Ziya Şimşek

Assessment of regional left ventricular functions by strain and strain rate echocardiography in type II diabetes mellitus patients without microvascular complications

OBJECTIVES We evaluated regional left ventricular myocardial functions by strain (S) and strain rate (Sr) echocardiography in patients with type II diabetes mellitus (DM) without microvascular complications. STUDY DESIGN The study included 40 DM patients (20 women, 20 men; mean age 52.4 ± 7.9 years) without microvascular complications, and 40 healthy controls (20 women, 20 men; mean age 52.8 ± 10.1 years). Left ventricular functions were evaluated by conventional Doppler, tissue Doppler, and S-Sr echocardiography. Longitudinal peak systolic S and Sr were measured from the basal, mid and apical segments of the left ventricle walls. Patients with DM duration of >3 years (n=24) and receiving medical therapy for DM (n=30) were also evaluated. RESULTS Conventional Doppler findings were similar in the patient and control groups. Among tissue Doppler variables, only early diastolic mitral annular velocity (Em) was significantly decreased (10 ± 2.9 vs. 11.4 ± 3.2 cm/sec, p<0.05), and accordingly, mitral inflow E/Em ratio was significantly increased (7.3 ± 2.5 vs. 6.3 ± 2, p<0.05) in patients with DM. The two groups were similar with respect to systolic S and Sr values, except for apical-lateral S, mid-anterior S, basal-anteroseptal S, apical-anterior Sr, and mid-anteroseptal Sr (p<0.05, for all). Patients with DM duration of >3 years and receiving medical therapy showed similar changes as the overall patient group. CONCLUSION The frequency of left ventricular diastolic dysfunction was higher in patients with DM. Irregular distribution of systolic S and Sr indices in the left ventricular segments may indicate that DM leads to heterogeneous myocardial involvement also in the early period.

The Impact of Trimetazidine Treatment on Left Ventricular Functions and Plasma Brain Natriuretic Peptide Levels in Patients with Non-ST Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

Background and Objectives The aim of this study was to investigate the impact of treatment with oral trimetazidine (TMZ) applied before and after percutaneous coronary interventions (PCI) on short-term left ventricular functions and plasma brain natriuretic peptide (BNP) levels in patients with non-ST segment elevation myocardial infarction (NSTEMI) undergoing PCI. Subjects and Methods The study included 45 patients who were undergoing PCI with the diagnosis of NSTEMI. The patients were randomized into two groups. The first group (n=22) of the patients hospitalized with the diagnosis of NSTEMI was given conventional therapy plus 60 mg TMZ just prior to PCI. Treatment with TMZ was continued for one month after the procedure. TMZ treatment was not given to the second group (n=23). Echocardiography images were recorded and plasma BNP levels were measured just prior to the PCI and on the 1st and 30th days after PCI. Results The myocardial performance index (MPI) was greater in the second group (p=0.02). In the comparison of BNP levels, they significantly decreased in both of the groups during the 30-day follow-up period (29.0±8 and 50.6±33, p<0.01 respectively). However, decreasing of BNP levels was higher in the group administered with TMZ. The decrease of left ventriclular end-diastolic volume was observed in all groups at 30 days after intervention, but was higher in the group administered with TMZ (p=0.01). Conclusion Trimetazidine treatment commencing prior to PCI and continued after PCI in patients with NSTEMI provides improvements in MPI, left ventricular end diastolic volume and a decrease in BNP levels.

