Yuksel Cavusoglu

The use of levosimendan in comparison and in combination with dobutamine in the treatment of decompensated heart failure

Levosimendan is a new calcium sensitizer with inotropic and vasodilatory actions mediated by the sensitization of contractile proteins to calcium, opening of potassium channels and inhibition of phosphodiesterase-3. Its alternative mechanisms of action to those of other traditional inotropes provide a new approach in the management of decompensated heart failure. In contrast to dobutamine, levosimendan does not increase myocardial oxygen demand and, therefore, it is thought to have a lower potential to induce increases in myocardial ischemia and cardiac arrhythmias. The commonly used inotropic agent dobutamine increases myocardial contractility at the expense of increased myocardial oxygen consumption and, therefore, it can result in poor outcomes. Although dobutamine may also have favorable hemodynamic and symptomatic effects, levosimendan has been shown to be superior to dobutamine in increasing cardiac output and decreasing pulmonary capillary wedge pressure in patients with decompensated heart failure. In the presence of concomitant β-blocker therapy, these favorable effects were present or even more pronounced during treatment with levosimendan, but not dobutamine. However, the mortality benefit of levosimendan observed in earlier trials has not been confirmed in recent, larger clinical trials. A distinct advantage of levosimendan over dobutamine is its prolonged hemodynamic effects, which last for up to 7 – 9 days. There are more data on the safety of levosimendan in ischemic patients than with any other inotropic drug and, therefore, levosimendan seems to be safe and effective in patients with ischemic heart disease when used at the recommended doses. Despite advances in heart failure therapy, many patients experience clinical deterioration, or do not respond to a single inotropic drug. Increasing evidence suggests the use of levosimendan in combination with dobutamine in patients with decompensated heart failure that is refractory to dobutamine alone.

Heart and brain interaction in patients with heart failure: overview and proposal for a taxonomy. A position paper from the Study Group on Heart and Brain Interaction of the Heart Failure Association

Heart failure (HF) is a complex clinical syndrome with multiple interactions between the failing myocardium and cerebral (dys‐)functions. Bi‐directional feedback interactions between the heart and the brain are inherent in the pathophysiology of HF: (i) the impaired cardiac function affects cerebral structure and functional capacity, and (ii) neuronal signals impact on the cardiovascular continuum. These interactions contribute to the symptomatic presentation of HF patients and affect many co‐morbidities of HF. Moreover, neuro‐cardiac feedback signals significantly promote aggravation and further progression of HF and are causal in the poor prognosis of HF. The diversity and complexity of heart and brain interactions make it difficult to develop a comprehensive overview. In this paper a systematic approach is proposed to develop a comprehensive atlas of related conditions, signals and disease mechanisms of the interactions between the heart and the brain in HF. The proposed taxonomy is based on pathophysiological principles. Impaired perfusion of the brain may represent one major category, with acute (cardio‐embolic) or chronic (haemodynamic failure) low perfusion being sub‐categories with mostly different consequences (i.e. ischaemic stroke or cognitive impairment, respectively). Further categories include impairment of higher cortical function (mood, cognition), of brain stem function (sympathetic over‐activation, neuro‐cardiac reflexes). Treatment‐related interactions could be categorized as medical, interventional and device‐related interactions. Also interactions due to specific diseases are categorized. A methodical approach to categorize the interdependency of heart and brain may help to integrate individual research areas into an overall picture.

Importance of Initiation Pattern of Polymorphic Ventricular Tachycardia in Patients with Implantable Cardioverter Defibrillators

Background: Stored intracardiac electrograms (ICEGs) are helpful in understanding the initiation mechanisms of sustained ventricular arrhythmias and in determining the appropriateness of the therapy delivered by implantable cardioverter defibrillators (ICDs).

Widespread thrombosis associated with recurrent intracardiac masses in a patient with Behçet's disease.

