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Objectives: The aim of this study was to compare transradial access (TRA) with transfemoral access (TFA) for chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Background: TRA reduces the risk for vascular access complications but may make complex PCI, such as CTO PCI, more challenging., Methods: FORT CTO (Femoral or Radial Approach in the Treatment of Coronary Chronic Total Occlusion) (NCT03265769) was a prospective, noninferiority, randomized controlled study of TRA vs TFA for CTO PCI. The primary study endpoint was procedural success, defined as technical success without any in-hospital major adverse cardiovascular events. The secondary study endpoint was major access-site complications., Results: Between 2017 and 2021, 610 of 800 patients referred for CTO PCI at 4 centers were randomized to TRA (n = 305) or TFA (n = 305). Mean J-CTO (Multicenter CTO Registry in Japan) (2.1 ± 0.1 vs 2.2 ± 0.1; P = 0.279), PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) (1.3 ± 0.9 vs 1.1 ± 1.0; P = 0.058) and PROGRESS CTO complication (2.4 ± 1.8 vs 2.3 ± 1.8; P = 0.561) scores and use of the retrograde approach (11% vs 14%; P = 0.342) were similar in the TRA and TFA groups. TRA was noninferior to TFA for procedural success (84% vs 86%; P = 0.563) but had fewer access-site complications (2.0% vs 5.6%; P = 0.019). There was no difference between TFA and TRA in procedural duration, contrast volume, or radiation dose., Conclusions: TRA was noninferior to TFA for CTO PCI but had fewer access-site complications., Competing Interests: Funding Support and Author Disclosures Dr Brilakis has received consulting and speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, the Cardiovascular Innovations Foundation (board of directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, Infraredx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; is an owner of Hippocrates; and is a shareholder of MHI Ventures and Cleerly Health. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: We planned a three arm randomized study to evaluate the safety and efficacy of a new blood stopper, Ankaferd blood stopper (ABS) along with short-time compression, compared to either short-time compression with conventional sterile gauzes (CSG) or with a TR band after transradial (TRA) procedures., Methods: The Ankaferd blood stopper as a new strategy to avoid early complications. After transradial procedures (ABS transradial) trial is designed in a prospective, randomized, placebo-controlled fashion and registered with http://clinicaltrials.gov (NCT02982733). Six hundred and thirty patients were randomized into three arms in a 1:1:1 fashion corresponding to three different strategies of patent hemostasis techniques after diagnostic or interventional catheterization., Results: One (0.49%) patient in the CSG group and one patient (0.48%) in the TR Band group developed RAO at the end of the hemostasis, compared with 0 (0%) in the ABS group. At 30 days follow-up none of the groups had any patients with RAO. As a secondary end-points the difference was not statistically significant regarding hematoma among the three groups (P = 0.70). Bleeding during deflation of the TR Band or removal of the elastic bandage occurred in 55 patients (26.96%) in the CSG group and in 56 (27.31%) patients in the TR Band group compared to 19 patients (9.40%) in the ABS group (P < 0.001)., Conclusion: Ankaferd blood stopper is a promising device for use in patent hemostasis, with no evidence on RAO at short-term or long term and with reduced risk of re-bleeding at the end of hemostasis., (© 2018 Wiley Periodicals, Inc.)

Background: This study sought to compare various outcomes among a new specifically designed transcatheter paravalvular leak closure (TPVLC) device and the devices that are being utilized off-label., Methods: Between April 2012 and January 2015, in a prospective two-center study, 52 patients who needed surgical reintervention due to a hemodynamically significant prosthetic paravalvular leak were studied. This study population was divided into two groups. Group I was composed of 32 patients who underwent paravalvular leak (PVL) closure with the currently available devices that are being utilized off-label, while group II consisted of 20 patients who were treated with the new specifically designed Occlutech PVL device., Results: Demographic and clinical variables indicated a higher rate of atrial fibrillation (P = 0.027) and chronic obstructive airway disease (P = 0.009) in group II. The apical approach was the most commonly used intervention route used for group II (P = 0.019). The procedural success rate was 100% (29 of 29 leaks) in group II while the rate was 92% (39 of 42 leaks) in group I. However, more secondary events were observed in group I, but they did not reach statistical significance (8 vs. 1, P = 0.064)., Conclusions: With its high procedural success rate and encouraging outcome results, the Occlutech device seems to satisfy the expectations of a specifically designed PVL closure device. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Introduction: The new definition of periprocedural myocardial infarction (type 4a MI) excludes patients without angina and electrocardiographic or echocardiographic changes suggestive of myocardial ischemia even though significant serum troponin elevations occur following percutaneous coronary intervention (PCI)., Aim: To evaluate the incidence and predictors of serum troponin rise following elective PCI in patients without clinical and procedural signs suggestive of myocardial necrosis by using a high-sensitivite troponin assay (hsTnT)., Material and Methods: Three hundred and four patients (mean age: 60.8 ±8.8 years, 204 male) undergoing elective PCI were enrolled. Patients with periprocedural angina, electrocardiographic or echocardiographic signs indicating myocardial ischemia or a visible procedural complication such as dissection or side branch occlusion were excluded. Mild-moderate periprocedural myocardial injury (PMI) and severe PMI were defined as post-PCI (12 h later) elevation of serum hsTnT concentrations to the range of 14-70 ng/l and > 70 ng/l, respectively., Results: The median pre-procedural hsTnT level was 9.7 ng/l (interquartile range: 7.1-12.2 ng/l). Serum hsTnT concentration elevated (p < 0.001) to 19.4 ng/l (IQR: 12.0-38.8 ng/l) 12 h after PCI. Mild-moderate PMI and severe PMI were detected in 49.3% and 12.2% of patients, respectively. Post-procedural hsTnT levels were significantly higher in multivessel PCI, overlapping stenting, predilatation and postdilatation subgroups. In addition, post-procedural hsTnT levels were correlated (r = 0.340; p < 0.001) with the stent lengths., Conclusions: High-sensitivite troponin measurements indicate a high incidence of PMI even though no clinical or procedural signs suggestive of myocardial ischemia exist. Multivessel PCI, overlapping stenting, predilatation, postdilatation and longer stent length are associated with PMI following elective PCI.