Efficacy of ivabradin to reduce heart rate prior to coronary CT angiography: comparison with beta-blocker

PURPOSE The objective of our study was to assess the effect of ivabradine on image quality of ECG-gated multidetector computed tomography (MDCT) coronary angiography. MATERIALS AND METHODS Computed tomography coronary angiography (CTCA) was performed on two groups. In Group 1 (n=54), an intravenous beta-blocker was administered to patients with a heart rate >70 beats per minute (bpm) just before CTCA. In Group 2 (n=56), oral ivabradine 5 mg was administered twice a day for three days prior to CTCA examination to patients with a heart rate >70 bpm and contraindication to beta-blockers. Images acquired on two different MDCT scanners were scored in terms of image quality of the coronary artery segments using a 5-point grading scale (Grade 1, unreadable; Grade 5, excellent). RESULTS The mean heart rates during CTCA were 64 ± 6.7 bpm for Group 1 and 59 ± 4.1 bpm for Group 2 (P < 0.05). Mean heart rate reduction was 9 ± 5% and 14 ± 8% for Groups 1 and 2, respectively (P < 0.001). A total of 880 segments were evaluated in 110 patients. When the best reconstruction interval was used, 89.8% and 95.5% of all the coronary segments showed acceptable image quality in Groups 1 and 2, respectively. Acceptable image quality of the middle right coronary artery was obtained in 78.3% of Group 1 and 92.4% of Group 2. These ratios for the other segments were 88.4% for Group 1 and 95.2% for Group 2. CONCLUSION Reduction of heart rates with ivabradine premedication improves the image quality of CTCA. It should be considered as an alternative drug, particularly in patients with contraindications to beta-blockers.

Trial design, statins, atrial fibrillation, and prevention: four horsemen of the apocalypse.

We have read with great interest the article entitled “Efficiency of postoperative statin treatment for preventing new onset postoperative atrial fibrillation in patients undergoing isolated coronary artery bypass grafting: a prospective randomized study” published in the June 2014 issue of The Anatolian Journal of Cardiology by Aydın et al. (1). This article was about the effect of postoperative statin treatment on new onset postoperative atrial fibrillation (POAF) in patients undergoing isolated coronary artery bypass grafting (CABG). The study consisted of 60 consecutive patients who were divided into two groups: those undergoing postoperative statin treatment (n=30) and those not undergoing it (n=30). They concluded that atorvastatin treatment (40 mg), when started in the early postoperative period after isolated CABG, reduces the incidence of new-onset POAF. AF is the most common cardiac arrhythmia after cardiac surgery, which generally occurs in 20%-40% of patients (2). POAF may be multifactorial and involves an interaction between surgical trauma, preexisting atrial pathology, activation of the inflammatory response and increased adrenergic tone (3). POAF generally occurs between days 2 and 4 after surgery, with a peak incidence on the second day (3). Several randomized controlled trials support the use of longer duration statin therapy preoperatively to reduce the incidence and risk of developing AF after elective cardiac surgery (4). In contrast, the authors of the present study (1) preferred to start atorvastatin treatment in the early postoperative period (average of 6 h after the operation). Inflammation has a major role in the pathogenesis of POAF, and the occurrence of anti-inflammatory effects of statins requires approximately 30 days after their initiation (5). In the present study (1), the time between surgery and AF development is similar in both groups. Therefore, a major point of discussion is after how many days or hours after should postoperative statin therapy be started or should be expected to obtain the beneficial effects of statins in a relatively short time interval. More importantly, most patients are often unable to take oral medications shortly after surgery, and there is no intravenous formula for statins. In cardiac surgery, manipulation of the pericardium is strongly associated with the development of POAF. Hence, it would be very useful if Aydın et al. (1) information about the occurrence of acute postoperative pericarditis and the development of AF in both groups. In conclusion, larger randomized studies are required to confirm the possible beneficial effects of statins on AF when administrated postoperatively.

