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The effect of malnutrition on outcomes after carotid artery stenting (CAS) is not well known. This study reports the relationship between malnutrition and post-procedure 30-day major adverse events (MAEs). A total of 978 patients hospitalized for CAS were enrolled in the study. Controlling nutritional status (CONUT) score, the nutritional risk index (NRI), and the prognostic nutritional index (PNI) were calculated. MAEs (myocardial infarction, stroke/transient ischemic attack and mortality) were compared. According to the CONUT score, NRI, and PNI, 9.4%, 41%, and 11.4% patients were moderately or severely malnourished, respectively; 74.8% were at least mildly malnourished by at least 1 score. Forty-seven patients (4.8%) had a post-procedure 30-day MAE. Continuous classifications of the indexes were independently associated with higher MAE. CONUT showed the highest predictive ability, whereas NRI had the lowest (C-index: CONUT, 0.701; NRI, 0.681; PNI, 0.688). According to categorical classification of indexes, only CONUT and PNI showed predictive ability for MAE. Malnutrition assessment could identify patients with CAS at elevated risk for MAE. CONUT, NRI, and PNI continuous scores were independent prognostic factors for the post-procedure 30-day MAE. According to our study, CONUT showed the highest predictive ability.

The CHA2DS2-VASc score predicts stroke and mortality risk in several cardiovascular diseases regardless of atrial fibrillation. In this study, we aimed to investigate the ability of CHA2DS2-VASc score to predict in-hospital and long-term outcomes in patients undergoing carotid artery stenting (CAS). The study population included 558 patients undergoing CAS. The patients were stratified into three groups based on their CHA2DS2-VASc scores [low (≤ 2, n = 123), moderate (3–5, n = 355) and high (6–8, n = 80)]. In-hospital and 3-year outcomes were compared between the groups. In-hospital rates of ipsilateral and major strokes and death were significantly different between the groups (1.6% vs. 3.9% vs. 16.2%; 1.6% vs. 4.5% vs. 16.2%; 0.8% vs. 3.1% vs. 13.8%, p

Background: Inflammatory mechanisms play an important role in both atherosclerosis and stroke. There are several inflammatory peripheral blood count markers associated with carotid artery stenosis degree, symptomatic carotid artery lesions and carotid artery stent restenosis that reported in previous studies. However, the prognostic role of the blood cell counts and their ratios in predicting in-hospital and long-term outcomes in patients undergoing carotid artery stenting (CAS) has not been comprehensively investigated. Systemic immune-inflammation index (SII) proved its' efficiency in patients with solid tumors and its' role was rarely examined in cardiovascular disorders and stroke. The current study evaluated the effect of this novel risk index on in-hospital and long-term outcomes in a large patient population who underwent CAS. Method: A total of 732 patients with carotid artery stenosis who underwent CAS were enrolled to the study. SII was calculated using the following formula: neutrophil-to-lymphocyte ratio pound total platelet count in the peripheral blood (per mm3) and the patients were stratified accordingly: T1, T2 and T3. In-hospital and 5-year outcomes were compared between the tertiles of SII. Results: During the hospitalization, major stroke, ipsilateral stoke, myocardial infarction, death and major adverse cardiovascular events (MACE) rates were significantly higher in high SII level (T3) compared to SII levels (T1 and 2). In longterm outcomes, ipsilateral stroke, major stroke, transient ischemic attack, death, and MACE were significantly higher in the patients with higher SII level (T3). The 5-year Kaplan-Meier overall survival for T1, T2, and T3 were 97.5%, 96.7% and 86.0% respectively. In-hospital and 5-year regression analyses demonstrated that high SII was independently associated with MACE and mortality. Conclusion: SII was independently associated with in-hospital and long-term clinical outcomes in patients undergoing CAS. Immune and inflammation status, as assessed easily and quickly using SII, has a good discriminative value in these patients. WOS:000686903400007 2-s2.0-85109196298 PubMed: 34242858

