Usefullness of peak mitral regurgitation velocity to left ventricular outflow tract time velocity integral ratio as a new prognostic marker for one year and long term mortality in failing heart

Background and aim

Systemic vascular resistance (SVR) is useful for risk estimation and therapy guidance in HF. It has been showed that the ratio of peak mitral regurgitation velocity (MRV) to left ventricular outflow tract velocity-time integral (LVOT VTI) correlated positively with SVR. We aimed to assess the association of MRV/LVOT VTI ratio with established prognostic markers and its prognostic role for predicting one year and long term composite end-points in patients with HF and reduced ejection fraction (HFrEF).

Material and methods

We prospectively enrolled a total of 72 patients with HFrEF and 10 control subjects. Patients were followed up patients for median 40.5 months. Primary composite endpoint (CEP) was defined as any of these outcomes including requiring mechanical circulatory support, cardiac transplantation and all-cause mortality.

Results

CEP(+) patients had higher MRV/LVOT VTI ratio than others (0.48±0.15 vs. 0.39±0.18 p=0.012). MRV/LVOT VTI ratio was positively correlated with functional status (β=0.539, p=0<001), serum BNP level (β=0.479, p<0.001),troponin I (β=0.415, p<0.001), and Uric acid level (β=0.235 p=0.018) and negatively correlated with SEATTLE score derived life expectancy (β=−0.248, p=0.032). Adjusted with other parameters, every 0.1 increase in MRV/LVOT VTI ratio increased the one-year CEP risk by 27% and long-term CEP risk by 24.6%. In Kaplan Meier analysis, patients with MRV/LVOTVTI ratio ≥0.39 had more long-term CEP compared to others.

Conclusion

MRV/LVOT VTI ratio seemed to be useful predictor of poor prognosis associated with other established HF prognostic markers.

Figure 1

Funding Acknowledgement

Type of funding source: None

Coronary sinus diameter to inferior vena cava diameter ratio in the diagnosis of cardiac tamponade: a novel approach

Background and aim

Coronary sinus (CS) as an intrapericardial, low-pressure, thin-walled structure can be easily compressed in cardiac tamponade. Whereas, inferior vena cava (IVC) is an extrapericardial structure which dilates in tamponade as opposed to the response of CS. The inverse relationship between these two venous structures may augment their role in the evaluation of tamponade imaging. Therefore, we assessed the usefullness of computerized tomographic measures of CS diameter, and also CS to IVC ratio (CS/IVC) to predict tamponade in clinically stable patients with large pericardial effusion.

Materials and methods

66 clinically stable patients who had large pericardial effusions, were included to the study. CS diameter was measured from the point at 1 cm proximal to the CS ostium11. IVC diameter was measured from the segment between its right atrial orifice and hepatic vein.

Results

Patients with tamponade had 40% smaller CS diameter (5.3±1.8 vs 8.8±2.6 mm p<0.001) and 35% lower CS/IVC ratio (20.7±5.5 vs 34.7±10.5% p<0.001).After adjusting with other parameters, only either CS diameter or CS/IVC ratio predicted tamponade respectively. (Nagelkerke r square value for CS diameter was 53.7% and 72.1% for CS/IVC ratio). 1 mm increase in CS diameter and 1% increase in CS/IVC ratio were associated with an increased odds ratio of 59% and 39% in predicting tamponade, respectively (p value <0.001).In ROC analysis, a cut of value of 6.85 mm for CS diameter, had 82.6% sensitivity and 83.7% specificity for predicting cardiac tamponade (Area under the curve 0.879, p<0.001). Additionally, a cut of value of 27% for CS / IVC ratio had 87.0% sensitivity and 86.0% specificity for predicting cardiac tamponade (Area under the curve 0.945, p<0.001).

Conclusion

The tomographic measures of both the CS diameter and the CS/IVC ratio predicted tamponade in clinically stable patients with large pericardial effusion. Compared with CS diameter, CS/IVC ratio seemed to be a more powerful predictor of tamponade

Figure 1

Funding Acknowledgement

Type of funding source: None

Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients

BACKGROUND

The association of epicardial adipose tissue (EAT) with coronary artery disease has been shown in previous studies. Furthermore, the relationship between EAT and acute coronary syndrome was studied recently. Herein, we investigated the relationship between EAT thickness and the thrombolysis in myocardial infarction (TIMI) risk score for non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris (USAP).