Behcet’s disease (BD) is a relapsing chronic inflammatory disease of unknown etiology. BD was initially characterized by a triad of recurrent oral aphtous ulcerations, genital ulcerations and uveitis, but it is now more commonly recognized to be a multi-system disease concomitant with vasculitis as its main pathological finding [1]. Although vascularmanifestations, particularly venous thrombosis, arteritis, and aneurysm formations, are not uncommon, a direct cardiac involvement is to be determined only rarely. We herein describe a patient with BD who developed recurrent operated intracardiac thrombi associated with inferior vena cava thrombosis, pulmonary arterial thrombosis, renal vein thrombosis and Budd–Chiari syndrome.

Mode of onset of polymorphic ventricular tachycardia in acute myocardial infarction

BACKGROUNDnPolymorphic ventricular tachycardia (PVT) can occur during acute myocardial infarction (MI). In the past, studies investigated the initiation pattern of ventricular tachycardias in different patient populations; however, the mode of onset of PVT in acute MI patients has not been investigated previously.nnnOBJECTIVEnTo retrospectively investigate the electrophysiological features of PVT with different initiation patterns in acute MI patients to assess whether there is a relationship of the initiation patterns of PVT with clinical and electrophysiological characteristics.nnnMETHODSnSixty-two rhythm strips defined as PVT from 53 patients (mean [± SD] age 63±8 years) with acute ST elevation MI were analyzed. All patients were monitored while they were hospitalized in the coronary care unit, and the electrocardiogram strips were obtained from continuous monitoring. PVT was defined as sudden-onset tachycardia if it was not preceded by ventricular ectopic beats. PVT that was preceded by single or multiple ectopic beats was defined as nonsudden-onset tachycardia.nnnRESULTSnNonsudden-onset episodes were more common than suddenonset episodes (40 episodes [64.5%] versus 22 episodes [35.5%]). In the nonsudden-onset group, 25 episodes (62.5%) were initiated after a single ectopic beat, while 15 episodes (37.5%) were initiated after multiple complexes. The mean (± SD) left ventricular ejection fraction of patients with nonsudden-onset PVT was decreased (53±6% versus 65±7%, P<0.01). Nonsudden-onset tachycardias had lower coupling intervals than suddenonset tachycardias. Similarly, the PVT cycle length was shorter in the presence of nonsudden-onset initiation. When nonsudden-onset PVT episodes were further subclassified based on the morphology of the first beat of tachycardia, 26 PVTs (65%) had a first beat of tachycardia similar to the subsequent PVT beats and 14 (35%) did not.nnnCONCLUSIONSnThese results demonstrate that PVT is often preceded by ventricular ectopy in acute MI patients. Nonsudden-onset PVT is usually characterized by a lower coupling interval, shorter PVT cycle length and an associated lower ejection fraction.

Diagnosis and management of acute heart failure.

Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an ‘aged’ population. As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department, intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.

Atrial Fibrillation after Percutaneous Coronary Intervention: Predictive Importance of Clinical, Angiographic Features and P-Wave Dispersion

Atrial fibrillation (AF) may occur during or after percutaneous coronary interventions (PCI). The purpose of the study was to determine the clinical, angiographic and electrophysiological predictors of AF after PCI. 225 patients undergoing PCI (mean age of 65 ± 11 years) who had sinus rhythm (SR) before balloon inflation were taken to study. Of these 22 developed AF in catheterization laboratory after balloon inflation or in 24 h following PCI (AF group), 203 did not (SR group). The patients in AF group were older (67 ± 9 vs. 63 ± 8 years, p < 0.05) and their ventricular ejection fraction was lower than SR group (56 ± 5 vs. 45 ± 7%, p < 0.05). The P-wave dispersion was significantly higher in AF group than SR group (53 ± 8 vs. 29 ± 10 ms, p < 0.001). For the patients with ST elevation myocardial infarction, the time from the onset of symptoms to balloon inflation was 3.7 ± 1.7 h in SR group. It was longer in AF group (4.1 ± 1.8 h, p < 0.05). TIMI perfusion grades 2 and 3 were achieved in 23 of 27 patients in SR group, and 5 of 8 patients in AF group. Multivessel disease was documented in 93 of the patients in SR group, and 12 in AF group. Clinical reperfusion was thought to be established in 20 in SR group, and 4 in AF group. In conclusion, our results show the importance of clinical factors, angiographic results and P-wave analysis in prediction of AF following PCI.

