wird. Hier wird der Fall eines Patienten vorgestellt, bei dem ein riesiger Thrombus an der Wand der linken Ventrikelspitze infolge eines HIT-Syndroms nach Vorderwandinfarkt auftrat.

Factors predicting long-term mortality in patients with hypertrophic cardiomyopathy.

In this study, we aimed to elucidate the factors affecting long‐term all‐cause mortality in patients with hypertrophic cardiomyopathy (HCM).

A case difficult to diagnose in adults: High sinus venous atrial septal defect

Sinus venous atrial septal defect (SVD) is highly difficult to diagnose because of its location. Below, we report a case of SVD which is misdiagnosed as pulmonary hypertension and anomalous pulmonary venous return. A 57-year-old female patient was referred to congenital disease outpatient clinic of a tertiary center. She was admitted to the hospital with complaints of fatigue and exercise dyspnea which had started a year ago. She had transthoracic echocardiography (TTE) examination done in another hospital which showed dilated right heart chambers and pulmonary hypertension. She underwent transesophageal echocardiography (TEE) examination with the suspicion of atrial septal defect (ASD), but no defect was seen. As her symptoms persisted, we repeated the TTE and TEE examination in our center. TEE revealed 0.6 cm ASD on the upper side of the interatrial septum. All four pulmonary veins were draining into the left atrium. Right heart catheterization (RHC) confirmed the diagnosis. A left-to-right shunt was detected and localized by a significant step-up in blood oxygen saturation found between mid and upper segments of the right atrium. According to our TEE and RHC results, we planned the surgical closure of the defect. Sinus venous ASD is deficiency of the superior portion of atrial septum adjacent to superior vena cava. Diagnosis of SVD is often more difficult than other forms of ASD and may require special imaging such as TEE, magnetic resonance imaging, or computed tomographic scanning. In conclusion, cardiologists must be aware about the possibility of SVD patients who have unexplained exertional dyspnea and fatigue, dilated right atrium and ventricle, pulmonary hypertension, paradoxical embolism, or atrial arrhythmias in their respective populations.

GRACE score also predicts anatomic complexity of coronary artery disease patients presenting with non-STEMI

Acute Coronary Syndromes (ACS) represent the most common cause of death in the western world. We retrospectively screened data of non-STEMI patients admitted to the coronary care unit of a tertiary center between March 2015 and March 2016. GRACE score was calculated and patients were classified into low (1 to 108), intermediate (109 to 140) and high risk (>40) groups according to GRACE categories. SYNTAX scores were also calculated. 201 patients (mean age: 63 ± 12 years, 53.7% female) were admitted with a diagnosis of non-STEMI. The mean GRACE score and SYNTAX score of study population were 105 ± 34.1 and 16.9 ± 12. Based on the GRACE score for in-hospital deaths, the SYNTAX score was 14.2 ± 10.1 in the low-risk group, 16.0 ± 13.4 in the intermediators group, and 24 ± 12.2 in high-risk group (ANOVA p<0.0001). Post-hoc Tukey analysis showed that the high-risk group had a significantly higher SYNTAX score than the low-risk and intermediate risk groups (p<0.0001 vs p=0.003 respectively). There were significant positive correlations between the SYNTAX score and GRACE scores of the study population calculated at admission for in-hospital deaths (r=0.363, p<0.0001). GRACE score can predict complexity of CAD (high risk coronary anatomy). As we can decide to perform early invasive strategy according to GRACE score, we may consider detecting high risk complex coronary anatomy during coronary angiography. So, we may be ready to discuss with heart team about treatment strategy (ad hoc-PCI, multi-vessel PCI or CABG) in patients with high GRACE score. Before giving ADP receptor antagonist, we may consider CABG requirement in these patient population.