Strain Echocardiographic Evaluation of Myocardial Involvement in Patients with Continuing Chest Pain after COVID-19 Infection

BACKGROUND

A new clinical manifestation called post or long coronavirus disease (p/l COVID) has walked into our lives after the acute COVID-19 phase. P/l COVID may lead to myocardial injury with subsequent cardiac problems. Diagnosing these patients quickly and simply has become more important due to the increasing number of patients with p/l COVID.

OBJECTIVES

We compared strain echocardiography (SE) parameters of patients who suffered from atypical chest pain and had sequel myocarditis findings on cardiac magnetic resonance (CMR). We aimed to investigate the value of SE for detection of myocardial involvement in patients with p/l COVID.

METHODS

A total of 42 patients were enrolled. Our population was separated into two groups. The CMR(-) group (n = 21) had no myocardial sequelae on CMR, whereas the CMR(+) group had myocardial sequelae on CMR (n = 21). The predictive value of SE for myocarditis was also evaluated by age-adjusted multivariate analysis. P values < 0.05 were considered statistically significant.

RESULTS

When compared with left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and global circumferential strain (GCS) had a stronger relationship (LVEF, p = 0.05; GLS, p < 0.001; GCS, p < 0.001) with p/l COVID associated myocardial involvement. GLS < 20.35 had 85.7% sensitivity and 81% specificity; GCS < 21.35 had 81% sensitivity and 81% specificity as diagnostic values for myocardial sequelae detected with CMR. While there was no difference between the groups in terms of inflammatory markers (C-reactive protein, p = 0.31), a difference was observed between biochemical markers, which are indicators of cardiac involvement (brain natriuretic peptide, p < 0.001).

CONCLUSION

SE is more useful than traditional echocardiography for making diagnosis quickly and accurately in order not to delay treatment in the presence of myocardial involvement.

Does MicroRNA Profile Differ in Early Onset Coronary Artery Disease?

OBJECTIVE

MicroRNAs have been explored as potential biomarkers for many pathological processes including coronary artery disease. In this study, we aimed to compare the circulating levels of selected atherosclerosis-associated miRNAs in patients with a history of early-onset coronary artery disease with that of age- and sex-matched healthy controls and older patients with late-onset coronary artery disease.

METHODS

Study population consisted of 30 patients with early onset coronary artery disease, 31 age- and sex-matched healthy controls, and 30 patients with late-onset coronary artery disease. Plasma levels of 13 microRNAs (endothelial cell-related miR-126, -92a/b; vascular smooth muscle cell-related miR-145; inflammation-related miR-16, -21, -125b, -146a/b, -147b, -150, -155; lipometabolism-related miR-27b, -122, -370) were evaluated by using real-time polymerase chain reaction.

RESULTS

In patients with early onset coronary artery disease, plasma expressions of the lipometabolism-related miR-27b, miR-122; inflammation-related miR-125b, miR-146a/b, miR-147b, miR-150, miR-155; and VSMC-related miR-145 were significantly downregulated and endothelial cell-related miR-126 was significantly upregulated compared to age- and sexmatched healthy controls. Circulating microRNA profile of patients with early onset coronary artery disease was also different from that of older patients with late-onset coronary artery disease. Plasma levels of miR-21, miR-27b, miR-122, miR-125b, miR-146b, miR-147b, and miR-155 were lower and plasma levels of miR-16 and miR-92a were higher in patients with early onset coronary artery disease compared to older patients with late-onset coronary artery disease.

CONCLUSION

MicroRNAs are promising biomarkers for early onset coronary artery disease.

Arcuate artery calcification on transvaginal sonography may predict coronary artery heart disease