Clinical importance of the initiation pattern of monomorphic ventricular tachycardia

We investigated the clinical and electrophysiological features of monomorphic ventricular tachycardia (MVT) with different initiation patterns in patients with implantable cardioverter defibrillator to assess whether there is a relationship between the initiation patterns of sustained MVT and clinical characteristics, and the efficacy of antiarrhythmic and electrical therapy. Fifty-five stored IECGs in twenty-two patients with MVT were evaluated. All MVT episodes were classified as initiating with ventricular premature beats (non-sudden onset MVT) or without ventricular ectopy preceding tachycardia (sudden onset MVT). Non-sudden onset MVT was characterized by shorter tachycardia cycle length (CL) and required higher shock energy for termination. Sudden onset MVT was precipitated by shortening of the sinus CL before tachycardia and was more common with relatively better preserved systolic function.

Influence of influenza vaccination on recurrent hospitalization in patients with heart failure

BackgroundThe current study aimed to evaluate the influence of regular annual influenza vaccinations on cardiovascular (CV) death and heart failure-related hospitalizations (HFrH) in stable outpatients with heart failure with reduced ejection fraction.MethodsThe Turkish research team-HF (TREAT-HF) is a network undertaking multicenter, observational cohort studies in HF. This study is a subgroup analysis of TREAT-HF outpatient cohorts who completed a questionnaire on influenza vaccination status and for whom follow-up data were available. A total of 656 patients with available follow-up data for CV death and HFrH including recurrent hospitalization were included in the study. Patients were classified into two groups: those who received regular influenza vaccination (40xa0%) and those who did not receive vaccination.ResultsDuring a mean follow-up of 15xa0±6xa0months, 113 (18xa0%) patients had CV death and 471 (72xa0%) patients had at least one HFrH. The CV death rate was similar in both groups of patients (16 vs. 19xa0%, p = 0.37), whereas, HFrH and recurrent HFrH were significantly less frequently encountered in patients who received regular influenza vaccination than in those who did not receive vaccination (43 vs. 92xa0% and 16 vs. 66xa0%, pxa0< 0.001, respectively). In a multivariate Cox proportional hazards model – in addition to a few clinical factors – vaccination status (HRxa0= 0.30, 95xa0% CI = 0.17–0.51, pxa0< 0.001) and graduation from university (HRxa0= 0.35, 95xa0% CI = 0.17–0.72, pxa0= 0.004) remained independently associated with the risk of recurrent HFrH.ConclusionRegular influenza vaccination does not influence CV deaths; however, it decreases HFrH including recurrent episodes of HFrH in outpatients with heart failure with reduced ejection fraction.ZusammenfassungHintergrundDie aktuelle Studie zielte darauf ab, den Einfluss regelmäßiger Grippeimpfungen auf den Tod aus kardiovaskulärer Ursache und Hospitalisierungen wegen Herzinsuffizienz (HFrH) bei stabilen ambulanten Patienten mit Herzinsuffizienz („heart failure“, HF) und verminderter Ejektionsfraktion zu untersuchen.MethodenDas türkische Wissenschaftlerteam HF (TREAT-HF) stellt ein Netzwerk dar, das multizentrische Beobachtungs-Kohorten-Studien bei HF durchführt. Die vorliegende Studie besteht aus einer Subgruppenanalyse von ambulanten Kohorten des TREAT-HF, die einen Fragebogen zum Grippeimpfstatus ausfüllten und bei denen Nachbeobachtungsdaten verfügbar waren. Insgesamt wurden 656 Patienten mit verfügbaren Follow-up-Daten zum Tod aus kardiovaskulärer Ursache und HFrH einschließlich wiederkehrender Hospitalisierung in die Studie eingeschlossen. Die Patienten wurden auf 2xa0Gruppen aufgeteilt: jene, die regelmäßig eine Grippeimpfung erhielten (40xa0%), und jene, die keine Impfung bekamen.ErgebnisseWährend einer durchschnittlichen Nachbeobachtung von 15xa0±6xa0Monaten kam es bei 113 (18xa0%) Patienten zum kardiovaskulär bedingten Tod und bei 471 (72xa0%) Patienten zu mindestens einer HFrH. Die Todesrate aus kardiovaskulärer Ursache war in beiden Patientengruppen ähnlich (16 vs. 19xa0%; pxa0= 0,37), während HFrH und wiederkehrende HFrH bei Patienten, die eine regelmäßige Grippeimpfung erhielten, signifikant seltener waren als bei jenen, die keine Impfung erhielten (43 vs. 92xa0% bzw. 16 vs. 66xa0%; pxa0< 0,001). In einem multivariaten Cox-Proportional-Hazards-Modell – zusätzlich zu einigen wenigen klinischen Faktoren – blieben der Impfstatus (HRxa0= 0,30; 95u202f%-KI = 0,17–0,51; pxa0< 0,001) und ein Universitätsabschluss (HRxa0= 0,35; 95u202f%-KI = 0,17–0,72; pxa0= 0,004) unabhängig voneinander mit dem Risiko wiederkehrender HFrH assoziiert.SchlussfolgerungEine regelmäßige Grippeimpfung hat keinen Einfluss auf den Tod aus kardiovaskulärer Ursache, senkt aber die HFrH einschließlich wiederkehrender Episoden von HFrH bei ambulanten Patienten mit Herzinsuffizienz und verminderter Ejektionsfraktion.

