Systemic immune inflammation index and its implication on in-stent restenosis among patients with acute coronary syndrome.

OBJECTIVE: This study aims to assess the predictive value of the Systemic Immune Inflammation Index (SII) in determining in-stent restenosis (ISR) likelihood in patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI). METHODS: The study enrolled 903 ACS patients undergoing PCI, categorized into ISR (+) and ISR (-) groups based on control coronary angiography results. Demographic, clinical, laboratory, and angiographic-procedural characteristics were systematically compared. RESULTS: The ISR (+) group encompassed 264 individuals (29.2%), while the ISR (-) group comprised 639 individuals (70.8%). Patients had a mean age of 55.8 ±â€…10.2 years, with 69% being male. The ISR (+) group had higher diabetes and smoking prevalence and notably larger stent dimensions. Lab parameters showed significantly elevated creatinine, total cholesterol, red cell distribution width, white blood cell and neutrophil counts, SII index and C-reactive protein (CRP) in the ISR (+) group, while lymphocyte levels were lower. Binary logistic regression identified stent diameter (odds ratio [OR]: 0.598, 95% confidence interval [CI]: 0.383-0.935; P  = 0.024), stent length (OR: 1.166, 95% CI: 1.132-1.200; P  < 0.001), creatinine (OR: 0.366, 95% CI: 0.166-0.771; P  = 0.003), CRP (OR: 1.075, 95% CI: 1.042-1.110; P  = 0.031), and SII index (OR: 1.014, 95% CI: 1.001-1.023; P  < 0.001) as independent ISR predictors. CONCLUSION: The SII index exhibits potential as a predictive marker for ISR in ACS patients post-PCI, indicating systemic inflammation and heightened restenosis risk. Integrating the SII index into risk models could identify high-risk patients for targeted interventions.

The predictive value of PRECISE-DAPT score for long-term mortality in patients with acute coronary syndrome complicated by cardiogenic shock.

BACKGROUND: Besides its primary clinical utility in predicting bleeding risk in patients with acute coronary syndrome (ACS), the PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Anti-Platelet Therapy) score may also be useful for predicting long-term mortality in ACS patients presenting with cardiogenic shock (CS) since several studies have reported an association between the score and certain cardiovascular conditions or events. The aim of the present study was to evaluate the utility of the PRECISE-DAPT score for predicting the long-term all-cause mortality in patients (n = 293) with ACS presenting with CS. METHODS: The PRECISE-DAPT score was calculated for each patient who survived in hospital, and the association with long-term mortality was studied. Median follow-up time was 2.7 years. The performance of the final model was determined with measurements of its discriminative power (Harrell's and Uno's C indices and time-dependent area under the receiver operating characteristic curve [AUC]) and predictive accuracy (coefficient of determination [R2] and likelihood ratio χ2). Hazard ratios (HRs) were used to assess the relationship between the variables of the model and long-term all-cause death. RESULTS: All-cause death occurred in 197 patients (67%). There was a positive association between the PRECISE-DAPT score (change from 17 to 38 was associated with an HR of 2.42 [95% CI: 1.59-3.68], R2 = 0.209, time-dependent AUC = 0.69) and the risk of death such that in the adjusted survival curve, the risk of mortality increased as the PRECISE-DAPT score increased. CONCLUSION: The PRECISE-DAPT score may be a useful easy-to-use tool for predicting long-term mortality in patients with ACS complicated by CS.

Comparison of Ticagrelor and Clopidogrel in Patients With Acute Coronary Syndrome at High Bleeding or Ischemic Risk.

Current guidelines recommend individualizing the choice and duration of P2Y12 inhibitor therapy based on the trade-off between bleeding and ischemic risk. However, whether a potent P2Y12 inhibitor (ticagrelor) or a less potent one (clopidogrel) is more appropriate in patients with acute coronary syndrome (ACS) in the setting of high bleeding or ischemic risk is not clear. The study aimed to compare the clinical outcomes of clopidogrel and ticagrelor in patients with ACS at high bleeding or ischemic risk. A total of 5,713 patients with ACS were included in this retrospective study. The Cox proportional hazard regression model was adjusted by applying the inverse probability weighted approach to reduce treatment selection bias. The primary clinical outcome was all-cause death. Secondary outcomes included in-hospital death, ACS, target vessel revascularization, stent thrombosis, stroke, or clinically significant or major bleeding. The median follow-up duration was 53.6 months. After multivariable Cox model using an inverse probability weighted approach, all-cause death in the overall population and subgroups of patients at high bleeding risk, and/or at high ischemic risk were not significantly different between clopidogrel and ticagrelor. Rates for secondary outcomes were also similar between the groups. In conclusion, ticagrelor and clopidogrel are associated with comparable clinical outcomes in patients with ACS irrespective of bleeding and ischemic risk.