Objective: Periprocedural myocardial injury (PMI) is known to be a predictor of in-hospital cardiac events and long-term adverse outcomes following a percutaneous coronary intervention (PCI). We aimed to evaluate the correlation between preprocedural serum lipid levels and PMI in patients undergoing elective PCI., Patients and Methods: The final study group included 195 patients (60.1±0.7 years old, 68 women and 127 men). Serum high-sensitive troponin T (hscTnT) concentrations were measured immediately before PCI and 12 h after PCI. Serum total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C), and triglyceride (TG) levels were determined immediately before PCI. Serum hscTnT concentrations were adjusted for the clinical and procedural characteristics of the patients using the weighted least-square regression analysis., Results: The average preprocedural hscTnT concentration was 8.1±0.2 ng/l. The average serum hscTnT concentration increased to 34.1±2.8 ng/l (P<0.001) 12 h after PCI. Postprocedural hscTnT concentrations were correlated positively to serum concentrations of TC (r=0.435; P<0.001), LDL-C (r=0.349; P<0.001), and TG (r=0.517; P<0.001). There was also a positive correlation (r=0.205; P<0.01) between postprocedural hscTnT and lesion length. Mild-moderate PMI (postprocedural hscTnT≥14 to <70 ng/l) and severe PMI (postprocedural hscTnT≥70 ng/l) were observed in 122 (48.7%) and 27 (13.9%) patients, respectively. The patients with severe PMI had higher serum TC (P<0.001), LDL-C (P<0.001), and TG (P<0.001) concentrations., Conclusion: The present study indicates that increased preprocedural TC, LDL-C, and TG serum levels are associated with PMI and its severity following elective PCI.

Objectives: Although heparin is highly effective in reducing the rate of radial artery occlusion after transradial catheterization, the optimal heparin dose is still controversial. The aim of this study was to evaluate the efficacy and safety of two different heparin doses during transradial coronary angiography., Methods: 490 consecutive patients undergoing transradial coronary angiography were prospectively enrolled into this double-blind randomized trial. A total of 202 patients enrolled in the low-dose (LD; 2,500 U of heparin) group and 202 patients enrolled in the high-dose (HD; 5,000 U of heparin) group were included in the final analysis. The primary endpoint of the study was radial artery occlusion. Bleeding and hematomas were the secondary outcome measures., Results: At day 7, radial artery occlusion occurred in 5.9% of the patients in the LD group and in 5.4% of the patients in the HD group (p = 0.83). Bleeding during deflation of the transradial band occurred in 6.4% of the patients in the LD group and in 18.3% of the patients in the HD group; the difference was statistically significant (p < 0.001). Higher-dose heparin was found to be an independent predictor of bleeding (p = 0.007)., Conclusion: A lower dose of heparin (i.e. 2,500 U) decreases bleeding during transradial band deflation without an increase in radial artery occlusion., (© 2015 S. Karger AG, Basel.)

Background: Radial artery occlusion (RAO) is an infrequent complication of transradial coronary procedures (TRA). To our knowledge, there is no satisfactory data regarding the late term incidence and predictors of RAO in the literature. Our aim was to establish the long-term incidence of radial artery occlusion and investigate its predictors., Methods: This was a single center prospective study. A total number of 409 consecutive patients undergoing their first TRA were recruited. Clinical and procedural data were all recorded. Doppler ultrasound examination was performed at 6-15 months following the intervention., Results: RAO was detected in 67 patients and 342 patients maintained radial artery patency. The overall RAO incidence was 16.4% at late term. Patients with RAO were younger than the patients with patent radial arteries (55.9 ± 9.7 vs. 59.1 ± 9.4 years, p = 0.014). The incidence of RAO in hypertensive patients (9.8%) was lower (p < 0.001) than the observed incidence (23%) in non-hypertensive patients. RAO group had higher rate (28%, p = 0.027) of post--procedural access site pain. Regression analysis revealed that hypertension was negative while post-procedural access site pain was positive independent predictors for RAO. In addition, the relative risk for RAO also increased significantly (p < 0.001) when the ratio of sheath/artery diameter (S/A) was > 1., Conclusions: The present study reveals that the long-term incidence of RAO is 16.4%. Hypertension, post-procedural access site pain and S/A ratio > 1 are independent predictors of RAO at late term.

Objectives: Our aim was to establish the frequency of radial artery spasm (RAS) and its predictors at the beginning of a transradial approach (TRA)., Methods: This was a single-center prospective study. A total of 1,722 consecutive patients undergoing their first transradial coronary procedure were recruited. After radial artery puncture, a hydrophilic sheath was used to complete arterial puncture, then 500 μg glycerol trinitrate and 2.5 mg verapamil were injected into radial artery along the sheath. After retrograde radial arteriography spasm was defined angiographically as a stenosis greater than 25%. Patient demographics, procedural data such as total procedural duration, the number of catheters and guidewires used, the amount of contrast media usage, dose area product (DAP) and fluoroscopy time, and vascular complications were recorded., Results: The overall spasm incidence was 10.3%. The procedural success rate was lower in patients with spasm than in patients without spasm (80% vs. 95.7%, P < 0.001). The patients with spasm were older (mean age 63.9 ± 9.4 years vs. 60.0 ± 11.2 years, P < 0.001) and more commonly female (51.3% vs. 34.4%, P < 0.001). Spasm was more common in hypertensive patients (66% vs. 56%, P < 0.009). Surprisingly, smoking was less common in patients with spasm (17% vs. 29%, P < 0.001). Multiple logistic regression analysis showed that female gender (OR = 1,524, 95% CI: 1.033-2.248, P = 0.034) was the only independent predictor of RAS at the beginning of the procedure., Conclusions: The incidence of RAS was 10,3%, and female gender was the sole independent predictor of RAS at the very beginning of the procedure in patients undergoing a TRA., (©2012, Wiley Periodicals, Inc.)