Özkan, Mehmet; Ardahan Üniversitesi, Sağlık Bilimleri Fakültesi, Hemşirelik Bölümü, Makale., Objective: Spontaneous echo contrast (SEC) is defined as dynamic, smoke-like echoes within the cardiac cavities with a characteristic swirling motion seen on echocardiography. Clin ical studies have demonstrated that SEC is a risk factor for left atrial thrombus formation and an important indicator for poten tial systemic embolism. Platelet indices have been associated with the presence of SEC in patients with mitral stenosis. The aim of this study was to investigate the relationship between platelet indices and SEC in patients with prosthetic heart valves. Methods: A total of 89 patients [female: 38 (42.4%); median age: 52 years (range: 36-67 years)] with SEC formation in the left atrium, and 257 control subjects [female: 123 (47.5%); me dian age: 56 years (range: 45-65 years)] without SEC forma tion were enrolled. All of the patients were evaluated by using transthoracic and transesophageal echocardiography. Labora tory tests including complete blood count and biochemical pa rameters were analyzed. Results: Patients with SEC formation had more frequent atrial fibrillation, higher left atrial diameter (LAD) and lower left ventriular ejection fraction values. Platelet indices including platelet count, platelet distribution width, mean platelet volume, and plateletcrit did not differ between the groups. Increased LAD was detected as the only independent predictor of SEC development. Conclusion: Platelet indices were not found to be associated with the presence of SEC formation in the left atrium among patients with mitral prosthetic valves. Therefore, the use of platelet indices alongside known echocardiographic and clin ical risk factors to predict SEC development in patients with a mitral prosthesis is debatable., Amaç: Spontan eko kontrast (SEK) ekokardiyografi ile kalp boşluklarında karakteristik girdapsı hareketi olan dinamik du man benzeri yansımalar olarak tanımlanmaktadır. Önceki klinik çalışmalar SEK mevcudiyetini sol atriyal trombüs gelişimi için bir risk faktörü ve olası sistemik embolizm için önemli bir göster ge olduğunu kanıtlamıştır. Mitral stenozu olan hastalarda SEK varlığı ile trombosit indeksleri arasındaki ilişki gösterilmiştir. Bu çalışmada mekanik protez kapaklı hastalarda trombosit indeks leri ve SEK arasındaki ilişkinin araştırılması amaçlanmıştır. Yöntemler: Bu kilinik çalışmaya sol atriyumda SEK formasyo nu izlenen 89 hasta [kadın: 38 (%42.4), ortalama yaş: 52 (36- 67) yıl ] ve SEK formasyonu izlenmeyen 257 kişiden oluşan kontrol grubu [kadın: 123 (%47.5), ortalama yaş: 56 (45-65) yıl] dahil edildi. Tüm hastalar transtorasik ve transözafajiyal ekokardiyografinin yanında tam kan sayımı ve biyokimyasal parametrelerinin olduğu labaratuvar testleri ile değerlendirildi. Bulgular: SEK formasyonuna sahip hastalarda daha sık atriyal fibrilasyon, daha geniş sol atriyal çap ve daha az sol ventrikül ejeksiyon fraksiyonu izlendi. Trombosit sayısı, trombosit dağı lım genişliği, ortalama trombosit hacmi ve pletaletkritten oluşan trombosit indeksleri açısından iki grup arasında farklılık izlen medi. Artmış sol atriyum çapı SEK formasyonunun tek bağım sız öngörücüsü olarak belirlendi. Sonuç: Mitral mekanik protez kapaklı hastalarda sol atriyumda SEK formasyonu ile trombosit indeksleri arasında bir ilişki bu lunamadı. Bu nedenle, trombosit indekslerinin daha önceden bilinen ekokardiyografik ve klinik risk faktörleri ile birlikte mitral protez kapaklı hastalarda SEK formasyonunun öngörüsünde kullanımı tartışmalıdır.