Predictive value of PRECISE-DAPT score for long-term all-cause mortality in atrial fibrillation patients with non-ST-elevation myocardial infarction.

Introduction: Atrial fibrillation (AF) may co-exist in patients with non-ST-elevation myocardial infarction (NSTEMI). In patients with NSTEMI, AF should therefore be regarded as an important risk factor irrespective of its presentation. To predict outcomes in AF patients presenting with NSTEMI, early risk stratification can help to identify the patients with a possible poor long-term prognosis. The development of the PRECISE-DAPT score aimed to predict the risk of bleeding in patients who underwent stent implantation and received dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI), providing a valuable tool for assessing bleeding risk in this specific patient population. Aim: To assess the performance of the PRECISE-DAPT score in predicting long-term prognosis in AF patients with NSTEMI. Material and methods: Five hundred and twenty-six consecutive AF patients presenting with NSTEMI were included in the present study. The PRECISE-DAPT score was calculated in each case and evaluated for the association of increased mortality in the study population, who survived in-hospital but died in the long term. Results: All-cause mortality deaths occurred in 278 (52.6%) patients. Higher PRECISE-DAPT score, shorter duration of P2Y12 inhibitor therapy, decreased left ventricular ejection fraction (LVEF), and a history of diabetes mellitus (DM) were all associated with an increased risk of all-cause mortality in the multivariable logistic regression model. Conclusions: High PRECISE-DAPT score was associated with higher long-term all-cause mortality in AF patients presenting with NSTEMI.

The relation of polymer structure of stent used in patients with acute coronary syndrome revascularized by stent implantation with long-term cardiovascular events.

INTRODUCTION: Drug-eluting stents (DES) have revolutionized percutaneous coronary intervention (PCI) by improving event-free survival compared to older stent designs. However, early-generation DES with polymer matrixes have raised concerns regarding late stent thrombosis due to delayed vascular healing. To address these issues, biologically bioabsorbable polymer drug-eluting stents (BP-DES) and polymer-free drug-eluting stents (PF-DES) have been developed. AIM: The aim of the present study is to evaluate and compare the long-term effects of different stent platforms in patients with acute coronary syndrome (ACS) undergoing PCI. MATERIAL AND METHODS: We conducted a retrospective, observational study involving 1192 ACS patients who underwent urgent PCI. Patients were treated with thin- strut DP-DES, ultra-thin strut BP-DES, or thin-strut PF-DES. The primary endpoint was a composite of cardiac death, target vessel myocardial infarction (TVMI), and clinically driven target lesion revascularization (CITLR) at 12 months and 4 years. RESULTS: The baseline demographics and clinical characteristics of patients in the three stent subgroups were similar. No significant differences were observed in target lesion failure (TLF), cardiac mortality, TVMI, and stent thrombosis (ST) rates among the three subgroups at both 12 months and 4 years. However, beyond the first year, the rate of CITLR was significantly lower in the ultra-thin strut BP-DES subgroup compared to thin-strut DP-DES, suggesting potential long-term advantages of ultra-thin strut BP-DES. Additionally, both ultra-thin strut BP-DES and thin-strut PF-DES demonstrated lower ST rates after the first year compared to thin-strut DP-DES. CONCLUSION: Our study highlights the potential advantages of ultra-thin strut BP-DES in reducing CITLR rates in the long term, and both ultra-thin strut BP-DES and thin-strut PF-DES demonstrate lower rates of ST beyond the first year compared to thin-strut DP-DES. However, no significant differences were observed in overall TLF, cardiac mortality and TVMI rates among the three stent subgroups at both 12 months and 4 years.