PATIENTS AND METHODS

The study included 144 patients with NSTEMI/USAP. The study population was divided into two subgroups according to TIMI risk scores as group I (≤ 4, n = 86) and group II (> 4, n = 58). Stepwise multivariable logistic regression analysis was used to assess the independent association of clinical parameters with TIMI risk score.

RESULTS

EAT thickness was higher in group II than in group I (8.2 ± 2.1 vs. 6.2 ± 2.2, p < 0.001). Moreover, patients in group II had higher rates of multivessel disease and Gensini score (p < 0.001). In univariate linear regression analysis, EAT was positively correlated with TIMI risk score and Gensini score. Multivariate regression analysis showed that EAT thickness (OR: 1.56, 95 % CI: 1.17-2.08, p = 0.003), LVEF (OR: 0.93, 95 % CI: 0.85-0.98, p = 0.03), and Gensini score (OR: 1.36, 95 % CI: 1.24-1.98, p = 0.002) were independently associated with a higher TIMI risk score.

CONCLUSION

In conclusion, EAT thickness is independently associated with TIMI risk score and may be an emerging risk factor for adverse events in NSTEMI/USAP patients.

Syncope as the primary manifestation of hydatid cyst. Report of two cases with different etiologies

Hydatid disease is a parasitic infestation that is caused by the larvae of the tapeworm Echinococcus granulosus. Clinical manifestations are extremely variable and related to the location and the size of the cysts. Syncope as the first clinical presentation of hydatid cyst is a very rare condition. Herein, we report two cases of patients with cardiac and pleural hydatid cysts who had syncope as the initial symptom.

Multiple thromboses at multiple sites. A known hereditary disease emerging late but suddenly and extensively

Hyperhomocysteinemia is a significant independent, usually heritable, prothrombotic risk factor for atherothrombotic cardiovascular, cerebrovascular, and peripheral vascular disease. We report a 42-year-old woman who had multiple embolic events.

Course of serum lipoprotein(a) and acute phase protein levels in patients undergoing open heart surgery

BACKGROUND

Lipoprotein(a) [Lp(a)] is an important risk factor in the pathogenesis of coronary artery disease because of its thrombogenic and atherogenic properties. Lp(a) also displays another property by acting as an acute phase reactant.

METHODS

In this work, the study group consisted of 20 male patients having coronary artery bypass under cardiopulmonary bypass (CPB). Preoperative and postoperative levels of plasma total cholesterol, triglyceride, apolipoprotein A1 (Apo A1), apolipoprotein B (Apo B), alpha-1 antitrypsin (a1-AT), alpha-2 macroglobulin (alpha 2-MG), alpha-1 acid glycoprotein (alpha 1-AG), Lp(a) were measured in all patients one day before and after the 1st, 2nd, 4th, and 10th days of CPB.

RESULTS

It was observed that the levels of Lp(a) levels gradually reached the preoperative levels at the 10th postoperative day period. Observed change of the Lp(a) levels was similar to that of the other acute phase proteins which are synthesized and released from liver. In contrast, alpha 2-MG has shown different behaviour in terms of operative values. The changes observed for all these 3 parameters were found to be statistically significant (p<0.01).

CONCLUSIONS

The data has indicated that Lp(a) levels show similar progress with alpha 2-MG levels. It can be concluded that serum levels of Lp(a) after coronary arterial bypass decrease depending upon several factors and reach basal levels at the end of a 10 day-period of postoperation. The main cause for this decrease might result from the contact of blood with foreign surfaces of the heart-lung machine.

Congestive heart failure associated with chronic venous insufficiency and leg ulcers secondary to an arteriovenous fistula caused by a shotgun wound 15 years ago

We present a 65-year-old man who had a significant arteriovenous fistula between the right arteria profunda femoralis and vena profunda femoralis. He had evidence of chronic venous insufficiency and chronic leg ulcers on his right leg, and he had clinical findings of congestive heart failure. An arteriovenous fistula was responsible for all of clinical situation that had been caused by a shotgun wound 15 years ago. Using ultrasonography, after palpating a marked thrill and mass during physical examination, established the diagnosis of arteriovenous fistula. Angiography was performed both to delineate the suspected vascular anatomy and to show the coronary arteries. The patient was operated on and no complication was experienced during or after the procedure. Dramatic improvement was seen in the clinical picture just after surgery, and heart size markedly reduced both on chest X-ray and echocardiographic examination.