OBJECTIVES: This study aims to evaluate the effect of cardiac rehabilitation (CR) on disease activity, functional status, fitness, and modified cardiovascular disease (CVD) risk factors in patients with rheumatoid arthritis (RA) with a moderate disease activity. PATIENTS AND METHODS: This single-center, controlled study included a total of 60 female RA patients (mean age 57.5 years; range, 50 to 64 years) with moderate disease activity according to the Disease Activity Score-28 (DAS28) between January 2014 and June 2015. The patients were divided into two equal groups as those receiving CR program (n=30) and those receiving home exercise program (HEP; n=30). The patients were evaluated at baseline, at Weeks 10 and 24 using exercise tolerance test (i.e., The Metabolic Equivalent of Task [MET] and maximal oxygen uptake [VO2 max]), Six-Minute Walk Test (6MWT), DAS28, Health Assessment Questionnaire (HAQ), modified Systematic Coronary Risk Evaluation (mSCORE), Short Form Health Survey-36 (SF-36), and Beck Depression Inventory (BDI). RESULTS: There was a significant improvement in the VO2 max (p

Objective In recent years, epicardial fat tissue (EFT) has been found to be strongly associated with the development of atrial fibrillation (AF) and post-ablation long-term recurrence. The current study investigated the procedural success rate of electrical cardioversion (ECV) and potential predictors of treatment failure in patients with nonvalvular persistent AF. Methods A total of 262 nonvalvular persistent AF patients who were scheduled for elective ECV were included in this prospective study. Routine transthoracic echocardiography was performed before the procedure and EFT thickness was measured. The presence of left atrial appendage thrombus was evaluated by transesophageal echocardiography. The patients were followed up for 6 months to examine any recurrence after ECV. Results The success rate of ECV was 85% and the recurrence rate was 35% during the 6-month follow-up period. The mean EFT thickness was 8.67 ± 1.2 mm in the persistent AF group with unsuccessful ECV and 6.81 ± 0.8 in the patients in whom sinus rhythm (SR) was maintained, the EFT was significantly thicker in the AF group (P = 0.001). EFT (P = 0.001) and left ventricular end-diastolic diameters (LVEDD) (P = 0.001) were significantly different between those who had maintained SR and those with recurrent AF during the 6-month follow-up period after ECV. In the multiple logistic regression analysis, LVEDD (odds ratio [OR]: 1.320 (1.023-1.703 95% confidence interval [CI]), P = 0.032)] and EFT [OR: 3.029 (1.013-9.055 95% CI), P = 0.047)] were identified as independent predictors of successful ECV. Conclusion Epicardial fat tissue thickness can be effectively used for the prediction of successful ECV and AF recurrence during follow-up in AF patients.

Plasma D-dimer level is an indicator of thrombosis and endogenous fibrinolytic activity. We investigated the association between the D-dimer levels and thrombus burden and cerebrovascular events in patients with obstructive prosthetic valve thrombosis (PVT). This retrospective study included 47 patients with obstructive left-sided PVT and 32 controls in whom PVT was excluded with comprehensive transthoracic and transesophageal echocardiography (TEE). The patient group included 11 aortic, 27 mitral, and 9 aortic and mitral valve PVT patients and the control group included 2 aortic, 25 mitral, and 5 aortic and mitral valve patients. Laboratory analysis including plasma D-dimer levels was performed at the time of admission in all patients. The baseline characteristics were similar between the two groups. The plasma D-dimer levels were significantly higher in patients with obstructive PVT compared with controls [680 (110-3590) vs. 310 (80-380) μg/l; P < 0.001]. By multivariate logistic regression analysis high D-dimer level, low-INR value on admission, high NYHA functional class and recent history of cerebrovascular accident (CVA), and transient ischemic attack (TIA) were the independent predictors of obstructive PVT. A plasma D-dimer level of greater than 365 μg/l predicted the presence of PVT with a sensitivity of 81% and a specificity of 69% (AUC= 0.781, P < 0.001). Plasma D-dimer levels were significantly higher in patients with a recent history of CVA/TIA [2140 (470-2980) vs. 590 (380-830) μg/l; P = 0.021]. In addition to the so-called indicators of PVT including subtherapeutic anticoagulation, increased D-Dimer levels may strengthen the suspicion of PVT. Moreover, higher plasma D-dimer levels were associated with higher thrombus burden and higher prevalence of recent CVA/TIA.