Atherosclerosis is a systematic disease affecting all arteries and is the most common cause of mortality. Our aim was to evaluate the predictive value of the presence of uterine arcuate artery calcification (AAC) for coronary heart disease (CHD) in women. Seventy women presenting with angina pectoris or a finding suggestive of cardiac ischaemia in non-invasive tests, scheduled for angiography between June 2014 and July 2015 were recruited in the study. One day before the coroner artery angiography, all of the patients were examined about the presence of AAC by transvaginal ultrasonography and were classified in the presence of CHD. CHD is classified as obstructive (obstruction >70%) or as non-obstructive (obstruction <70%) according to the severity of stenosis. The association of AAC is evaluated with the presence and severity of CHD that's diagnosed by angiography. CHD was present in 87.2% of women with positive for AAC and in 4.3% of who were negative for AAC (p = .001). AAC positive women were more likely to develop obstructive CHD than non-obstructive CHD (66.6% versus 30.9%, p = .001), respectively. Sensitivity and specificity of AAC for CHD were 97.6% and 78.5%, respectively. AAC detected by transvaginal ultrasound seems to have a strong association with both presences of CHD and the severity of disease. Impact statement What is already known on this subject? Atherosclerosis affecting all arteries is the primary cause of mortality and morbidity of coronary heart disease (CHD) (Lim et al. 2011). Uterine artery calcification and its association with atherosclerosis were first reported by Camiel et al. (1967). Ozdemir et al. (2016) found a correlation between carotid artery intima thickness and the presence of uterine arcuate artery calcification (AAC). What do the results of this study add? Very few studies have been performed in this area investigating the relationship of AAC and non-invasive predictors of atherosclerosis or the relationship between arterial calcifications and cardiovascular or systemic disease. Our study is the first to evaluate the correlation between AAC and CHD confirmed using coronary artery angiography at a high sensitivity rate (97.6%). What are the implications of these findings for clinical practice and/or further research? Our study presents an alternative, easy and non-invasive method for the prediction of subclinical CHD in clinical practice. From the view of a gynaecologist, cardiology consultation of patients with AAC detected by transvaginal ultrasonography during the routine gynaecologic examination may be useful and protective against serious cardiac problems. Thus, this study is of great importance in terms of predicting when the majority of CHD patients are asymptomatic or in the subclinical phase.

Association of cardiac adaptations with NT-proBNP levels after percutaneous closure of atrial septal defect

OBJECTIVE

The aim of this study was to evaluate the early effects of transcatheter closure of secundum atrial septal defect (ASD) on atrial and ventricular diameters and functions evaluated by transthoracic echocardiography, and to assess the relation of morphological changes to N-terminal pro-brain natriuretic peptide (NT-proBNP) levels.

METHODS

Twenty-two patients with secundum-type ASD referred for percutaneous closure were included in the study as well as 22 healthy individuals who served as a control group. TTE and concurrent blood sampling were performed prior to and 24 hours and 30 days after the closure procedure.

RESULTS

At follow-up 24 hours and 30 days after the closure, the right atrial (RA) area, right ventricular (RV) area, RV end-diastolic volume (EDV), and RV end-systolic volume (ESV) decreased, while left ventricle (LV) EDV (LVEDV), LVESV, and LV stroke volume (LVSV) increased. Global RV systolic and diastolic function indices, such as the tricuspid annular plane systolic excursion, the tricuspid E/A and E/e' ratio decreased immediately after the closure. The NT-proBNP value increased in the 24 hours following closure, and after 30 days, it was still higher than the measurement recorded before the transcatheter closure. The LV structural and functional parameters were significantly correlated with the NT-proBNP value (LVEDV: r=0.37, p=0.02; LVESV: r=0.38, p=0.01; left atrium area: r=0.46, p=0.002; mitral E/e': r=0.28, p=0.04).

CONCLUSION

Percutaneous ASD closure can lead to both early and sustained changes in cardiac anatomy and function involving both sides of the heart. The NT-proBNP level had increased at 24 hours post procedure, and was also notably increased 30 days after the percutaneous ASD closure, which is associated with increased LV diameter and volume.

Transvenous extraction of pacemaker and implantable cardioverter defibrillator leads using Evolution® mechanical dilator sheath: a single center confirmatory experience

Objective

In recent years there has been an increase in clinical situations requiring lead extraction procedures of implanted cardiac devices. In our clinic, extraction procedures are performed with Evolution® mechanical lead extraction system. In this manuscript we aimed to evaluate our lead extraction procedures.

Methods

We retrospectively evaluated lead extraction procedures carried out on 41 patients [30 male, 11 female patient; mean age 61.5 ± 18.5 median 67 (23–85)] between 2008 and 2015 using Evolution® system. Procedural success, major and minor complications are determined according to previously published guidelines.