Lymphocytopenia is associated with poor NYHA functional class in chronic heart failure patients with reduced ejection fraction

OBJECTIVEnIn heart failure (HF) patients, functional capacity has been demonstrated to be a marker of poor prognosis, independent of left ventricular ejection fraction (EF). Lymphocyte count is currently recognized in certain risk stratification scores for chronic HF, and severe HF is associated with lymphocytopenia. However, no data exists on the association between lymphocyte count and functional capacity in patients with stable HF. This study aimed to assess the relationship between lymphocyte count and New York Heart Association (NYHA) functional capacity in systolic HF outpatients.nnnMETHODSnThe Turkish Research Team-HF (TREAT-HF) is a network which undertakes multi-center observational studies in HF. Data on 392 HF reduced ejection fraction (HFREF) patients from 8 HF centers are presented here. The patients were divided into two groups and compared: Group 1 comprised stable HFREF patients with mild symptoms (NYHA Class I-II), while Group 2 consisted of patients with NYHA Class III-IV symptoms.nnnRESULTSnPatient mean age was 60±14 years. Lymphocyte count was lower in patients with NYHA functional classes III and IV than in patients with NYHA functional classes I and II, (0.9 [0.6-1.5]x1000 versus 1.5 [0.7-2.2]x1000, p<0.001). In multivariate logistic regression analysis, lymphocyte count (OR: 0.602, 95% CI: 0.375-0.967, p=0.036), advanced age, male gender, presence of hypertension, EF, left atrium size, systolic pulmonary artery pressure, neutrophil and basophil counts, creatinine level, and diuretic usage were associated with poor NYHA functional class in systolic HF outpatients.nnnCONCLUSIONnThe present study demonstrated that in stable HFREF outpatients, lymphocytopenia was strongly associated with poor NYHA function, independent of coronary heart disease risk factors.