The past 65 years have witnessed remarkable progress in the development of safe, hemodynamically favorable mechanical heart valves. Today, there are a large number and variety of prostheses in use and many prostheses have been used for a while and then discontinued. When patients lack reliable information about their heart valve prostheses, identification of valve model becomes difficult even for specialized physicians in this area. A combination of cinefluoroscopy and echocardiography makes it possible to provide accurate and detailed information regarding identification of prosthetic valve models. Fluoroscopic examination is a useful technique to evaluate patients following mechanical heart valve replacement. However, transthoracic echocardiography and transesophageal echocardiography have almost replaced cinefluoroscopy in the evaluation of prosthetic heart valves. Especially, real-time three-dimensional transesophageal echocardiography provides distinctive images of prosthetic heart valves, particularly for those in the mitral position. A large body of literature has been published to familiarize physicians with the radiological appearance of numerous mechanical prostheses. However, there is a lack of data regarding the identification of prosthetic valve models based on echocardiographic appearance. In this review, we aimed to describe distinctive echocardiographic and cinefluoroscopic markers for identifying the type and brand of several commonly used mechanical prosthetic heart valves.

There are few data on the effects of low hemoglobine levels on the left atrium (LA) in anemic patients. Our aim was to evaluate left atrial (LA) volume and functions in anemic patients using real time three-dimensional echocardiography (RT3DE) and also to investigate changes in variables of LA after the correction of anemia. In total, 55 iron-deficiency anemia patients without traditional cardiovascular (CV) risk factors and 30 age- and gender-matched controls were studied. Assessments included history, physical examination and echocardiography. Of the 55 patients with anemia enrolled, 50 (39 females and 11 males 40.3 years) were followed and underwent echocardiography after correction of the anemia. LA maximum volume (LAVmax), LA minimal volume (LAVmin), LAVmax index (LAVI), before atrial contraction volume (LAVpreA), LA total emptying fraction, LA active emptying volume were higher in anemic patients. LA passive emptying fraction was significantly lower in anemic patients. Following correction of anemia, LA volume and function parameters were observed to be significantly reduced. Moreover, significant increase was noted in LA passive emptying fraction. Correlation analysis was performed and a significant negative correlation was noted between the percentage change in hemoglobin level and percentage change in LAVI (r = − 0.382, p = 0.003). It was shown that volume and functions of LA are impaired in anemic patients. However impaired parameters were improved after correction of anemia. It may be thought that RT3DE LA parameters can be used as an important preclinical marker of disease pathogenesis before developing heart failure or atrial arrhythmia.

Sustained monomorphic ventricular tachycardia is rarely a concomitant condition with myocardial bridging for which no evidence-based medical management has yet been certainly described. Here, in this case study, we present a case of malignant ventricular arrhythmia that may be associated with the myocardial bridge on the coronary artery. The clinical management and medical treatment of the patient are discussed.

Background: Thrombolysis is an effective treatment strategy for prosthetic valve thrombosis (PVT). Recombinant tissue-type plasminogen activator (rt-PA) is widely used as a thrombolytic agent. Infusion of rt-PA may trigger the production of anti–tissue plasminogen activator (tPA) antibodies (ATAs). We aimed to evaluate the possible relationship between ATA levels and PVT formation, and the role of baseline ATA levels on outcomes of thrombolytic therapy in patients with PVT. Methods: This prospective, single-center cohort study included 28 patients with PVT undergoing thrombolysis and 31 controls with normal prostheses. Plasma samples were collected from patients with PVT at baseline and at 15th, 30th, 90th, and 180th days after thrombolysis and from controls at baseline only. The ATA levels were assessed in human plasma by an enzyme-linked immunosorbent assay. Results: Baseline ATA-immunoglobulin (Ig) G and IgM were significantly higher in patients with PVT than in controls. The levels of IgM and IgG peaked at 15th and 30th days after rt-PA infusion, respectively. Subtherapeutic international normalized ratio and baseline ATA-IgM were independent predictors of PVT. Thrombolysis failed in 6 patients (21%) in whom baseline IgM levels were significantly higher than successfully lysed patients. Rethrombosis occurred in 9 patients (32%) in whom baseline IgG levels were significantly higher than those without rethrombosis. There was a moderate positive correlation between baseline and 15th-day IgM levels and the dose of rt-PA needed for successful lysis. Conclusion: The ATA levels tended to be higher in patients with PVT at the time of initial diagnosis compared to controls without PVT. In addition, such patients with PVT and high ATA levels may be at high risk for failed thrombolysis or rethrombosis.