Results

Mean duration of the lead implantation was 88.4 ± 62.5 months (6–240). Implanted device was a pacemaker in 27 (65.8 %) and ICD in 14 (34.2 %) of patients. Total 67 leads were extracted from the patients, 22 (32.8 %) were atrial, 30 (44.2 %) were ventricular, 14 (21.5 %) were dual coil defibrillator and 1 (1.5 %) was coronary sinus lead. Indications for lead removal were pacemaker decubitis and infection in 29 (70.8 %), lead dysfunction in 11 (26.8 %) and subclavian vein thrombosis in 1 (2.4 %) patient. Success rate with Evolution® system without using snare was 85.3 %. Clinical success rate was 97.5 % procedural success rate was 95.1 % and failure occured in one patient. Major complications occured in 2 (4.8 %) patients, 1 (2.4 %) was procedure related mortality. Minor complications were seen in 5 (12.2 %) of patients.

Conclusions

In our single center study it is shown that extraction of pacemaker and defibrillator leads of relatively long implantation duration and in an older age patient group may be successfully carried out using the Evolution® system. However due to potentially serious complications it is adviced to be done by experienced operators in centers with cardiovascular surgery backup.

Percutaneous closure of perimembranous ventricular septal defects associated with septal aneurysm in adults

OBJECTIVE

Percutaneous closure of perimembranous ventricular septal defects (pmVSD) has become an accepted alternative to surgical closure in selected cases. However, closure of pmVSDs associated with septal aneurysm is more challenging. We report our experience of device closure of pmVSDs associated with septal aneurysm.

METHODS

Between 2008 and 2012, percutaneous closure of pmVSD associated with septal aneurysm was attempted in 11 adult patients in our institution. The patients were followed up at 1, 3, 6, and 12 months after the procedure.

RESULTS

Mean age of the patients (64% male, 36% female) was 36.2±1.3 years. Diameter of the left and right ventricular openings of the aneurysm measured by ventriculography was 13.5±5.6 mm and 5.9±2.2 mm, respectively. The defect was occluded with Amplatzer pmVSD Occluder in 4 patients, Amplatzer Muscular Ventricular Septal Defect Occluder in 4 patients, Amplatzer Duct Occluder I in 1 patient, and Amplatzer Duct Occluder II in 2 patients (AGA Medical Corp., Plymouth, MN, USA). The procedure was succesfull in all patients. Mean follow-up time was 22±1.9 months. There was no device- or procedure-related complications at the acute setting or mid-term follow-up.

CONCLUSION

Percutaneous closure of pmVSDs associated with aneurysm is more challenging than that of simple defects. The selection of the device type and size should be made according to the configuration and size of the aneurysm and defect.

[Evaluation of lead extraction procedures using the Evolution Mechanical Dilatator Sheath lead extraction system: A single centre experience]

OBJECTIVE

In recent years, there has been an increase in clinical situations requiring extraction of leads of implanted cardiac devices. This study aimed to evaluate the Evolution Mechanical Dilator Sheath system, presently in use in our clinic for lead extraction procedures.

METHODS

Lead extraction procedures carried out on 20 patients (14 men, 6 women; mean age 61±19; range 23 to 85 years) between 2008 and 2013 using the Evolution system were retrospectively evaluated. Procedural success, and major and minor complications were determined by previously published guidelines.

RESULTS

Mean implantation duration of the leads was 97±65 months (8-204). Fifteen (75%) patients had undergone pacemaker implantation and 5 (25%) had been implanted with a defibrillator. A total of 35 leads were removed from the patients. Seventeen (49%) were ventricular and 12 (34%) were atrial. Five (14%) were defibrillator coils and 1 a coronary sinus lead. Indications for lead extraction were device infection in 18 (90%) patients and lead dysfunction in 2 (10%). Complete procedural success was 95%. Failure occurred in 1 patient. The major complication rate was 5% and minor complications were seen in 25% of patients. No case of mortality was present.

CONCLUSION

In this single centre study, it was shown that extraction of pacemaker and defibrillator leads of longer implant duration may be successfully carried out using the Evolution system. However, due to potentially serious complications it is advised that extraction be done by an experienced operator in centres with cardiovascular surgery facilities.

Epidemiology of atrial fibrillation in Turkey: preliminary results of the multicenter AFTER study

OBJECTIVES

Although atrial fibrillation (AF) is one of the most common rhythm disorders observed in clinical practice, a multicenter epidemiological study has not been conducted in our country. This study aimed to assess our clinical approach to AF based upon the records of the first multicenter prospective Atrial Fibrillation in Turkey: Epidemiologic Registry (AFTER) study.