Objectives: Our aim was to establish the frequency of arterial anatomic variations and its relation to coronary procedural outcome in patients undergoing a first transradial coronary procedure., Methods: This was a single center prospective study. A total of 1,446 consecutive patients undergoing their first transradial coronary procedure were recruited. Retrograde radial arteriography was performed to define radial artery anatomy. If the operator encountered serious problems during crossing the subclavian-aortic truncus, retrograde subclavian arteriography was also performed. Patient demographics; procedural data such as: total procedural duration, the number of catheters and guidewires used, the amount of contrast media usage, dose area product (DAP), and fluoroscopy time; and vascular complications were recorded., Results: Anatomic variations were noted in 270 patients (18.6%), and these patients were significantly older (mean age 64.4 ± 10.4 vs. 59.2 ± 10.8 years, P < 0.001) and more commonly female (46% vs. 33%, P < 0.001) with significantly higher procedural failure rates (8.8% vs. 5.6%, P = 0.006). In addition, procedural duration (P < 0.001) and fluoroscopy time (P < 0.001) were statistically longer in patients with anatomic variations. Anatomic variations also had an adverse impact on the amount of contrast agent usage (63.9 ± 28.3 mL vs. 59.1 ± 25.3 mL, P = 0.006) and minor vascular complication rate (P = 0.007)., Conclusions: This study indicates that anatomic variation of the arterial path has an adverse impact on transradial coronary procedural outcome., (©2011, Wiley Periodicals, Inc.)

Objectives: Our aim was to compare the effectiveness between right radial approach (RRA) and left radial approach (LRA) by means of a randomized study in a large unselected patient population undergoing diagnostic coronary angiography., Methods: Totally, 1,000 patients were randomized to undergo to RRA (n = 500) or LRA (n = 500). Procedure success was defined as coronary angiography completed with the initial radial artery approach without changing to another route. Performance of the procedure: Total procedural duration, the number of catheters and guidewires used were recorded. Safety of the procedure: The parameters collected for radiation exposure were dose area product (DAP) and fluoroscopy time., Results: The percentage of success was not different between the two aproaches (LRA, 94.0%; RRA,93.8%; P = 0.96). The crossover rate to femoral was low, accounting for 38 cases (3.8%), without differences between RRA and LRA (20 and 18 cases, respectively, P > 0.05). An almost triple incidence of operator-reported subclavian tortuosity in the RRA compared with LRA was observed (44 cases vs. 15 cases, P < 0.001). With respect to the total procedural duration there was no difference between those two aproaches (LRA, 8.54 ± 4.09 min vs. RRA, 8.63 ± 5.20; P = 0.772). However, the fluoroscopy time was significantly shorter via the LRA compared with RRA (2.76 ± 2.00 min vs. 3.08 ± 2.62 min; P = 0.029)., Conclusions: LRA for coronary angiography is associated with the same success rate and procedural duration time compared with RRA. However, the fluoroscopy time is significantly shorter in favor of LRA., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Primary percutaneous coronary intervention (PCI) is the treatment of choice for acute myocardial infarction, especially for high-risk patients, but the data for low-risk patients are conflicting. A very low-risk subgroup of acute inferior myocardial infarction can be identified by electrocardiographic and clinical criteria during admission. We aimed to compare the outcomes of primary PCI and streptokinase treatment in this subgroup, which has not been evaluated separately before., Material/methods: We retrospectively analyzed in-hospital and 10-month follow-up outcomes of 97 patients with inferior acute myocardial infarction and clinical and electrocardiographic criteria predicting low risk who have been treated with primary PCI or streptokinase., Results: Forty-eight patients received streptokinase, and 49 had undergone primary PCI. Both during the in-hospital period and follow-up, the groups did not differ in the end points of death, reinfarction, or stroke (in-hospital: 2.1% versus 4.1%, P=.57; follow-up: 8.9% versus 8.9%, P=1.000). Length of hospital stay was longer in the streptokinase group (6.5+/-2.5 versus 9.1+/-3.7 days, P=.001). Rate of repeat revascularization was reduced in the PCI group at 10 months (28.9% versus 55.6%, P=.002)., Conclusions: When streptokinase and primary PCI are compared in isolated inferior acute myocardial infarction patients with a low-risk profile, there are no differences for in-hospital and long-term rates of death, reinfarction, or stroke. Primary angioplasty reduces the length of initial hospital stay, and reduces repeat admissions by decreasing the need for subsequent revascularization procedures. Large-scale studies are needed to reach a final conclusion.