Background Inflammation and malnutrition play a critical role in the outcomes of patients undergoing carotid artery stenting (CAS). Prognostic nutritional index (PNI) is commonly utilized to evaluate the peri-operative immune-nutritional status of patients undergoing colorectal cancer surgery and is independently associated with survival. We assessed the association between immune-nutritional status, indexed by PNI, and outcomes in CAS patients. Methods A total of 615 patients hospitalized for CAS in a tertiary heart center were enrolled in the study. PNI was calculated using the following formula: 10× serum albumin value (g/dL) + 0.005 × total lymphocyte count in the peripheral blood (per mm3). In-hospital and 5-year outcomes (ipsilateral stroke, major stroke, transient ischemic attack, myocardial infarction, and mortality) were compared between the tertiles of PNI. Results In-hospital outcomes were similar between the groups except the increased mortality in decreasing tertiles of PNI. During a mean follow-up duration of 51.1 months, the lower PNI tertile was related to unfavorable outcomes. After adjusting for multi-model Cox regression analysis, PNI persisted as an independent prognostic factor for mortality and major stroke. Conclusion PNI was independently associated with long-term mortality and major stroke in CAS patients. Malnutrition and inflammation, which can be assessed easily and quickly using PNI, have an important prognostic value in the patients undergoing CAS.

Abnormalities in ventricular repolarization (VR) parameters have been associated with sudden cardiac death (SCD) in patients with rheumatoid arthritis (RA). The benefits of cardiac rehabilitation (CR) in patients with RA are well recognized. We aimed to assess its impact on VR indexes in patients with RA.This study included 45 patients with RA (36 female, age 58 ± 5.5 years) and 50 age- and sex-matched otherwise healthy controls. Baseline electrocardiogram (ECG) recordings were used to compare VR parameters such as maximum and minimum QT intervals, and corrected, and dispersion (QTmax, QTmin, cQTmax, cQTmin, QTd, cQTd, respectively), JT and cJT intervals, Tp-e and cTp-e intervals, and Tp-e/QT and Tp-e/cQT ratios in patients with RA and healthy individuals. The effects of 6-week CR in patients with RA were also evaluated by comparing pre- and post-CR ECGs, exercise tolerance test (MET and VO2max) and RA characteristics (C-reactive protein (CRP), Disease Activity Score 28 (DAS28) and Health Assessment Questionnaire(HAQ)).In comparison with the healthy individuals, the patients with RA had significantly higher cQTmax and QTmin intervals, QTd, cQTd, Tp-e and cTp-e intervals, and Tp-e/QT and Tp-e/cQT ratios. At the end of CR, all VR indexes (p 005), except QTd, were significantly decreased as did the results for CRP, DAS28, and HAQ (all p 0.05), and MET and VO2max (p 0.05 for both) were significantly increased in patients with RA.CR may provide an improvement in the majority of VR indexes which are related with ventricular arrhythmia and SCD in patients with RA. Changes in ETT parameters and RA characteristics may contribute to improvement of several VR indexes such as cQTd, cJT and Tp-e intervals at the end of CR.

WOS: 000447683800018, PubMed: 29970239, Coronary thromboembolism (CE) is a rare cause of prosthetic valve derived complications. This study investigates the diagnosis and treatment strategies for non-ST elevation acute coronary syndrome (NSTEACS) in patients with prosthetic heart valves. Forty-eight NSTEACS patients with prosthetic heart valves (mitra1:27; aortic:14; mitral+aortic:7) were included in this study. All patients underwent transthoracic and transesophageal echocardiographic examination and coronary angiography. Normal coronary angiographic findings, or visible trombus in one of the coronary arteries, international normalized ratio