STUDY DESIGN

Taking into consideration the distribution of the population in our country, 2242 consecutive patients with at least one AF attack determined by electrocardiographic examination in 17 different tertiary health care centers were included in the study. Inpatients and patients that were admitted to emergency departments were excluded from the study. Epidemiological data of the patients and the treatment administered were assessed.

RESULTS

The mean age of the patients was determined as 66.8 ± 12.3 years with female patients representing 60% of the study population. While the most common AF type in the Turkish population was non-valvular AF (78%), persistent/permanent AF was determined in 81% of all patients. Hypertension (%67) was the most common co-morbidity in patients with AF. While a stroke or transient ischemic attack or history of systemic thromboembolism was detected in 15.3% of the patients, bleeding history was recorded in 11.2%. Also, 50% of the patients were on warfarin treatment and 53% were on aspirin treatment at the time of the study. The effective INR level was detected in 41.3% of the patients. The most frequent cause of not receiving anticoagulant therapy was physician neglect.

CONCLUSION

These results demonstrate the necessity for improved quality of physician care of patients with AF, especially with regards to antithrombotic therapy.

Impaired quality of life in patients with intermittent atrial fibrillation

Objective:

The quality of life (QoL) is impaired in patients with atrial fibrillation (AF). However, the data on the perceived QoL of patients with different types of AF is limited. In this study, we investigated the QoL of patients with intermittent and chronic AF.

Methods:

The study was designed as an observational cross-sectional study, and 135 consecutive patients with documented AF admitted to the cardiology outpatient clinic in a tertiary hospital were recruited. The pattern of AF was classified as intermittent or chronic AF. The European Heart Rhythm Association (EHRA) classification and symptom severity score were used to quantify the symptoms related to AF. The QoL was assessed by the Short Form-36 and the Canadian Cardiovascular Society Severity in Atrial Fibrillation (SAF) scale.

Results:

Thirty-nine percent of the patients (n=52) had intermittent AF and 61% (n=83) had chronic AF. In the overall patient population, 92% reported having at least one of the symptoms that can be attributable to AF. Although the prevalence of symptoms were similar in patients with intermittent or chronic AF, the patients with intermittent AF perceived more severe palpitations (symptom severity score 2.4±1.7 vs. 1.5±1.5, p=0.003). Patients with intermittent AF had higher EHRA and SAF scores than the patients with chronic AF (2.6±0.9 vs. 1.9±0.8, p<0.001; 2.5±1.3 vs. 1.7±1.2, p<0.001, respectively).

Conclusion:

Outpatients with AF have a high prevalence of symptoms and impaired QoL. The impairment of subjective health-related QoL is worse in patients with intermittent AF.

[Evaluation of quality of life using the Umea 22 questionnaire among patients with atrioventricular nodal tachycardia undergoing successful radiofrequency ablation treatment]

OBJECTIVE

Atrioventricular nodal reentrant tachycardia (AVNRT) attacks is one of the common arrhythmias adversely affecting quality of life. The Umea 22 (U22) is a questionnaire developed for the assessment of symptoms associated with supraventricular tachycardia (SVT), and it is found to be effective in evaluation of quality of life after radiofrequency ablation. Using this questionnaire, the study aimed to assess quality of life among Turkish patients with ANRT before and after the successful RFA.

METHODS

The study was conducted between January 2011 and September 2013, and included 57 patients who had undergone RFA due to AVNRT. The U22 questionnaire was administered pre-procedure and at 6 months post-procedure. The participants were asked to report on their general well-being, arrhythmia effects on their wellbeing, and intensity of discomfort associated with episodes. They were asked to provide a score from 1 to 10 in order to determine to severity of discomfort, and the quantity of symptoms was then assessed according to the visual analogue scale (VAS).

RESULTS

Patients' general wellbeing (7.5±2.3 vs. 8.7±1.8, p<0.001), the effects of arrhythmia episodes on general well-being (8.1±1.7 vs. 1.0±2.1, p<0.001), frequency of symptoms (2.8±0.8 vs. 0.4±0.9, p<0.001) and duration of symptoms were reduced significantly after RFA. The rate of drug use among patients also decreased after RFA (70% vs. 23%, p=0.017).

CONCLUSION

Treatment success was high in patients undergoing RFA due to AVNRT according to the U22 quality of life questionnaire. General and arrhythmia-associated quality of life had improved significantly by the 6th month post-procedure.