Effects of candesartan and perindopril on renal function, TGF-beta1 plasma levels and excretion of prostaglandins in stable renal allograft recipients

AIMS

Although on account of their nephroprotective effects, ACE inhibitors and angiotensin receptor antagonists appear to be advantageous for patients after renal transplantation, their use in these patients has been limited up to now. This is in part due to the risk of inducing a decrease in the glomerular filtration pressure gradient with subsequent impairment of allograft function. The aim of the present study was to investigate the effects of ACE inhibitors and angiotensin receptor antagonists on renal function, excretion of prostaglandins as a parameter of glomerular hemodynamics and TGF-beta1 plasma levels during an 8-week withdrawal phase in pretreated patients.

PATIENTS AND METHODS

Sixteen patients with stable long-term allograft function undergoing therapy with candesartan (group 1) and 16 patients with stable long-term allograft function undergoing therapy with perindopril (group 2) were included in the study. Any signs of chronic allograft dysfunction were defined as exclusion criteria. Renal function, albuminuria, TGF-beta1 plasma levels as well as the excretion of thromboxane B2 and 6-keto-prostaglandin-F-1alpha were monitored during an 8-week withdrawal phase of the angiotensin receptor antagonist or ACE inhibitor, respectively. Normotension was maintained throughout the study period through adjustment of other anti-hypertensive drugs.

RESULTS

Creatinine clearance as well as TGF-beta1 plasma levels and the excretion of prostaglandins remained unchanged after discontinuation of candesartan or perindopril. However, after withdrawal of the substances a significant increase in albuminuria was noted in both patient groups throughout the observation period. After 8 weeks, median albuminuria had increased by 63% in group 1 and by 163% in group 2.

CONCLUSIONS

We were able to demonstrate that the use of ACE inhibitors and angiotensin receptor antagonists in patients after renal transplantation is safe. Favorable effects of both substances on albuminuria were detectable in patients who showed no signs of chronic allograft dysfunction according to the usual criteria. Therefore, a nephroprotective effect of candesartan as well as of perindopril, is highly probable in patients after renal transplantation. Further investigations regarding routine use in these patients are therefore mandatory.

[Glomerulonephritis secondary to chronic infection of a ventriculoatrial shunt]

HISTORY AND ADMISSION FINDINGS

A 39-year-old man was referred for assessment of a nephrotic syndrome. He reported deteriorating health with bouts of fever and microhaematuria and proteinuria in the past year. At the age of 24 years a ventriculoatrial shunt had been inserted for an internal hydrocephalus. At another hospital he was given steroids for a nephrotic syndrome suspected of being associated with membranoproliferative glomerulitis, but the disease progressed. On admission he had severe generalised oedema with a temperature of 38,5;C. His general condition was poor. He had no neck stiffness.

INVESTIGATIONS

Parameters of inflammation were raised. Serum creatinine and creatinine clearance were normal. Levels of complements C3 and C4 were reduced. The proteinuria was 9g/24h. Renal biopsy revealed type 1 membranoproliferative glomerulonephritis. Micrococcus roseus/varians was demonstrated several times by aerobic blood cultures.

TREATMENT AND COURSE

The findings suggested chronically infected ventriculoatrial shunt as cause of the glomerulonephritis. The shunt was, therefore, removed. The same pathogens were grown from it on aerobic culture medium. Six months after removal and replacement of the shunt and treatment of the infection the proteinuria had fallen to 0.45 mg/h; serum creatinine was 1.0 mg/dl.

CONCLUSION

When membranoproliferative glomerulonephritis has been demonstrated, secondary forms should be considered in the differential diagnosis. In most cases specific treatment can prevent progression of the renal disease.

Correlation of perineural invasion on radical prostatectomy specimens with other pathologic prognostic factors and PSA failure

OBJECTIVE

The aim of this study is to evaluate the relationship between perineural invasion (PNI) and other pathologic prognostic factors in radical retropubic prostatectomy (RRP) specimens and also to assess the role of PNI in prostate-specific antigen (PSA) recurrence after RRP.

METHOD

191 consecutive patients had undergone RRP for clinically localized prostate cancer between 1992 and 2000. PNI in RRP specimens and its relation to histopathologic stage and surgical margins is investigated retrospectively. PNI, histopathologic stage, surgical margin status, Gleason score and PSA parameters were used as variables in multivariate analysis for recurrence.