Introduction: Procoagulant activity of heparanase has been recently described in several arterial and venous thrombotic disorders. In this study, we aimed to investigate the role of heparanase with regard to thrombus burden, thromboembolism, and treatment success with unfractionated heparin (UFH) in patients with prosthetic valve thrombosis (PVT). Methods: This study enrolled 79 PVT patients who received UFH for PVT and 82 controls. Plasma samples which were collected from patients both at baseline and after the UFH treatment and from controls at baseline only, were tested for heparanase levels by heparanase enzyme-linked immunosorbent assay. Results: The PVT group included 18 obstructive and 61 non-obstructive PVT patients who received UFH infusions for a median duration of 15 (7–20) days. The UFH treatment was successful in 37 (46.8%) patients. Baseline heparanase levels were significantly higher in the patient group than in the controls [0.29 (0.21–0.71) vs. 0.25 (0.17–0.33) ng/mL; p = 0.002]. Baseline heparanase levels were significantly higher in obstructive PVT patients. There was a significant increase in heparanase levels after UFH treatment. Post-UFH heparanase levels were higher in patients who experienced treatment failure compared to successfully treated group. Baseline and post-UFH heparanase levels were significantly higher in patients with a thrombus area >=1 cm2 and with a recent history of thromboembolism. Conclusions: Increased heparanase levels may be one of the esoteric causes for PVT. UFH treatment may trigger an increase in heparanase levels which may affect the treatment success. Increased heparanase levels may be associated with high risk of thromboembolism and increased thrombus burden in PVT patients. © 2018 Elsevier Ltd

Giriş: Nötrofil-lenfosit oranı (NLO) akut koroner sendromlarınfizyopatolojisi ile ilişkilidir. ST segment elevasyonlu miyokart infarktüsünde(STEMİ) gözlenen inflamatuvar süreç NLO’da artışa sebep olabilir. Çalışmamızda,STEMİ ile hastaneye başvuran hastalarda kardiyojenik şok (KŞ) gelişen vegelişmeyen gruplar arasında NLO’da fark olup olmadığı araştırıldı. Hastalarve Yöntem: Çalışmaya akut STEMİ ile başvurantoplam 203 hasta alındı. Yüz hasta KŞ grubunu oluşturdu. Yüz üç hastada isekomplikasyonsuz STEMİ mevcuttu. Tüm hastalardan rutin kan örnekleri alındı. NLOanalizi yapıldı.Bulgular: NLO gruplar arasında anlamlı olarak farklı bulundu (9.9± 7.9 vs. 6.2 ± 4.3, sırasıyla, p< 0.001).“Multiple logistic regression” analizi, KŞ’yle komplike STEMİ’nin şokizlenmeyen STEMİ hasta grubuna göre daha yüksek NLO değerlerine sahip olduğunugösterdi (β= 1.07, %95 CI 1.01-1.15, p= 0.03).Sonuç: Çalışmamızda hastaneye başvuruda ölçülen NLO’nun KŞ gelişen STEMİ hastalarında anlamlı olarakdaha yüksek olduğu bulundu. Artmış NLO oranı KŞ gelişecek hastaları predikteetmede kullanılabilir., Introduction: Neutrophilto lymphocyte ratio (NLR) is related to the pathogenesis of acute coronarysyndromes. The inflammatory process in ST-elevation myocardial infarction(STEMI) may cause an increase in NLR. In this study, we aimed to investigatewhether admission NLR is associated with STEMI complicated by cardiogenicshock.Patients and Methods: Thestudy population comprised patients who had presented with acute STEMI. Allpatients referred underwent routine blood tests, including common blood cellcounts, and NLR analysis.Results: STEMIshowed characteristics of cardiogenic shock in 100 patients and wasuncomplicated in 103 patients. NLR was significantly different between the twogroups (9.9 ± 7.9 vs. 6.2 ± 4.3, respectively, p< 0.001). Multiple logisticregression analyses showed that NLR was significantly associated with STEMIcomplicated by cardiogenic shock (β= 1.07, 95% CI 1.01-1.15, p= 0.03).Conclusion: Our results demonstrated thatadmission NLR was higher in patients with STEMI complicated by cardiogenicshock. To prove this relationship between NLR and cardiogenic shock, furtherinvestigations are needed.