The validity and reliability of the Turkish version of the University of Toronto Atrial Fibrillation Severity Scale

BACKGROUND/AIM

There are various instruments to assess quality of life (QoL) in patients with atrial fibrillation (AF). The aim of this study is to determine the reliability and validity of the Turkish version of the University of Toronto Atrial Fibrillation Severity Scale (AFSS).

MATERIALS AND METHODS

The AFSS and Short Form-36 (SF-36) were completed by 130 patients with documented AF. The Canadian Cardiovascular Society Severity in Atrial Fibrillation (SAF) scale and European Heart Rhythm Association (EHRA) scale were also utilized by the attending physicians. To assess test-retest reliability, the AFSS was readministered to 47 clinically stable patients at a 1-month follow-up visit. Internal consistency reliability, test-retest reproducibility, and construct validity were evaluated.

RESULTS

The mean age of the patients was 63.1 + 10.9 years and 58.5% of patients were male. The outcome scores of the Turkish version of the AFSS showed good correlations with theoretically related SF-36 domains. Additionally, AFSS outcome scores showed a linear correlation with the SAF and EHRA scores. Cronbach's alpha values for internal consistency were consistent and similar with the English language version of the AFSS. Intraclass correlation coefficients for reproducibility exceeded 0.80 for every item.

CONCLUSION

Convergent-divergent and known-groups validity and reliability were established for the Turkish version of the University of Toronto AFSS.

Decline in mean platelet volume in patients with patent foramen ovale undergoing percutaneous closure

Introduction

The presence of patent foramen ovale (PFO) is considered a possible cause for cryptogenic stroke. The mechanism underlying the ischaemic neurological events in the presence of PFO has not been firmly established. The purpose of this study was to compare: (1) the mean platelet volume levels in PFO patients with and without a cryptogenic stroke, and (2) pre- and post-procedural mean platelet volumes (MPV) in patients undergoing percutaneous PFO closure.

Methods

Sixteen PFO patients undergoing percutaneous closure to prevent recurrent ischaemic events and 15 asymptomatic patients with PFO were enrolled in the study. Mean platelet volume was compared between patients with and without a history of stroke. We also compared pre- and postprocedural MPV levels in patients undergoing percutaneous PFO closure.

Results

Mean platelet volume, which is a marker for platelet activity, was similar in PFO patients with and without stroke (9.34 ± 1.64 vs 9.1 ± 1.34 fl; p = 0.526). Interestingly, MPV decreased significantly after percutaneous closure compared to pre-procedural levels (9.34 ± 1.64 vs 8.3 ± 1.12 fl; p = 0.001).

Conclusion

Our findings suggest interatrial communication through a PFO may be related to increased MPV and increased platelet activity.

Evaluation of aortic elastic properties in patients with exaggerated systolic blood pressure response to exercise testing

We aimed to evaluate the aortic elastic properties in subjects with hypertensive response to exercise stress test (HRE). Sixty-six patients were divided into two groups (33 patients in HRE group and 33 patients in normotensive group). Baseline demographic characteristics were similar. The mean aortic stiffness index (ASI) was significantly higher (p=0.001) whereas aortic distensibility (AD) was significantly lower (p=0.029) in patients suggesting HRE. The C-reactive protein levels of patients with HRE was higher in the HRE group (p=0.03). AD was significantly correlated with age (r=-0.406, p<0.001), pre-test systolic blood presure (SBP) (r=-0.427, p<0.001), peak exercise SBP (r=-0.307, p=0.01), peak exercise diastolic blood presure (DBP) (r=-0.315, p=0.008), and recovery time (3 min) SBP (r=-0.497, p=0.004). Age (β=-0.506, p=0.003) and peak DBP (β=-0.322, p=0.049) were independent predictors of decreased AD. In conclusion, we found a deterioration in arterial elastic properties in patients with HRE.

Echocardiographic signs of right ventricle changes after Trastuzumab treatment in breast cancer patients with erb-2 overexpression

Objective:

Left ventricular (LV) dysfunction after trastuzumab treatment in erb-2 breast cancer cases has been fully investigated. However, there is not enough data about the effect of trastuzumab treatment on right ventricular (RV) functions. This study is designed to evaluate the right heart changes by performing echocardiography after trastuzumab treatment in patients with erb-2 breast cancer.