Objective: The aim of this study is to compare the impact of two different loading conditions on myocardial contractility in asymptomatic patients with normal EF by using stain rate imaging (SRI)., Methods: A total of 27 patients with severe aortic regurgitation (mean age 50 ± 11 years) and 25 patients with severe aortic stenosis (mean age 53 ± 15 years) were prospectively recruited. Fifteen healthy subjects (mean age 50 ± 6 years) were enrolled as the control group. For the evaluation myocardial contractility, longitudinal LV function was chosen and, midventricular segment shortening was analyzed for the septum, LV lateral wall from apical four-chamber view and for the anterior, inferior wall from apical two-chamber view., Results: Longitudinal peak systolic strain rate values of each segment derived from analysis of a total of 804 segments were significantly decreased in the patients population (P < 0.001). Global longitudinal peak systolic strain rate was also significantly decreased in aortic stenosis and regurgitation compared to the control group (-1 ± 0.5, -0.9 ± 0.3, and -1.6 ± 0.3, P = 0.001). As far as the comparison between patients with aortic stenosis and aortic regurgitation, neither global strain rate nor strain rate for each wall was found to be different., Conclusion: We conclude that longitudinal LV function is reduced in both pressure and volume overload, and both of this overload patterns are equally harmful to the ventricle., (© 2010, Wiley Periodicals, Inc.)

Background: There are very few scientific data about the effectiveness of primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) due to stent thrombosis (ST). The purpose of the present study is to investigate the efficacy and outcome of primary PCI for STEMI due to ST in the largest consecutive patient population with ST reported to date., Methods: A total of 2,644 consecutive STEMI patients undergoing primary PCI were retrospectively enrolled into the present study. The primary end point of this study was successful angiographic reperfusion defined as postprocedural Thrombolysis In Myocardial Infarction grade III flow. The secondary end points were cardiovascular death and reinfarction., Results: Stent thrombosis was the cause of STEMI in 118 patients (4.4%). In patients with ST, angiographic success (postprocedural Thrombolysis In Myocardial Infarction grade III flow) was worse than in patients with de novo STEMI (76.3% vs 84.8%, P = .01). Patients with ST had significantly higher incidence of in-hospital cardiovascular mortality than patients with de novo STEMI (10.2% vs 5.3%, P = .02). In-hospital reinfarction rate was similar in both groups. In addition, long-term (mean 22 months) cardiovascular mortality and reinfarction rates were significantly higher in patients with ST compared with those without (17.4% vs 10.5%, P = .02 and 15.6% vs 9.5%, P = .03, respectively)., Conclusions: Primary PCI for treatment of ST is less effective, and these patients are at increased risk for in-hospital and long-term mortality compared with patients undergoing primary PCI due to de novo STEMI., (Copyright 2010 Mosby, Inc. All rights reserved.)

Platelet volume is a marker of platelet function and activation. An elevated mean platelet volume (MPV) is associated with acute coronary syndromes (ACS). Recurrent cardiovascular events were found to be higher in patients with aspirin resistance. In this study, we investigated the effect of MPV on prognosis of patients with and without aspirin resistance by PFA-100 in settings of non-ST-segment elevated ACS. Two hundred and twenty patients with ACS were followed for an average of 14.86 +/- 5.93 months for the occurrence of death, myocardial infarction (MI) and revascularization. Aspirin effect on platelet function was assessed by PFA-100. According to MPV value and aspirin resistance status, patients were divided into four groups. Group 4 (with an elevated MPV and aspirin resistance) was significantly associated with worse prognosis for composite endpoint (death, MI and revascularization), death and MI (for all, log-rank P < 0.0001). Multivariate analysis showed that presence of an elevated MPV and aspirin resistance was an independent predictor of composite endpoint [hazard ratio 8.21, 95% confidence interval (CI) 3.48-19.35, P < 0.0001], death (hazard ratio 5.48, 95% CI 1.62-18.53, P = 0.006) and MI (hazard ratio 4.44, 95% CI 1.57-12.58, P = 0.005). Presence of an elevated MPV and aspirin resistance was significantly associated with death, MI and the composite endpoint, due to the lack of beneficial effect of aspirin on activated platelets. Patients with ACS, especially in the presence of an elevated MPV may benefit from the evaluation of aspirin resistance for risk stratification.

Background: Previous studies have reported a circadian variation of ventricular tachyarrhythmias. However, there is no detailed information of the daily distribution of ventricular tachycardia (VT) and ventricular fibrillation (VF) episodes. The purpose of this study was to evaluate the daily distribution of episodes of ventricular tachyarrhythmia in patients with implantable cardioverter defibrillators., Material/methods: We used data stored by last-generation implantable cardioverter-defibrillators (ICD) to retrospectively evaluate the circadian distribution of VT and VF in 70 patients with ICD. The distribution of tachyarrhythmias was categorized into four time zones: zone 1 (06:00-11:59), zone 2 (12:00-17:59), zone 3 (18:00-23:59), and zone 4 (00:00-05:59)., Results: During a follow-up of a mean of 3.1+/-1.3 years, a total of 791 ventricular arrhythmias were recorded from which 631 events were VT and 160 VF. A circadian variation of episodes of ventricular tachyarrhythmia was evident. The incidence of ventricular arrhythmia sharply increased in zone 1 (8.82+/-2.13, p<0.0001). Episodes of VT had peaks in zones 1 and 2 (7.44+/-2.03 and 2.70+/-0.65, p<0.001) and episodes of VF had peaks in zones 1 and 4 (1.38+/-0.39 and 1.30+/-0.51, p<0.011). No difference was observed between patients who used betablocker and those who did not., Conclusions: Malignant ventricular tachyarrhythmias have a circadian distribution. VT peaks occur in the morning and noon hours and VF peaks occurs at the night and morning hours. Betablocker and/or amiodarone usage do not alter this distribution.