We have read with great interest the letter to the Editor entitled “Prosthetic valve thrombosis: when prevention is better than treatment” authored by Tarzia et al. They aimed to emphasize the role of ultrasound phonocardiography in early detection of mechanical prosthetic valve thrombosis (PVT), which could have an impact on prognosis of the patient. Despite the great improvements in technology over the past 4 decades, PVT has been associated with a significant death risk. Therefore, diagnosis and management of PVT are crucial, especially in the developing countries where this condition is prevalent. Transthoracic echocardiography is usually the first imaging modality to evaluate suspected PVT, but it is limited in evaluating valve mobility and mechanism of valvular obstruction. Transesophageal echocardiography, especially real-time (RT) handling of 3-dimensional information, has been a milestone in the era of cardiovascular imaging of both native and prosthetic valves. Real-time 3-dimensional transesophageal echocardiography provides better visualization of the atrial and ventricular sides of the prosthesis, improves understanding of the relation between cardiac structures, and helps in discriminating pannus from thrombus. Cinefluoroscopy is a noninvasive, readily available method for detecting PVT, especially in patients with bileaflet prosthetic valves, and plays a complementary diagnostic role in evaluating disk mobility of the prosthesis. Multislice computed tomography has also been proven to be a useful tool in the differential diagnosis of prosthetic valve dysfunction including PVT and pannus. Briefly, multimodality imaging is usually required for exact diagnosis of PVT. As Tarzia et al have stated, an early detection of thrombotic formations appears decisive for patient's prognosis. We appreciate their effort to detect early PVTwith the utility of in vitro and in vivo ultrasound phonocardiographic analysis of the closing sound produced by several mechanical heart valves. They could be able to distinguish functional and dysfunctional prosthesis, differentiating obstructive from nonobstructive forms and identify precocious apposition of minimal thrombi in several different type of prostheses. We completely agree with the authors that prevention of PVT is crucial for avoiding future catastrophic outcomes. Analysis of the prosthetic valves with artificial neural network and ultrasound phonocardiography could provide essential clues for early detection of PVT.

Background The aim of this study was to assess whether epicardial fat thickness (EFT) is associated with the severity of heart failure in patients with nonischemic dilated cardiomyopathy (NICMP). Methods The study group was composed of 93 patients with NICMP and38 age- and sex-matched healty individuals as the control group. The EFT was identified during end-systole at the point on the free wall of the right ventricle. Results Patients with NICMP had significantly lower mean EFT than those in the control group (4.1 ± 0.8 vs. 6.1 ± 1.8 mm, P

Fibrinogen is related to the pathogenesis of atherosclerosis. The inflammatory process in atherosclerosis may cause an increase in plasma fibrinogen level. Therefore, in this study we proposed to investigate whether plasma fibrinogen is associated with the patency of saphenous vein graft in patients at least 1 year after coronary artery bypass graft (CABG) surgery.Patients who had undergone CABG surgery at least 1 year previously with at least one saphenous vein graft were included in the study. Patients were directed to cardiac catheterization for stable anginal symptoms or positive stress test results. Before coronary angiography, all patients underwent routine blood tests including assessment of plasma fibrinogen levels.Saphenous vein grafts were found to be patent in 199 patients and occluded in 132 patients. Plasma fibrinogen levels were significantly different between the two groups (2.85 ± 0.49 g/L vs. 3.62 ± 0.82 g/L, p0.001, respectively). Although the time duration after CABG operation differs significantly between the two groups (p = 0.004), multiple logistic regression analysis showed that plasma fibrinogen levels were found to be significantly associated with the patency of vein graft (odds ratio = 0.27, 95% confidence internal: 0.16-0.48, p0.001).Our results demonstrated that plasma fibrinogen levels were higher in patients with an occluded saphenous vein graft. To conclusively prove the relationship between plasma fibrinogen values and saphenous vein graft patency, additional investigation would be necessary.Atherosclerosis; Coronary artery bypass graft; Fibrinogen; Saphenous vein.