Methods:

Forty-two consecutive breast cancer patients with erb-2 overexpression mean age 50.4±11.6 years who were decided to receive trastuzumab treatment were enrolled. Echocardiographic examinations including 2-D, spectral, and tissue Doppler measurements were performed at the baseline (T1) and repeated after 6 months (T2).

Results:

Tricuspid annular plane systolic excursion (TAPSE) was decreased, RV myocardial performance index (RVMPI) and tricuspid E/e’ ratio was increased after trastuzumab treatment (1.84 vs. 2.14; p<0.01) (0.46 vs. 0.56, p<0.01) (4.4±1.07 vs. 5.08±1.46; p=0.04). Median serum NT-ProBNP levels, troponin I, and hs-CRP levels were similar between the groups. LVEF and TAPSE were negatively correlated with dosage of trastuzumab (r=-0.392, p=0.04; r=-0.522, p=0.006). There was a stepwise decrease in LVEF when trastuzumab used with anthracyclines however this not reached statically significant (62.4±2, 60±4.5; p=0.06).

Conclusion:

In our study; we observed a trend of RV deterioration after trastuzumab treatment. These preliminary RV changes were demonstrated by using TAPSE, RV tissue Doppler imaging derived MPI and E/e’ ratio parameters by echocardiography and these parameters could also use as markers of trastuzumab toxicity in this population.

Relationships between P wave dispersion, atrial electromechanical delay, left atrial remodeling, and NT-proBNP levels, in patients with hypertrophic cardiomyopathy

BACKGROUND

We evaluated the associations among the well-known atrial fibrillation (AF) predictors including P-wave dispersion (PWD), intra- and inter-atrial electromechanical dyssynchrony (EMD), left atrial (LA) phasic functions, and plasma N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) levels, in patients with hypertrophic cardiomyopathy (HCM).

METHODS

Seventy patients with HCM and age and sex matched 70 subjects were enrolled. PWD, LA total emptying fraction (LATEFr), active emptying fraction (LAAEFr), passive emptying fraction (LAPEFr), expansion index (LAEI) intra- and inter-atrial EMD were calculated. Levels of NT-proBNP of all subjects were determined.

RESULTS

Higher PWD (p = 0.006), significantly decreased LAEI (p < 0.001), LATEFr, and LAPEFr (both p values < 0.001) values and significantly increased inter-atrial (p < 0.001), LA (p = 0.001), and right atrial dyssynchrony (p < 0.001) were observed in the HCM group compared to controls. PWD was negatively correlated with LAEI (r = -0.236, p = 0.005) and LATEFr (r = -0.242, p = 0.04), however not with LAPEFr (p = 0.7), or LAAEFr (p = 0.3). Except for the LA lateral wall PA' (r = 0.283, p = 0.02), PWD was not correlated with any atrial EMD parameter. Inter-atrial dyssynchrony was related to LAEI (r = -0.272, p = 0.001), LATEFr (r = -0.256, p = 0.03), and LAPEFr (r = -0.332, p = 0.006), but not, however, to LAAEFr (p = 0.4). The plasma NT-proBNP levels of patients were not correlated with either PWD (p = 0.927) or inter-atrial dyssynchrony (p = 0.102).

CONCLUSIONS

PWD and inter-atrial dysynchrony seem to independently promote AF, although both are associated with LA reservoir function in HCM populations. The NT-proBNP level is not associated with these two AF predictors in patients with HCM. NT-proBNP seems to be a poor marker of atrial electrical remodeling in HCM patients.

Obstruction of superior vena cava flow during transcatheter atrial septal defect closure with the Atriasept ASD occluder

In this paper, we describe a patient with a large secundum atrial septal defect ASD (26 mm) with adequate rims that were suitable for percutaneous closure. While closing this ASD, the superior vena cava (SVC) was occluded with the right atrial disc of the Atriasept ASD occluder (Cardia) and thus the device was retrieved before its release. After retrieval of this device, an Amplatzer ASD occluder was successfully implanted without disturbing the caval flow.

The atrial fibrillation in Turkey: Epidemiologic Registry (AFTER)

BACKGROUND

AFTER (Atrial Fibrillation in Turkey: Epidemiologic Registry) is a prospective, multicenter study designed with the aim of describing the prevalence and epidemiology of AF practice in Turkey. This study aims to evaluate stroke risk in non-valvular atrial fibrillation (AF) and anticoagulant drug utilization within conformity to AF guidelines.