Prevalence of Fabry Disease in patients with left ventricular hypertrophy in Turkey: Multicenter study (LVH-TR subgroup analysis).

PURPOSE: In this prospective study we aimed to determine the rate of Fabry Disease (FD) in patients with left ventricular hypertrophy (LVH), and to evaluate the clinical presentations of patients with FD in a comprehensive manner. In addition, we aimed to raise awareness about this issue by allowing early diagnosis and treatment of FD. METHODS: Our study was planned as national, multicenter, observational. Totally 22 different centers participated in this study. A total of 886 patients diagnosed with LVH by echocardiography (ECHO) were included in the study. Demographic data, biochemical parameters, electrocardiography (ECG) findings, ECHO findings, treatments and clinical findings of the patients were recorded. Dry blood samples were sent from male patients with suspected FD. The α-Gal A enzyme level was checked and genetic testing was performed in patients with low enzyme levels. Female patients suspected of FD were genetically tested with the GLA Gene Mutation Analysis. RESULTS: FD was suspected in a total of 143 (16.13%) patients included in the study. The α-Gal-A enzyme level was found to be low in 43 (4.85%) patients whom enzyme testing was requested. GLA gene mutation analysis was positive in 14 (1.58%) patients. Male gender, E/e' mean ,and severe hypertrophy are important risk factor for FD. CONCLUSION: In daily cardiology practice, FD should be kept in mind not only in adult patients with unexplained LVH but also in the entire LVH population. Dry blood test (DBS) should be considered in high-risk patients, and mutation analysis should be considered in required patients.

Endocarditis-TR: Diagnosis, treatment, and prognosis of the infective endocarditis patients admitting tertiary centres of Turkey.

BACKGROUND: Infective endocarditis (IE) is still a significant cause of morbidity and mortality among cardiovascular diseases. ENDOCARDITIS-TR study aims to evaluate the compliance of the diagnostic and therapeutic methods being used in Turkey with current guidelines. METHODS: The ENDOCARDITIS-TR trial is a multicentre, prospective, observational study consisting of patients admitted to tertiary centres with a definite diagnose of IE. In addition to the demographic, clinical, microbiological, and echocardiographic findings of the patients, adverse events, indications for surgery, and in-hospital mortality were recorded during a 2-year time interval. RESULTS: A total of 208 IE patients from 7 tertiary centres in Turkey were enrolled in the study. The study population included 125 (60.1%) native valve IE (NVE), 65 (31.3%) prosthetic IE (PVIE), and 18 (8.7%) intracardiac device-related IE (CDRIE). One hundred thirty-five patients (64.9%) were culture positive, and the most frequent pathogenic agent was methicillin-susceptible Staphylococcus aureus (MSSA) (18.3%). Among 155 (74.5%) patients with an indication for surgery, only 87 (56.1%) patients underwent surgery. The all-cause mortality rate was 29.3% in-hospital follow-up. Multivariable Cox regression analysis revealed that absence of surgery when indicated (HR: 3.29 95% CI: 0.93-11.64 p = 0.05), albumin level at admission (HR: 0.46 95% CI: 0.29-0.73 P < 0.01), abscess formation (HR: 2.11 95% CI: 1.01-4.38 p = 0.04) and systemic embolism (HR: 1.78 95% CI: 1.05-3.02 p = 0.03) were ascertained independent predictors of in-hospital all-cause mortality. DISCUSSION: The short-term results of the ENDOCARDITIS-TR trial showed the high frequency of staphylococcal IE, relatively high in-hospital mortality rates, shortage of surgical treatment despite guideline-based surgical indications and low usage of novel imaging techniques. The results of this study will provide a better insight to physicians in respect to their adherence to clinical practice guidelines.

Successful treatment of patent ductus arteriosus accompanying right-sided aortic arch and aberrant left subclavian artery: a case report.