Aim: The relationships between clinical events and acetylsalicylic acid resistance (AR), as well as its frequency, have been established in stable patients with coronary artery disease (CAD). Although acute coronary syndrome (ACS) patients taking acetylsalicylic acid have been accepted as a high-risk population, the role of AR has not been investigated in these patient groups. Thus, in the present study, the impact of AR was investigated in patients with ACS who were taking acetylsalicylic acid., Methods: Between January 2001 and February 2003, 140 ACS patients were included in the present prospective study. All patients had ACS while taking acetylsalicylic acid. Coronary angiographic scores for severity and extent of CAD were determined for all patients. The effect of acetylsalicylic acid on platelet function was assessed by the platelet function analyzer PFA-100 (Dade Behring, USA). The primary end point was the composite of death, myocardial infarction, cerebrovascular accident and revascularization. The mean follow-up period was 20 months., Results: Patients with AR were older than patients without AR (63.8+/-10.8 years versus 58.3+/-11.2 years; P=0.005). Moreover, myocardial damage was higher in patients with AR according to cardiac troponin T values (1.11+/-1.3 mug/L versus 0.41+/-0.5 mug/L; P=0.01). The composite end point of death, myocardial infarction, cerebrovascular accident or revascularization was present in 16 of 45 patients (35%) with AR and in 13 of 79 patients (16%) without AR (hazard ratio 2.46, 95% CI 1.18 to 5.13; P=0.016). After adjustment for age, platelet count, cardiac troponin T value and CAD severity score, AR remained an independent predictor for long-term adverse events (hazard ratio 3.03, 95% CI 1.06 to 8.62; P=0.038)., Conclusions: The clinical event rate was found to be higher in ACS patients with AR than in those without AR. Thus, it may be concluded that there is a strong correlation between a worse prognosis and AR in these patients.

Background: Radiofrequency (RF) catheter ablation is the procedure of choice for the potential cure of atrioventricular nodal reentrant tachycardia (AVNRT) with high success rates. We hypothesed that as a result of the close proximity of Koch's triangle and low inter-atrial septal fibers, the RF ablation applied at this region may result in prolongation of inter-atrial conduction time (IACT)., Methods: RF ablation of AVNRT was performed by conventional technique. IACT was measured before and 20 minutes after RF ablation during sinus rhythm. Number of ablations given and duration of ablation were noted., Results: The study group was consisted of 48 patients (36 [75%] female, 12 [25%] male, mean age 43.4 +/- 14. 5 years). RF ablation was successful in all patients. Mean RF time was 4. 0 +/- 3. 3 minutes and mean number of RF was 11. 9 +/- 9, 8. The mean IACT was 70.1 +/- 9.0 ms before ablation and 84.9 +/- 12.7 ms after ablation, which demonstrated a significant prolongation (p<0.001). The prolongation of IACT was very well correlated with the number of (r=0.897, p<0.001) and duration of RF (r=0.779; p<0.001)., Conclusions: RF ablation of AVNRT results in prolongation of IACT. The degree of prolongation is associated with the duration and number of RF ablations given. The relationship between this conduction delay and late arrhythmogenesis need to be evaluated.

The objective of this study was to compare the anatomic course of anomalous coronary arteries by axial and three-dimensional volume-rendered electron beam computed tomography (EBCT) angiography and X-ray catheter angiography (CAG). We performed a blinded study where patients who previously underwent CAG with (n = 14) and without (n = 14; age- and gender-matched controls) anomalous coronary anatomy were studied with EBCT coronary angiography. Forty to 50 EKG-triggered 3 mm overlapping axial slices were acquired with 2 mm table movement within one breath hold during the i.v. injection of 140 cc of nonionic iodinated contrast (4 ml/sec). The axial source images and volume-rendered three-dimensional reconstructions were evaluated for the presence, type, and course of coronary anomalies and the results were compared to those of CAG. All normal and anomalous coronary arteries were identified by both modalities in all subjects. Identified anomalies include single coronary artery (n = 3), left-sided right coronary artery (n = 3), right-sided left main coronary artery (n = 3), anterior descending coronary artery (n = 2), circumflex coronary artery (n = 2), and separate left-sided ostia for left anterior descending and circumflex coronary arteries (n = 1). In five cases, there was discrepancy in the course of the anomalous vessels between the two modalities. Consensus reading among cardiologist and radiologists favored the interpretation of EBCT over catheter angiography. Noninvasive EBCT coronary angiography compares well with CAG in identifying anomalous coronary arteries and may provide confirmatory evaluation of their precise anatomic relationships to the heart and great vessels., (Copyright 2005 Wiley-Liss, Inc.)

Aspirin is widely used for secondary prevention of cardiovascular disease, but is not effective for all patients. This phenomenon is called as aspirin resistance. Although the prognosis is worse in patients who develop acute coronary syndrome (ACS) while using aspirin, the frequency of aspirin resistance in these patients has not been evaluated. We aimed to evaluate the frequency of aspirin resistance in patients with ACS and to determine its relationship with the angiographic severity and extent of the associated coronary artery disease. The present study included 104 patients with ACS (75 men, 60.4 +/- 10.8 years) who were hospitalized while using aspirin for at least last 7 days and 100 patients with stable coronary artery disease (73 men, 57.6 +/- 10.6 years), documented by coronary angiography, history of revascularization or myocardial infarction (MI), and the use of aspirin for last 7 days. The latter group had no MI or ACS for last 3 months. Platelet function was assessed with PFA-100, which simulates primary homeostasis at injured blood vessels. Coronary angiography was performed in 83 cases of the patients with ACS during hospital stay. Aspirin resistance is more prevalent in patients with ACS (40.3%) when compared with stable coronary artery disease patients (27%). The difference was statistically significant (p = 0.04). The ACS patients with aspirin resistance were older and had severe myocardial damage. However, there were no significant differences in angiographic severity and extent of coronary artery disease between aspirin-resistant and aspirin-sensitive patients. Frequency of aspirin resistance is higher in patients who develop ACS while using aspirin than that in patients with stable coronary artery disease.