METHODS

Patients were recruited in 17 referral hospitals reflecting all the population of 7 geographical regions of Turkey. 2242 consecutive patients who had been admitted with AF on ECG were included in the study. 1745 of these patients, who had non-valvular AF, were included in the statistical evaluation. Stroke risk was evaluated with the CHA2DS2-VASc score.

RESULTS

The average age of participants was determined to be 69.2 ± 11.5 years (56% female). Persistent-permanent AF was found to be the most common type of non-valvular AF (78%). The most common comorbid disorder was hypertension (73%). It was found that oral anticoagulant therapy was used by 40% of all patients, 37% of whom had effective INR (2.0-3.0). Upon multivariate analysis, age was found to be the only independent predictor of stroke among the variables' effects on thromboembolic events that created CHA2DS2-VASc abbreviations (OR 1.026, p < 0.001).

CONCLUSIONS

These results suggest that stroke risk scores should be thoroughly heeded based on guidelines, and that anticoagulation must be applied according to their guidance.

[Cardiac device related infective endocarditis; analysis of 15 cases]

OBJECTIVES

We aimed to investigate the demographic and clinical characteristics, echocardiographic and microbiologic features, and outcomes of patients with permanent pacemaker (PM) and implantable cardioverter-defibrillator (ICD) endocarditis in this study.

STUDY DESIGN

The study population consisted of 15 patients with permanent PM and ICD endocarditis. Data on demographics, medications, clinical procedures, microbiology, echocardiography, surgery, and outcome were collected.

RESULTS

The mean age of the patients was 57 ± 16. Seven patients (47%) were female. Of the 15 permanent PM and ICD endocarditis patients, 5 died during hospital follow-up (33%). Four patients (27%) experienced a pulmonary embolism. Culture-negative endocarditis was seen in 5 cases (33%). Staphylococci were the most common causative organisms (60%). Three patients had undergone surgical treatment (20%).

CONCLUSION

Cardiac device-related endocarditis remain a rare but potentially fatal complication of device implantation.

[Percutaneous closure of ventricular septal defects in adult patients: our initial experience]

OBJECTIVES

We evaluated our initial experience with percutaneous closure of ventricular septal defects (VSD) in adult patients.

STUDY DESIGN

Percutaneous closure of VSDs in adult patients was launched in 2007 in our center. This study included the first five patients (3 women, 2 men; mean age 32.6 years; range 17 to 44 years) with a perimembranous (n=4) or muscular (n=1) VSD. Before percutaneous intervention, all the patients were assessed by transthoracic (TTE) and, when necessary, transesophageal (TEE) echocardiography, heart catheterization, and ventriculography. Percutaneous closure was performed under fluoroscopy and TEE or TTE guidance using the Amplatzer device (perimembranous asymmetric VSD occluder in perimembranous VSDs and muscular VSD occluder in muscular VSD).

RESULTS

The mean VSD diameter was 7.4 mm (range 5 to 11 mm) by echocardiography, and 8.2 mm (range 6 to 11 mm) by ventriculography. The mean left ventricular end-diastolic diameter was 47.2 mm, and the mean distance between the VSD and the aorta was 5.6 mm. Percutaneous closure was successful in all the patients. Ventriculography obtained immediately after the procedure showed minimal passage from the interventricular septum in three patients, but there was no passage on control TTE examination on the first day after the procedure. Aortic, tricuspid, and mitral valves showed normal function. No rhythm problems were seen. All the patients were discharged within one or two days after the procedure.

CONCLUSION

Percutaneous closure of VSDs has become a good alternative to surgical repair in recent years, with high success rates and low morbidity. The results of percutaneous closure of VSDs are also successful in adult patients.

[Oral anticoagulant use in patients with atrial fibrillation]

OBJECTIVES

Oral anticoagulant therapy has been shown to decrease the risk for vascular complications in patients with atrial fibrillation (AF). We evaluated the frequency of oral anticoagulant use in patients with AF, whether oral anticoagulant use was associated with effective INR values, and the reasons for not including an anticoagulant in the treatment.

STUDY DESIGN

The study included 426 consecutive patients (256 women, 170 men; mean age 66+/-11 years) who presented with a diagnosis of AF between October 2007 and November 2008. The patients were inquired about whether they were using warfarin and/or aspirin and the reasons for not taking an oral anticoagulant. The INR levels were measured in those receiving warfarin.