Background: The coexistence of a right-sided aortic arch (RAA), an aberrant left subclavian artery (ALSA), and a patent ductus arteriosus (PDA) is a rarely seen vascular ring anomaly. There is currently no general guideline consensus on the management and follow-up of this congenital defect, posing a challenge to the clinicians. At this point, the heart team plays a critical role in the management of the disease. Case summary: In the present case, a 25-year-old male patient was presented to the outpatient clinic with dyspnoea and fatigue. A transthoracic echocardiography revealed PDA with a left-to-right shunt. To evaluate the anatomy thoroughly, a thoracic computed tomographic angiography was performed and showed PDA accompanying ALSA and RAA. The patient was evaluated by the Heart Team, and a percutaneous closure of PDA was recommended due to signs of left ventricular volume overload. The closure was successfully performed with Amplatzer vascular plug II. At follow-up, the patient was free of symptoms. Discussion: Clinicians should be aware of the potential concomitant lesions during the diagnostic work-up. In selected patients, percutaneous closure of PDA may be the first-line therapy in experienced centres.

A novel electrocardiographic parameter for the prediction of atrial fibrillation after coronary artery bypass graft surgery "P wave peak time".

OBJECTIVES: Patients with postoperative atrial fibrillation (POAF) have increased risk of both short- and long-term mortality and morbidity; therefore, prediction of POAF is crucial in the preoperative period of the patients undergoing coronary artery bypass graft surgery. Electrocardiography (ECG) is the simplest and cost-effective tool in the preoperative workup of the patients for the prediction of POAF. A newly defined ECG parameter P wave peak time (PWPT) has been shown as a marker of atrial fibrillation development in non-surgical patients and we investigated its role in patients undergoing cardiac surgery. METHOD: A total of 327 patients undergoing isolated or combined cardiac surgery were involved and the primary endpoint was defined as the development of POAF. The study population was divided into two groups based on the presence or absence of POAF. Groups were compared for both standard P wave parameters and for PWPT on surface ECG. The predictors of POAF were assessed by multivariate regression analysis. RESULTS: The frequency of POAF was 20.4% (n = 67). P wave peak time in leads D2 (65.1 ± 11.8 vs 57.2 ± 10, p < 0.01) and V1 (57.8 ± 18 vs 44.8 ± 12.3, p < 0.01) were longer in patients with POAF. In multivariate regression analysis, PWPT in leads DII and V1 were independent predictors of POAF (OR: 1.11, 95%CI: 1.02-1.21, p = 0.01, OR: 1.06, 95%CI: 1.00-1.13, p = 0.03 respectively). CONCLUSION: PWPT in leads DII and V1 can predict the development of POAF in patients undergoing cardiac surgery.

Percutaneous closure of a complex fistula that originates from all coronary arteries and drains to the pulmonary artery.

A coronary-to-pulmonary-artery fistula (CPAF) is defined as a connection between the coronary arteries and the pulmonary arteries (PAs). Invasive treatment options for CPAFs include surgical ligation and transcatheter coil or plug embolization. A 60-year-old female patient was referred to our hospital with symptoms of exercise-induced angina (Canadian Cardiovascular Society Class III [CCS-3]). Her relevant history included elective stenting of the left anterior descending (LAD) artery in 2013 and surgery for an LAD to PA fistula in 2015. Upon recurrence of the same fistula in 2017, she underwent a failed antegrade (from LAD to PA) attempt for percutaneous closure of the fistula. A retrograde approach was decided because of the extensive tortuosity of the fistula's proximal part that led to the previous failed attempt and the likelihood of ceasing whole blood flow at the fistula's distal neck. Through right femoral venous access, we advanced a 5 Fr. 45 cm TorqVue low-profile delivery system (St. Jude Medical, Little Canada, MN, USA) over a J-tip 0.035-inch guidewire to the PA. The antegrade imaging guidance enabled us to advance the guidewire to the distal neck of the fistula retrogradely. As the distal part of the fistula was similar to a tunnel-shaped patent ductus arteriosus (PDA) and was measured 4 mm at the narrowest diameter, we opted for an Amplatzer duct occluder II 6 × 6 (Abbott Vascular, Chicago, IL, USA) to close it.

Relationship between Epicardial Fat Tissue Thickness and CRP and Neutrophil-Lymphocyte Ratio in Metabolic Syndrome Patients Over 65 Years.