Diabetic retinopathy (DR) is an early and frequent marker of other vascular complications of diabetes and its relation with coronary ischemia is known. The aim of the present study was to evaluate the association between DR and indices of coronary artery disease (CAD) severity and extent determined by coronary angiography. Sixty-nine diabetic patients undergoing coronary angiography for suspected CAD were evaluated. The severity and extent of CAD were scored from coronary angiograms by using 3 scores. Retinopathy was graded by fundus examination. There were differences in the severity score, extent score, number of vessels with disease, duration of diabetes, diabetes therapy, history of previous myocardial infarction (MI), and serum creatinine level among patients with and without DR. CAD severity was associated with the presence of DR (r: 0.53, P < 0.001), grade of DR (r: 0.52, P < 0.001), duration of diabetes (r: 0.28, P: 0.019), history of previous MI (r: 0.36, P: 0.002); and serum creatinine level (r: 0.24, P: 0.049) where the presence of DR was the only independent factor related to the severity score in multivariate analysis (r: 0.48, P < 0.001). The parameters related to the extent score were the presence of DR (r: 0.50, P < 0.001); grade of DR (r: 0.48, P < 0.001); previous MI (r: 0.37, P: 0.002) and age of the patient (r: 0.26, P: 0.033). Factors independently related to the extent score in multivariate analysis were the presence of DR (r: 0.37, P: 0.001), previous MI (r: 0.30, P: 0.006), and age of the patient (r: 0.22, P: 0.003). Among diabetics who are suspected of having CAD, those with retinopathy have more diffuse and severe coronary atherosclerosis, compared with diabetics without retinopathy. This cannot be explained by a longer duration or inferior control of the disease.

Although many patients with coronary artery disease are being treated by coronary stents, in-stent restenosis is the major limitation of percutaneous coronary stenting procedures. Most stents are made of stainless steel, and that, allergic reactions to nickel ions released from coronary stainless-steel stents may be one of the triggering mechanisms for in-stent restenosis. We aimed to evaluate the relationship between in-stent restenosis and nickel allergy in a prospective study. For this purpose, we applied epicutaneous patch test for nickel in 43 patients who had undergone elective intracoronary stent placement for stable angina pectoris in the day following stent placement and evaluated the presence of nickel allergy. Control angiography was performed at 6 months to determine in-stent restenosis. Three (6.9%) patients had allergic reaction to nickel and 16 (37%) patients had developed in-stent restenosis. One of the 3 patients with nickel allergy had diffuse in-stent restenosis and the others not. The present study therefore does not support the proposed relationship between nickel allergy and development of in-stent restenosis in patients having stainless steel stents. Large scale studies are needed to reach a final conclusion.

Objective: Elevated mean platelet volume predicts restenosis after percutaneous transluminal coronary angioplasty but its effect on the development of in-stent restenosis is not known. We assessed the effect of mean platelet volume measured before coronary stent implantation for stable angina pectoris on subsequent development of in-stent restenosis., Methods and Results: We retrospectively analysed the data of 60 patients who had stent implantation on one native coronary artery for stable angina pectoris and control angiographies for clinically suspected restenosis within 6 months. Mean platelet volume was measured by auto analyzer one day before stent implantation. Clinical and demographic data and laboratory results were obtained from the hospital charts of the patients. In-stent restenosis was evaluated visually from control angiograms. Angiographic in-stent restenosis was present in 35 (58%) of 60 patients and 25 (42%) patients had no restenosis. Mean platelet volume in the in-stent restenosis group was 8.28 +/- 0.71 fl compared to 7.63 +/- 0.74 fl in the no-restenosis group (p = 0.001). There was a positive correlation between preprocedural mean platelet volume and development of in-stent restenosis (r = 0.44; p < 0.001). A mean platelet volume value of > or = 8.4 fl was associated with an odds ratio of 16.0 for development of in-stent restenosis, with high specificity and positive predictivity but poor sensitivity and negative predictivity (96%, 93%, 40% and 53%, respectively)., Conclusions: Mean platelet volume measured before stent implantation is correlated with subsequent development of in-stent restenosis. If preprocedural mean platelet volume is greater than 8.4 fl, in-stent restenosis is more probable to occur.

Background and Aim of the Study: Mitral regurgitation (MR) shows different characteristics in mitral valve prolapse (MVP); hence, it is important to assess MR severity accurately in these patients. The study aim was to compare Doppler echocardiographic methods in making such assessment., Methods: Forty-seven patients with confirmed MVP and at least moderate mitral insufficiency, as established by Doppler echocardiography, were studied. Quantitative Doppler was used as the reference standard method. Color Doppler mapping was used to determine regurgitant jet area (JA/LAA), flow convergence (EROA-PISA) and vena contracta width (VCW). Systolic pulmonary venous flow reversal (SPVFR) and mitral E-wave velocity were also monitored., Results: Univariate analysis showed severe MR to be significantly correlated to age, presence of atrial fibrillation, left ventricular systolic and diastolic diameter, left atrial diameter, mitral E velocity, JA/LAA, VCW, EROA-PISA and the presence of SPVFR. On multivariate analysis, the strongest determinants of severe MR were EROA-PISA, VCW and E velocity. The greatest area under the receiver-operator curve for diagnosing severe MR was observed with EROA-PISA. The 45-mm2 threshold of EROA-PISA had the highest risk ratio of severe MR with a high sum of sensitivity and specificity. However, the JA/LAA had the lowest risk ratio and negative predictive value for severe MR., Conclusion: PISA, VCW, E velocity and SPVFR measurements may be used to evaluate MR severity semi-quantitatively in patients with MVP; however, the ratio of JA/LAA appears to be a less reliable method in this respect.