A challenging image during pacemaker implantation

This venographic appearance is compatible with venospasm. Although it is usually known as an arterial phenomenon, severe spasm can be seen in the central veins, as in this case. Venous spasm has been reported during right heart catheterizations and central venous catheter placements for digital subtraction angiography, with an incidence of 2% and 5%, respectively (1). Because of its strongest effect on the venous system, nitroglycerin is a reasonable approach for relieving the spasm. However, venous spasm may not resolve with nitroglycerin. As in our case and in two previously reported cases of central venous spasm during pacemaker implantation, incremental doses of intravenous nitroglycerin failed to relieve the venospasm (2, 3). Venous spasm during pacemaker implantation is a rare clinical entity, with only a few cases reported in the literature (2-4). The exact mechanism of venous spasm remains unknown, but it may be related to the chemical effect of the contrast or a mechanical effect of multiple needle punctures and guidewire placement (2). Paget-Schroetter syndrome is a form of upper extremity deep vein thrombosis that can occur spontaneously or after vigorous exercise. It is also known as effort thrombosis, and the pathogenesis involves extrinsic compression and repetitive injury of the subclavian vein between the first rib and overlying clavicle, particularly during strenuous activities involving arm elevation or exertion (5, 6). Subclavian vein and artery transposition is a very rare anomaly in which the subclavian vein and subclavian artery are switched in position or transposed. In this rare anatomic variation, the usual location of the subclavian artery (cephalad to the subclavian vein) is switched to caudal to the subclavian vein. In such cases, ultrasound imaging is necessary for understanding the anatomic relationship of the artery, vein, clavicle, and lung (7). Lead-induced venous thrombosis is reported in an average of 12% (range 2%-22%) of patients, from several days to 9 years after pacemaker implantation, and only 1% to 3% of patients with upper extremity venous thrombosis develop symptoms (8). In the hospital course and control visit, our patient had no signs or symptoms attributable to venous thrombosis. Indeed, there was no evidence for venous thrombosis on the venography (presence of a collateral vessel, a visible thrombus, and/or long length of the occlusion). Therefore, venous thrombosis is a much less likely possibility (9). This report highlights the importance of using venography after multiple unsuccessful attempts to puncture the subclavian vein and using hydrophilic guidewires in cases of venous spasm with successful cannulation and no good flashback. At the end of the procedure, a venography was performed again and revealed partial reversal of the venospasm (Fig. 3, Video 3). Yavuzer Koza, Ziya Şimşek, Muhammed Hakan Taş, Hüseyin Şenocak Department of Cardiology, Faculty of Medicine, Atatürk University; Erzurum-Turkey

Comparison of the effects of metoprolol or carvedilol on serum gamma-glutamyltransferase and uric acid levels among patients with acute coronary syndrome without ST segment elevation

Objective: Serum gamma-glutamyltransferase (GGT) and uric acid levels measured in patients with acute coronary syndrome without ST segment elevation (NSTEMI) are important in diagnosis and in predicting the prognosis of the disease. There is a limited number of clinical studies investigating the effects of beta-blockers on GGT and uric acid levels in these patients. In our study, we aimed to investigate the effects of beta-blocker therapy on GGT and uric acid levels. Methods: We conducted a randomized, prospective clinical study. Hundred patients with NSTEMI were included in this study, and they were divided into two groups. Fifty patients were administered metoprolol succinate treatment (1 × 50 mg), whereas the remaining 50 patients were administered carvedilol treatment (2 × 12.5 mg). Thereafter, all of the patients underwent coronary angiography. Blood samples were taken at the time of admission, at the 1st month, and 3rd month to detect GGT and uric acid levels. Results: There was no statistically significant difference among the metoprolol or carvedilol groups in terms of the GGT levels measured at the baseline, 1st month, and 3rd month (p=0.904 and p=0.573, respectively). In addition, there was no statistically significant difference among the metoprolol or carvedilol groups in terms of uric acid levels measured at the baseline, 1st month, and 3rd month (p=0.601 and p=0.601, respectively). Conclusion: We found that GGT and uric acid levels did not show any change compared to the baseline values, with metoprolol and carvedilol treatment initiated in the early period in patients with NSTEMI.