OBJECTIVE: There are no data evaluating the association of neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) with epicardial fat tissue thickness (EFTT) in elderly metabolic syndrome (MS) patients. In this study, we aimed to investigate the relationship of EFTT with CRP and NLR in patients with MS over 65 years. METHODS: A cross-sectional study was performed. Fifty patients (patient group) with MS and 25 subjects (control group) without MS were allocated in the study. All parameters were compared in patient and control groups. The correlations between NLR, CRP, and EFTT were evaluated. RESULTS: White blood cell and neutrophil levels were higher in MS group (p=0.020 and p=0.019, respectively). Both transverse and longitudinal EFTT were increased in MS patients (p<0.001). There was a significant correlation between the EFTT and NLR but not with CRP in the MS group (r=0.4, p=0.003). CONCLUSION: Our study showed that both longitudinal and transverse EFTT are associated with NLR in patients older than 65 years with MS. In geriatric MS patients, higher NLR level may be an indicator of increased visceral fat around the myocardium.

The association of preprocedural C-reactive protein/albumin ratio with in-stent restenosis in patients undergoing iliac artery stenting.

Introduction: In-stent restenosis (ISR) still constitutes a major problem after percutaneous vascular interventions and the inflammation has a pivotal role in the pathogenesis of such event. The C-reactive protein/albumin ratio (CAR) is a newly identified inflammatory biomarker, and it may be used as an indicator to predict ISR in subjects with coronary artery stenting. In light of these data, our main objective was to investigate the relationship between the preprocedural CAR and ISR in patients undergoing successful iliac artery stent implantation. Methods: In total, 138 consecutive patients who had successful iliac artery stent implantation in a tertiary heart center between 2015 and 2018 were enrolled in the study. The study population was categorized into two groups; patients with ISR and those without ISR during follow-up. The CAR was determined by dividing CRP by serum albumin. Results: In the multivariable regression analysis; the CAR (HR: 2.66, 95% CI: 1.66-4.25, P < 0.01), stent length (HR: 1.01, 95% CI: 0.99-1.02, P = 0.04), and HbA1c levels (HR: 1.22, 95% CI: 0.99-1.51, P = 0.04) were independently related with ISR. A receiver operating curve analysis displayed that the CAR value of >0.29 predicted ISR with sensitivity of 97.5% and specificity of 88.8% (AUC 0.94, P < 0.01). Conclusion: Our findings provide evidence that the CAR may be an applicable inflammatory biomarker in predicting ISR in subjects undergoing iliac artery stenting for the treatment of peripheral artery disease (PAD). Also, the stent length and poor glycemic control were found to be associated with ISR.

The association of inflammatory markers and echocardiographic parameters in Behçet's disease.

Background: The main objective of the current study is to find out if any association exists between specific inflammatory markers such as homocysteine (Hcy) and pentraxin-3 (PTX-3) and cardiac involvement determined by means of echocardiographic parameters in patients with Behçet disease (BD).Methods: From January 2011 to January 2012, a total of 62 Behçet's patients were enrolled in the study. Thirty-two healthy subjects constituted the control group. The diagnosis of BD was made as proposed by International Study Group of BD.Results: The mean PTX-3, Hcy, and C-reactive protein levels were significantly higher in patients with BD compared to the control group. The electromechanical delay (EMD) times were found to be prolonged in patients with BD. Also, the aortic stiffness index (SI) and elastic modulus (Ep) were significantly higher, while the aortic dispensibility was significantly lower in patients with BD. The left atrial volume, left atrial volume index, E/A ratio, E/E' septal, IRight-EMD, PA'-ML, PA'-MS, PA'-TL, SI, and Ep were correlated with PTX-3 levels. In addition, the E/A, PA'-ML, PA'-MS, SI, and Ep displayed correlation with Hcy levels in patients having BD.Conclusion: Elevated levels of PTX-3 and Hcy were found to be correlated with cardiac involvement determined by means of echocardiographic parameters in patients with BD.

Association of the positive T wave in lead aVR with short-term mortality in patients with acute pulmonary embolism.