RESULTS

Permanent AF was present in 72.8%, and paroxysmal AF was present in 27.2%. Patients = or >75 years of age accounted for 32.4%. The risk for stroke was high in 69.3%, moderate in 21.8%, and low in 8.9%, hypertension being the most frequent risk factor (66.7%). Inquiry about medications showed that 107 patients (25.1%) were taking aspirin and warfarin, 21 patients (4.9%) and 237 patients (55.6%) were taking warfarin and aspirin alone, respectively, while 61 patients (14.3%) used none. The incidence of oral anticoagulant use was 30.1%, being significantly low in patients = or >75 years of age (p=0.0001), and having hypertension (p=0.023) or coronary artery disease (p=0.004). Effective INR values recommended by the guidelines were attained in 47.7% (n=61) of patients receiving warfarin. Sex, age, clinical risk factors, and socioeconomic parameters were not associated with achievement of target INR values. The most frequent reason for not starting anticoagulant treatment was the low tendency of physicians to prescribe the drug (74.3%), followed by the presence of contraindications (9.8%).

CONCLUSION

The most important factor for inadequate oral anticoagulant use especially in patients having a high risk for stroke is the low incidence of prescription of the drug by the physicians, suggesting low influence of the guidelines on the clinical practice.

Thrombus formation on the delivery sheath during transcatheter atrial septal defect closure

WEB SITE FEATURE

Additive prognostic value of NT-proBNP over TIMI risk score in intermediate-risk patients with acute coronary syndrome

OBJECTIVES

We evaluated the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) for further risk stratification of intermediate-risk patients with non-ST elevation acute coronary syndromes (NSTE-ACS).

STUDY DESIGN

The study included 137 intermediate-risk patients (85 men, 52 women; mean age 62+/-11 years) with ACS, based on the TIMI risk score (scores 3 to 5). Serum NT-proBNP levels were measured 12 hours after the last anginal episode. The patients were divided into four groups according to the following NT-proBNP quartiles: 17-310 pg/ml (n=34), 313-688 pg/ml (n=35), 724-2,407 pg/ml (n=34), and 2,575-24,737 pg/ml (n=34). Primary endpoint of the study was mortality. The mean follow-up was 21.8+/-7.1 months.

RESULTS

There were 27 deaths (19.7%), 14 of which were in the 4th quartile (4th vs 1st, 2nd, and 3rd quartiles: p=0.02, p=0.01, and p<0.01, respectively). The first three quartiles did not differ significantly in this respect. In Kaplan-Meier analysis, patients in the 4th quartile had the lowest cumulative survival (log rank test, 4th vs 1st, 2nd, and 3rd quartiles: p=0.041, p=0.026, and p=0.009, respectively). NT-proBNP level was significantly higher in nonsurvivors than in survivors (p=0.01). In univariate analysis, mortality was also associated with the TIMI risk score, ejection fraction, and age. Patients who died were older (65.6+/-11.9 years vs 60.7+/-11.0 years; p=0.048) and had a lower ejection fraction (46.3+/-11% vs 54.1+/-9.8%; p<0.001) than patients who survived. Mortality rates corresponding to TIMI risk scores of 3, 4, and 5 were 25.9%, 29.6%, and 44.4%, respectively (p=0.58 for TIMI 3 vs 4; p=0.001 for TIMI 3 vs 5; p=0.013 for TIMI 4 vs 5). Cox proportional hazards regression analysis showed that only TIMI risk score was an independent predictor of mortality (hazard ratio 2.3, 95% confidence interval 1.4-3.8, p=0.001).

CONCLUSION

NT-proBNP has an additive predictive value over TIMI risk score in predicting long-term mortality in intermediate-risk patients with ACS.

A late presentation of tetralogy of Fallot with pulmonary atresia and coronary-pulmonary artery collateral and a congenital aortic stenosis

We report a 40-year-old man with an unoperated tetralogy of Fallot with pulmonary atresia and congenital aortic valvular stenosis. A well-developed coronary-pulmonary arterial collateral arising from the left main coronary artery was also demonstrated. Although rare cases of tetralogy of Fallot with congenital aortic stenosis has been reported, this is the first particular case demonstrating a triad of these abnormalities.