Objective: This study was planned to determine pulmonary artery pressure and pulmonary vascular resistance by using tricuspid annular tissue Doppler imaging in patients with valvular and congenital heart disease., Methods: The study group consisted of patients with valvular and congenital heart disease (n=28). Healthy volunteers (n=10) were included into the control group. Systolic (Sm), early (Em) and late diastolic velocity (Am), isovolumetric relaxation time (IVRTm) were measured from tricuspid annulus by tissue Doppler imaging. Patients of the study group underwent cardiac catheterization and right atrial mean pressure, right ventricle and pulmonary artery systolic- diastolic pressures (PASP and PADP), and pulmonary capillary wedge pressure (PVR, dyn/s/cm-5) were obtained., Results: There were no significant differences between the groups according to age, gender, left and right ventricle ejection fraction, tricuspid annular Sm, Em and Am velocities and velocity- time integrales (p>0.05). IVRTm was increased in the study group (73.75+/-3.1 ms, p<0.05). For Sm velocities of 11 cm/sec, prediction of PASP >/=30 mmHg was calculated with specificity of 57%, sensitivity of 93%, positive predictive value of 88%, negative predictive value of 68% and accuracy of 75%. For Sm velocities - time integral value of 2.7 cm/sec, prediction of the PVR >/=65 dyn/s/cm-5 was estimated with sensitivity of 88%, specificity of 36%, positive predictive value of 68%, negative predictive value of 66% and accuracy of 68 %., Conclusion: Pulmonary artery pressure and pulmonary vascular resistance in patients with valvular and congenital heart disease can be predicted by using the Sm wave parameters detected with tricuspid annular tissue Doppler imaging.

Some patients with hypertrophic nonobstructive cardiomyopathy (HNCM) suffer symptoms resembling those in obstructive type despite no left ventricular outflow tract (LVOT) gradient could be detected on resting echocardiography. To investigate the value of dobutamine stress echocardiography (DSE) in determining the dynamic left ventricular (LV) obstruction of patients with HNCM. The study was conducted on 31 patients who were diagnosed HNCM on resting echocardiography and 9 healthy person as a control group. Intraventricular flow acceleration of > 3 m/sec on DSE was accepted as dynamic LVOT obstruction. Group 1 and 2 included patients without and with dynamic LVOT obstruction, respectively. The occurrence of chest pain and dyspnea seen during DSE was more frequent in group 2 than group 1 and control group. The frequency of SAM was significantly higher (p < 0.05) and the septal angle was significantly lower (p < 0.001) in Group 2. The presence of SAM significantly correlated with the peak gradient (r = 0.61, p < 0.001). The septal angle had significant negative correlations with the peak gradient (r = -0.77, p < 0.001) reached at DSE. The relative risk for peak gradient was highest when septal angle was < or = 100 degrees, with a sensitivity of 93%, specificity of 80%, positive predictive value of 82%, negative predictive value of 92%, and predictive accuracy of 87%. DSE is a reliable tool for the diagnosis of dynamic LV obstruction in patients with HNCM. The presence of SAM together with a low septal angle is highly predictive for the presence of a dynamic LVOT obstruction detected by DSE.

Background and Aims of the Study: Recent studies evaluating the severity of valvular insufficiencies have focused on the effective regurgitant orifice area (EROA), which corresponds hydrodynamically to the cross-sectional area of the vena contracta (VC). The study aim was to quantify aortic regurgitation (AR) by using color Doppler imaging of the VC., Methods: Fifty-five patients with chronic AR were enrolled into the study. VC was visualized by transthoracic echocardiography from the apical echocardiographic window. The quantitative Doppler (QD) method, depending on mitral and aortic stroke volumes, was taken as a reference method. EROA, regurgitant volume (RV) and regurgitant fraction (RF) were calculated using both VC and QD simultaneously in all patients, and the results obtained with each method were compared., Results: EROA(QD) (r = 0.96), RFQD (r = 0.84), RVQD (r = 0.82), and AR grade 3+ or 4+ (r = 0.74) were statistically significantly correlated with VC (4.8+/-1.2 mm). In the multivariate analysis, VC was related only to EROA(QD). The EROA (r = 0.96, p <0.001; mean difference 0+/-0.03 cm2, SEE = 0.004 and p >0.05), RV (r = 0.97, p <0.001; mean difference =1.3+/-4.8 cm3, SEE = 0.65 cm3 and p >0.05) and RF (r = 0.93, p <0.001; mean difference = 1.46+/-4.9%, SEE = 0.66% and p >0.05) obtained by both methods agreed well with each other. VC had a sensitivity of 80%, a specificity of 86%, and an accuracy of 84% in determining severe AR for VC > or =5.5 mm., Conclusion: The vena contracta can be visualized using a transthoracic approach from the apical window. The severity of AR can be evaluated using the VC width itself, and also in combination with Doppler data.

Background and Aims of the Study: In order to provide patients with better exercise capacity, interventional therapy to the mitral valve is often carried out in mitral stenosis (MS). Hence, it is crucial to determine exercise capacity before deciding on the time of intervention. The study aim was to demonstrate whether resting parameters of the mitral valve, notably left ventricular diastolic filling period (LVDFP) and mitral valve resistance (MVR), relate to restricted exercise capacity., Methods: Forty-six patients (30 females, 16 males; mean age 44+/-11 years; range: 33-55 years) with rheumatic MS were enrolled. Exercise capacities of patients were grouped according to NYHA classification and maximal exercise tolerance values obtained using exercise testing. Exercise capacity in male patients was quantified. Relationships between patient variables and exercise capacity were evaluated using simple linear regression analysis. In order to identify determinants of exercise capacity, a discriminate multivariate analysis was performed with variables, which were found to correlate significantly in the univariate analysis., Results: There were no correlations between echo score, MVR, planimetric mitral valve area (MVA), MVA obtained by the pressure half-time method or calculated by the continuity equation, and transmitral mean gradient and exercise capacity classes as defined by both NYHA and exercise testing. The only predictor of exercise capacity class determined by discriminate multivariate analysis using the significant parameters in the linear regression analysis was LVDFP. The quantified exercise capacity in male patients correlated only with LVDFP (r = 0.64, p = 0.008)., Conclusion: Exercise capacity cannot be predicted using routine resting parameters of the mitral valve (including MVR) in patients with MS. In this respect, the LVDFP may be of value.