Fractional flow reserve (FFR) assessment is widely used to determine significance of intermediate coronary lesions. Previously, components of the metabolic syndrome (MS) which may affect FFR validity were not tested cumulatively. In this study, we investigate the possible effect of MS on FFR assessment.We retrospectively evaluated 178 consecutive patients who had undergone FFR assessment. Thirty-two patients were excluded. All of the coronary lesions were in the left anterior descending artery. They were evaluated with quantitative coronary angiography (QCA). In 105 patients the MS was present and 41 patients were without the MS. According to the severity of the coronary lesions in QCA, patients were divided into three groups: 40-50%, 51-60% and 61-70% lesions. FFR measurements were compared in each group with respect to MS presence. Coronary artery lesions were accepted as haemodynamically significant if FFRor = 0.80. Age of the population, lesion length, lesion diameter and adenosine dosage performed during FFR assessment were not different between patients with MS or without MS. When the lesions were divided into three categories according to the severity of the luminal narrowing expressed in stenosis percentages as 40-50, 51-60, and more than 61%, the observed FFR values decreased with advancing lesion category (P = 0.04). However, observed FFR values did not differ between the patients with MS and without MS in each category (P = 0.88). After exclusion of the diabetic patients, FFR values still did not differ between the patients with MS and without MS in each category (P = 0.78).Presence of the metabolic syndrome has no significant effect on FFR assessment. This study provides additional data for the reliability of FFR in patients with MS.

A 36-year-old female patient was admitted to our clinic with chronic atypical chest and back pain. She had a history of 3-day hospitalization in the intensive care unit after a severe blunt chest trauma in a car accident 25 years ago. She had no clear evidence of bloody pericardial effusion or pericardial intervention. The heart was observed to have regular rhythm without any murmur, rub, or gallop. Lung fields were clear. Electrocardiography demonstrated sinus rhythm along with non-specific ST-T wave …

A 63-year-old female with a history of scleroderma was referred to our institution for the investigation of dyspnea and atypical chest pain. On physical examination, her blood pressure was 132/88 mmHg and pulse rate was 116 beats/min. She was cyanotic and had an arterial oxygen saturation level of 85%. On cardiac examination, a left parasternal heave was noted; there were soft S1 and hard S2 with a grade III/VI holosystolic murmur heard over the left sternal border, which increased on inspiration. A 12-lead electrocardiogram demonstrated sinus tachycardia and right bundle branch block. Echocardiography showed a normally functioning left ventricle and enlarged right atrium, right ventricle and D-shaped septum (Figure 1). There was severe tricuspid regurgitation, and the estimated pulmonary artery systolic pressure was 106 mmHg. The patient was hospitalised for medical stabilisation. Furthermore, cardiac catheterisation revealed no atherosclerotic coronary artery disease; however, it incidentally revealed diffuse coronary cameral fi stulae (CCF) involving the circumfl ex-obtuse marginal system and diagonal branches emptying into the left ventricle (Figure 2), delineating the endocardial border very well (Figures 3, 4). Because of the fi stulae were diffuse and many smalls, an intervention was not considered. CCF are rare congenital or acquired anomalous with abnormal vascular communications between the coronary arteries and cardiac chamber. A vast majority (approximately 90%) of CCF communicates with the right-sided chambers of the heart, and in the remaining cases, they drain to the left side of the heart or to both sides (1) . The pathophysiology of CCF is unclear. Rudraiah et al. suggested that angiogenesis secondary to hypoxia may play a role in the development of CCF in the absence of acquired causes (e.g. exogenous trauma, previous invasive cardiac procedures or atherosclerosis) (2) . In this respect, hypoxia occurring in the setting of scleroderma may contribute to the development of CCF in the present case.

A 57-year-old male, who had undergone mitral valve replacement with a 29mm Hancock II bioprosthesis for mitral stenosis in 1987, was admitted to the outpatient clinic with exertional dyspnea. Transthoracic echocardiography revealed moderate mitral stenosis and regurgitation (Fig. A, B). Transesophageal echocardiography showed moderate calcification on the leaflets and two regurgitation jets (Fig. C). Real-time three-dimensional transesophageal echocardiography showed a perforation with additional paravalvular defect (Fig. D), and color image illustrated three mitral regurgitation jets (Fig. E). He was referred for valve surgery, the mitral bioprosthesis was removed, a no. 27 ATS mechanical prosthesis was replaced, and a no. 32 Contour 3D® annuloplasty ring was implanted to the tricuspid valve. Macroscopic examination revealed a perforation on the one of the leaflets (Fig. F). The case presented here is an extremely rare example of the long-term durability, over 26 years, of a Hancock II bioprosthesis in the mitral position. When a literature search was conducted, this case was found to represent the longest durability interval reported from the implantation of a bioprosthesis valve in the mitral position. 497