Background: Lead aVR provides prognostic information in various settings for patients with cardiovascular diseases. The present study aimed to investigate the prognostic value of a positive T wave in lead aVR (TaVR) for patients with acute pulmonary embolism (APE).Methods: We screened a total of 412 consecutive patients who were hospitalised with a diagnosis of APE between 2008 and 2018. We investigated electrocardiograms (ECGs) for the presence of a positive TaVR and classified other abnormal ECG findings. Additionally, clinical data, such as echocardiographic findings were recorded, and pulmonary embolism severity index (PESI) scores were calculated. The predictors of mortality at 30 days were investigated as the clinical outcome by logistic regression analysis.Results: In our study population, 54 patients (13.1%) died within 30 days. The prevalence of female gender, congestive heart failure, chronic obstructive pulmonary disease, and mean PESI scores were significantly higher in patients with a positive TaVR compared to those without it. Systolic blood pressure of patients with positive TaVR was significantly lower than that of patients without positive TaVR. In multivariate regression analysis; PESI scores (OR: 1.03; 95% CI: 1.01-1.04, p < .01), Right ventricular end-diastolic diameter (RVEDD) (OR: 1.07 95% CI: 1.01-1.13, p = .02), and a positive TaVR (OR: 4.41; 95% CI: 1.63-11.96, p < .01) were independently correlated with mortality.Conclusion: Positive TaVR, PESI scores, and RVEDD at hospital admission may have prognostic value in patients with APE. Positive T wave in lead aVR could be a useful marker in early risk stratification of pulmonary embolism.

Prognostic value of serum uric acid levels in patients with non-STEMI undergoing percutaneous coronary intervention.

BACKGROUND: Because myocardial infarction in young adults is rare, there has been limited research on the condition in this patient group. Very few data are available regarding the long-term outcomes of patients under 40 years of age with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing invasive treatments. The prognostic value of uric acid (UA) in young patients with NSTEMI who undergo percutaneous coronary intervention (PCI) has also not been studied. The purpose of this study was to evaluate the long-term clinical outcomes of this specific subset of young patients. In addition, we aimed to identify the role of serum UA in predicting the long-term prognosis of young patients with NSTEMI who have undergone PCI. METHODS: We performed a retrospective analysis of 213 young adult patients (≤40 years old) with NSTEMI who underwent PCI during their hospitalization at our tertiary referral center. RESULTS: The mean age of the 213 patients was 36.8 ± 3.3 years (range, 21-40 years). The median follow-up was 930 days. Our patients were predominantly male (88.3%) and the most frequent traditional cardiovascular risk factors were smoking and dyslipidemia. Baseline TIMI flow 0-1, estimated glomerular filtration rate (eGFR), and UA were found to be independently correlated with long-term major adverse cardiovascular events (MACEs) in multivariate Cox regression analysis. CONCLUSION: In the present study, baseline TIMI flow 0-1, admission eGFR, and UA levels were correlated with MACEs during long-term follow-up in young patients with NSTEMI.

A Rare Cause of Angina After Coronary Bypass Grafting; Left Internal Mammary Artery to Pulmonary Artery Fistula and Successful Treatment with Transcatheter Coil Embolization.

Fistula from left internal mammary artery (LIMA) to pulmonary artery (PA) is rarely encountered in daily practice. In recent years, endovascular therapy options have emerged for the treatment of fistula formations and replaced with surgery. A 53-year-old man admitted to our outpatient clinic with symptoms of typical angina and shortness of breath despite optimal medical therapy. In his relevant history, he had a coronary artery bypass graft (CABG) operation in 2009 in which his LIMA was anastomosed to left anterior descending (LAD) and ramus artery sequentially. Coronary angiography including selective imaging of LIMA demonstrated a fistula formation originating from the proximal portion of the LIMA and draining to PA. After successful closure of fistula with transcatheter coil embolization, the patient was discharged without any complication and symptom. In conclusion, although LIMA to PA fistula is an infrequent clinical condition, it should be considered as a potential cause of persistent angina after CABG operation. Treatment options include conservative medical therapy, surgical ligation and endovascular interventions. The best therapy should be individualised for each patient in respect to patient's symptoms, surgical compatibility and anatomy of fistula.