Objective: This study was planned to assess the vena contracta (VC), flow convergence area (PISA) and jet area (JA) methods in evaluating the severity of mitral regurgitation (MR) and to test the accuracy of a proposed algorithm using these methods., Methods: Eighty-seven patients with chronic MR were enrolled in the study. VC of < 0.3 cm, maximal MR flow rate calculated by PISA (Qmax) of < 72 cm3/sn and JA of < 4 cm2 were classified as mild MR. VC of > 0.5 cm, Qmax of > 240 cm3/sn and JA of > 8 cm2 were classified as severe MR. Whereas the values between these ranges were called to be moderate MR. The algorithm was planned as follows: In the first step, VC width was measured. If a patient has VC = 0.3-0.5 cm, it was used Qmax in the eccentric jets and JA in the central jets in the second step. The severity of MR were considered as severe, moderate and mild for > 50%, 21-49% and 20% of the regurgitant fraction calculated by the reference method (the quantitative Doppler method depending on aortic and mitral stroke volumes), respectively., Results: The sensitivity of VC was low in differentiating between moderate and severe MR (63%). In eccentric jets, the regurgitant volume calculated by PISA was higher than that of reference method (70 +/- 49 vs. 59 +/- 29 cm3) and the JA was found to be less than that of central jets despite similar regurgitant fraction (6.8 +/- 3.2 vs. 8.5 +/- 3.3 cm2). The algorithm agreed well with the reference method and it was better than those of each tree methods (Cappa coefficients 0.89 vs. 0.65, 0.63 and 0.45 for VC, Qmax and JA; respectively). The accuracies of the algorithm in discriminating between mild and moderate MR or severe and non-severe MR were high (98% and 95%, respectively)., Conclusions: The severity of MR can be determined accurately and simply by using VC, PISA and JA methods together.

Objective: Systolic pulmonary venous flow reversal (SPVFR) has been evaluated in mitral regurgitation (MR) primarily by transoesophageal echocardiography (TEE). There is limited study on the value of SPVFR obtained from transthoracic echocardiography (TTE) for the quantification of MR. In this study, determinants of SPVFR and the accuracy of SPVFR obtained with TTE in determining the severity of MR were investigated., Methods and Results: Fifty patients with MR in whom reference quantitative Doppler evaluation was carried out formed the study group. Thirty-nine of them underwent cardiac catheterization. In all patients, SPVFR was evaluated by pulsed Doppler echo placed both at the right and left pulmonary vein in the apical four-chamber view. The SPVFR was present in 26 (52%) patients. Atrial fibrillation, and grade III-IV MR by catheterization were more frequent in patients who had SPVFR. Patients with SPVFR had increased values for regurgitant orifice area, regurgitant volume, regurgitant fraction, and left atrium/left ventricle diameters and volumes compared to patients without SPVFR. After multivariate analysis regurgitant fraction (RF) was the single and most powerful determinant of SPVFR (p<0.001). The SPVFR had high sensitivity, specificity and accuracy for the diagnosis of severe MR (89, 95 and 92%, respectively)., Conclusion: It was concluded that SPVFR is a useful method for the evaluation of the severity of mitral regurgitation.

This study was designed to assess the reliability of the proximal isovelocity surface area (PISA) method for the estimation of shunt quantification in perimembranous ventricular septal defects (PVSD). The study group was composed of 30 patients (age 11 +/- 7 years, 13 female) with PVSD. The shunt flow (Qp-Qs) and the ratio of the pulmonary flow to the systemic flow (Qp/Qs) were calculated by spectral Doppler and catheterization. The Qp-Qs, the defect area (DA), and the shunt volume (SV) were obtained by the PISA method. The PISA method estimated the DA (cm(2)/m(2)), the SV (cm(3)/m(2)), and the Qp-Qs (L/min/m(2)) to be equal to (2 x pi x R(2) x NL)/(V(max) x Body surface area), DA x TVI(shunt), and to SV x Heart rate, respectively (R is the distance of the maximal PISA from the first aliasing line to the left ventricular side of the defect, NL is the nyquist limit, and V(max) and TVI(shunt) are the peak velocity and time-velocity integral of transdefect Doppler tracing obtained by continuous-wave Doppler). The PISA method (3.4 +/- 1.5 L/min/m(2)) underestimated the Qp-Qs according to spectral Doppler (r = 0.96, P < 0.001; mean difference -0.74 +/- 0.61 L/min/m(2); SEE = 0.11 L/min/m(2), P < 0.001) and catheterization (r = 0.92, P < 0.001; mean difference -0.45 +/- 0.7 L/min/m(2); SEE = 0.13 L/min/m(2), P < 0.001). The correlations between the PISA findings (Qp-Qs, DA, SV) and the catheterization Qp/Qs (r = 0.86, 0.84, and 0.86; P < 0.001, respectively), or between these and the spectral Doppler Qp/Qs (r = 0.80, 0.80, and 0.79; P < 0.001, respectively) were significant. The accuracies of the PISA findings in identifying large defects were high (0.90, 0.93, and 0.90 for cut-off values of Qp-Qs = 3.67 L/min/m(2), DA = 0.44 cm(2)/m(2), and SV = 43 cm(3)/m(2), respectively). As a result, the PISA method can be a simple and reliable alternative to the spectral Doppler method in the identification of large shunts in PVSD.