RESULTS

PNI is correlated statistically significantly with histopathologic stage, positive surgical margins, specimen Gleason score and recurrence. Mean time to failure was earlier in patients with PNI than patients without PNI (56 vs. 73 months, log-rank 15.67, p<0.001). Lymph node involvement, positive surgical margins and PNI remained as independent predictors of recurrence in multivariate analysis. All patients with PNI, positive surgical margins and lymph node metastasis failed in 6 months.

CONCLUSION

PNI is an important prognostic factor that should be taken into consideration in clinical patient management and follow-up after RRP. The presence of PNI together with positive surgical margins and lymph node metastasis may warrant early adjuvant treatment.

Lymph nodal involvement by renal angiomyolipoma

Angiomyolipoma of the kidney is a clonal neoplasm, apparently part of a family of neoplasms derived from perivascular epithelial cells. A 40-year-old woman presented with right flank pain and an otherwise non-significant medical history. An abdominal computed tomography scan revealed an 18 cm solid mass in the mid-portion of the right kidney and multiple perihilar lymph nodes. Presumptive diagnosis was renal cell carcinoma. Right radical nephrectomy and a perihilar lymph node dissection was performed through a Chevron incision for the anticipated diagnosis of renal adenocarcinoma. The renal tumor was diagnosed as angiomyolipoma and a component was identified pathologically in a dissected lymph node. There was no evidence of tumor recurrence in the follow-up period of eight years. The consensus from other studies suggests that this phenomenon is a manifestation of the multicentric nature of angiomyolipoma, rather than due to metastasis. Genetic studies may resolve this question in the future.

Role of DNA methylation at GATC sites in the dnaA promoter, dnaAp2

DnaA protein is required for the initiation of DNA replication at the bacterial chromosomal origin, oriC, and at the origins of many plasmids. The concentration of DnaA protein is an important factor in determining when initiation occurs during the cell cycle. Methylation of GATC sites in the dnaAp2 promoter, two of which are in the -35 and -10 sequences, has been predicted to play an important role in regulating dnaA gene expression during the cell cycle because the promoter is sequestered from methylation immediately following replication. Mutations that eliminate these two GATC sites but do not substantially change the activity of the promoter were introduced into a reporter gene fusion and into the chromosome. The chromosomal mutants are able to initiate DNA replication synchronously at both moderately slow and fast growth rates, demonstrating that GATC methylation at these two sites is not directly involved in providing the necessary amount of DnaA for precise timing of initiation during the cell cycle. Either sequestration does not involve these GATC sites, or cell cycle control of DnaA expression is not required to supply the concentration necessary for correct timing of initiation.

Discrepancy between Gleason scores of biopsy and radical prostatectomy specimens

OBJECTIVE

The grade of the prostate cancer is an important factor in defining prognosis and deciding on treatment. In this study, we compared the Gleason score determined by 18-gauge core needle biopsies with both the Gleason score and pathological staging of the radical prostatectomy specimens.

PATIENTS AND METHODS

Between July 1992 and September 1998, we performed 144 radical retropubic prostatectomies for clinically localized prostatic carcinoma, after a negative frozen section in bilateral pelvic lymphadenectomy in all cases. Ten patients with pathologic stage T1a and T1b were excluded. The final study group consisted of 134 patients, all of whom had been diagnosed with adenocarcinoma by transrectal needle biopsies with an 18-gauge automated spring-loaded biopsy gun. No patients received neoadjuvant therapy, including androgen deprivation and radiation therapy. All patients had a designated Gleason score on the needle biopsy and prostatectomy specimens.

RESULTS

We found that grading error was greatest with well-differentiated (Gleason score 2-4) tumors, The accuracy was 15% for Gleason score 2-4 on needle biopsy. Of the 113 evaluable patients with Gleason score 5-7 on needle biopsy, 110 (97%) were graded correctly. All of the Gleason score 8-10 on needle biopsy was graded correctly. But only 1 patient in our series had Gleason score 8 on needle biopsy. Twenty-seven (25%) of 110 patients with a biopsy grade of Gleason score <7 had the cancer upgraded to 7. Of patients with both Gleason score <7 in the needle biopsy and Gleason score 7 in the prostatectomy specimen, only 3 (11%) had tumor confined to the prostate.