Hyponatremia and heart failure: the overlooked piece of the puzzle

Hyponatremia may occur with a high, low, or normal serum osmolality. Pseudohyponatremia is an artifact of measurement as a result of interference between abnormally high concentrations of lipids or proteins and sodium. In pseudohyponatremia, the serum osmolality is usually normal (1). In hypertonic hyponatremia, the serum osmolality is more than 295 mOsm/kg. Hypertonic hyponatremia occurs when the plasma contains an osmotically active substance such as mannitol or excess glucose. The serum Na concentration falls approximately by 1.6 mEq/L for every 100 mg/dL rise in the serum glucose concentration above the normal concentration (1). Hypovolemic hyponatremia is associated with a deficit in serum sodium and total body water. Sodium loss is more prominent than water loss. As sodium deficits can be due to renal or extrarenal losses, urine sodium may be <30 mmol/L or >30 mmol/L, respectively (2). In chronic heart failure, the incidence of hyponatremia is approximately 20–30%, and loop diuretics have less potential for causing hyponatremia than thiazides (2). In our patient, we considered hypotonic hyponatremia (effective serum osmolarity<275 mOsm/kg, urine sodium concentration<30 mmol/L, and high urine osmolality>1.003) as a consequence of water retention. Despite fluid restriction, ultrafiltration, and intravenous diuretic therapy, hyponatremia did not resolve. After reviewing the relevant literature, we did not find any possible offending drug other than thiazide or loop diuretics that could be associated with hyponatremia. However, according to 4766 reports from the FDA and social media, 4619 people reported having side effects when taking rivaroxaban. Among them, 8 (0.17%) had hyponatremia (3). As in our case, hyponatremia was found among those who take rivaroxaban, especially for those who are females, more than 60 years old, have been taking the drug for <1 month, also take medication hydrochlorothiazide, and have atrial fibrillation/flutter. After the cessation of rivaroxaban, serum sodium levels continuously increased, and the patient was discharged from the hospital with a serum sodium level of 136 mmol/L. At the two-week followup, her serum sodium level was 138 mmol/L.

OP-229 Right Ventricular Systolic and Diastolic Functions Using Two-Dimensional Speckle Tracking Echocardiography in Patients with Irritable Bowel Syndrome

A B S T R A C T S group 3. Mean ages of group 1 and 2 were significantly higher than mean age of group 3 (p<0.01). There were no statistically significant differences between group 1 and group 2 in terms of RV functions. In group 1, IVA and RVAXC values were significantly lower than group 3 (p<0.001). In group 1, IRTRV value was significantly higher than group 3 (p<0.001). RVEF, RVAC and IVC values were significantly lower in groups 1 and 2 than group 3 (p<0.001). TAFS, RVMWFS, RVOTFS values were significantly lower in groups 1 and 2 than group 3 (p<0.001). After evaluating all groups, a positive significant correlation was found between RV fractional shortening rates measured with anatomic M-mode echocardiography, and RV ejection fraction. Positive correlations were observed between TAFS and RVEF (r: 0.58, p<0.01); RMWFS and RVEF (r: 0,67, p<0.01); RVOTFS and RVEF (r:0.50, p<0.01). Also, a positive correlation was observed between TAFS, RVOTS, RVMWFS and RVAC. Conclusion: Anatomic M-mode echocardiography can be used in cases of poor imaging quality. RVOTFS, TAFS and RVMWFS showed a significant positive correlation with RV functions of RVEF and RVAC. Based on this result, we found that RV fractional shortening has an important role in assessing RV functions.

PP-036 CORONARY-TO-PULMONARY ARTERY FISTULA AND CONCOMITANT ACUTE CORONARY SYNDROME: TWO CASES

Corresponding Author: Dr. Selami Demirelli Email: demirelli23@yahoo.com Received: January 7, 2014 | Accepted: January 24, 2014 | Published Online: February 10, 2014 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (creativecommons.org/licenses/by/3.0) Conflict of interest: None declared | Source of funding: Nil | DOI: http://dx.doi.org/10.17659/01.2014.0014 Introduction