CONCLUSION

The potential for grading error is greatest with well-differentiated tumors and of patients with both Gleason scores <7 in the needle biopsy and Gleason score 7 in the prostatectomy specimen, only 11% had tumor confined to the prostate. This effects treatment policy, especially for watchful waiting criteria.

Double layered autogenous vein graft patch reconstruction of the common carotid-internal jugular fistula caused by gunshot wound

Hereby we present a case with a common carotid-internal jugular fistula caused by gunshot wound. The patient was a 32-year old male who had an entrance hole of a bullet on his right anterior cervical area, at the C4 level with a hematoma surrounding it. The exit hole could be detected at the sublingual area. By palpation a thrill and on auscultation a souffle was noted. Neither crepitation, nor any neurologic deficit or any symptom of Horner's syndrome was present. The emergency digital subtraction angiography (DSA) showed a fistulisation to internal jugular vein (IJV) approximately 0.5 cm below the common carotid artery (CCA) bifurcation level. During the operation a hematoma and a false aneurysm was observed on the CCA. Also, proximally to the bifurcation, a communication of CCA with IJV was noted. The wall of the JJV was rather thinned and the size of the vessel had considerably enlarged. Following the evacuation of the hematoma and debridement, the integration of the artery was achieved by placing a double layered autogenous vein graft patch over the 0.5 x 1.5 cm defect. The 0.3 x 1.5 cm defect laterally over the IJV was primarily sutured. The patient was discharged on the fifth day. The control DSA taken on the twelfth day showed a perfect integration of the vessels. We considered the case noticeable due to its rather rare incidence and the double layered autogen vein patch graft reconstruction.

Pediatric safety pin ingestion

Fifteen consecutive children with ingested safety pins were evaluated retrospectively. Eight patients were males and seven were girls. The mean age of the patients was 5.4 years ranging from 7 months to 16 years. Two of 15 patients were mentally retarded Seven safety pins ingestion were noted by parents, three older children applied with safety pin swallowing. Three infants referred with hypersalivation and swallowing difficulty. One of two mentally retarded patients had recurrent aspiration pneumonia, the other had neck abscess. These patients' lesions were detected incidentally by thoracic X-ray. Nine safety pins were at the level of the cricopharyngeus, one at the level of the aortic arch and five at the esophagogastric junction. A right esophagoscopy was used for extraction of safety pins under general anesthesia and endotracheal intubation were used. Before esophagoscopy control plain X-ray was obtained for location of safety pin. Nine safety pins were extracted by esophagoscopy. Three safety pins spontaneously and three during anesthesia induction passed through the esophagus falling down the stomach. Five of these six safety pins were spontaneously extracted without complication. However one open safety pin lodged at the duodenum and laparotomy was required. In this article, etiology and management of safety pin ingestion in children are discussed.

Cholesterol crystal embolism. Case report

A 60-year-old man presented with a cholesterol crystal embolism that gave a rather confusing clinical picture. An immediate multidisciplinary approach established the diagnosis and the rapid, dramatic skin loss that exposed vital structures over his thigh and lower leg was reconstructed by an ipsilateral inferior pedicled rectus abdominis musculocutaneous flap with a lateral oblique cephalad fasciocutaneal component. The case, which a plastic surgeon would rarely encounter, is interesting because of the diagnostic approach and the management.

Family planning in Isparta, Turkey

Family planning practices were reported by 491 married women, aged 15-49, who applied to the Family Planning Centre in Isparta, Turkey. Eighty-four percent of the women used contraception, the IUD being used most frequently. Almost half of the women married before age 18 years.

Treatment of penile incarceration in an impotent patient

We report a case of penile incarceration in a 53-year-old impotent man. The base of the penis was encircled by a metal ring in order to achieve better erection. There was marked oedema of the entire penis distal to the constricting ring. The metal ring was removed successfully by cutting it with a steel saw.

Congenital lobar emphysema. A case report

One infant, age 19 days, with congenital lobar emphysema whose main symptoms included dyspnea, cyanosis and severe infant Respiratory Distress Syndrome, was presented in this paper. The most reliable diagnostic tool was chest x-ray films with anteroposterior and lateral views. As additional diagnostic method, thorax computerized tomography was also used. The affected lobe was the left upper lobe. Resection of the affected lobe was performed with good results.