A Rare Cause of Angina After Coronary Bypass Grafting; Left İnternal Mammary Artery to Pulmonary Artery Fistula and Successful Treatment with Transcatheter Coil Embolization / Uma Causa Rara de Angina Após Revascularização do Miocárdio: Fístula da Artéria Mamária Interna Esquerda para Artéria Pulmonar e Tratamento Bem-Sucedido com Embolização Transcateter com Molas

Abstract Fistula from left internal mammary artery (LIMA) to pulmonary artery (PA) is rarely encountered in daily practice. In recent years, endovascular therapy options have emerged for the treatment of fistula formations and replaced with surgery. A 53-year-old man admitted to our outpatient clinic with symptoms of typical angina and shortness of breath despite optimal medical therapy. In his relevant history, he had a coronary artery bypass graft (CABG) operation in 2009 in which his LIMA was anastomosed to left anterior descending (LAD) and ramus artery sequentially. Coronary angiography including selective imaging of LIMA demonstrated a fistula formation originating from the proximal portion of the LIMA and draining to PA. After successful closure of fistula with transcatheter coil embolization, the patient was discharged without any complication and symptom. In conclusion, although LIMA to PA fistula is an infrequent clinical condition, it should be considered as a potential cause of persistent angina after CABG operation. Treatment options include conservative medical therapy, surgical ligation and endovascular interventions. The best therapy should be individualised for each patient in respect to patient's symptoms, surgical compatibility and anatomy of fistula.

Resumo A fístula da artéria mamária interna esquerda (AMIE) para a artéria pulmonar (AP) é raramente encontrada na prática diária. Nos últimos anos, opções de terapia endovascular surgiram para o tratamento de formações de fístula e foram substituídas por cirurgia. Um homem de 53 anos de idade, internado em nosso ambulatório com sintomas de angina típica e falta de ar, apesar da terapia clínica ideal. Em seu histórico relevante, ele teve uma cirurgia de revascularização miocárdica (CRM) em 2009, na qual sua AMIE foi anastomosada à descendente anterior esquerda (DAE) e à artéria ramus sequencialmente. A angiografia coronária, incluindo imagens seletivas da AMIE, demonstrou uma formação de fístula proveniente da porção proximal da AMIE e drenando para AP. Após o fechamento bem-sucedido da fístula com embolização transcateter com mola, o paciente recebeu alta sem qualquer complicação e sintoma. Em conclusão, embora fístula entre AMIE e AP seja uma condição clínica pouco frequente, deve ser considerada como uma causa potencial de angina persistente após a operação de revascularização do miocárdio. As opções de tratamento incluem terapia médica conservadora, ligadura cirúrgica e intervenções endovasculares. A melhor terapia deve ser individualizada para cada paciente em relação aos sintomas do paciente, compatibilidade cirúrgica e anatomia da fístula.

Assessment of Atrial Conduction Times in Patients with Newly Diagnosed Parkinson's Disease.

BACKGROUND: An increased risk of ischemic stroke has been reported in patients with Parkinson's disease (PD). Atrial fibrillation (AF) is strongly associated with ischemic stroke. Prolonged atrial electromechanical delay (EMD) is an independent predictor for the development of AF. AIMS: The aim of the present study was to evaluate the atrial conduction parameters in patients with PD and to assess their relation with the severity of PD. STUDY DESIGN: We prospectively enrolled 51 consecutive patients with newly diagnosed PD and 31 age- and sex-matched non-PD subjects. METHODS: To assess atrial electromechanical coupling (PA), the time intervals from the onset of p wave on ECG to the late diastolic wave at the septal (PAs) and lateral (PAl) mitral annulus and lateral tricuspid annulus (PAt) were measured on Tissue Doppler Echocardiography (TDE). The difference between PAs-PAl, PAs-PAt, and PAl-PAt were defined as left intra-atrial, right intra-atrial, and interatrial EMD, respectively. P-wave dispersion (PWD) was calculated from the 12-lead ECG. RESULTS: PWD, PAs, PAl, and PAt durations were significantly prolonged in the PD group (all p < 0.001). Interatrial, right, and left intra-atrial EMD were also significantly longer in PD patients (p < 0.001, p < 0.001 and p=0.002, resp.). There were significant positive correlations between disease severity (UPDRS score) and PWD (r=0.34, p=0.041), left intra-atrial (r=0.39, p=0.005), and interatrial EMD (r=0.35, p=0.012). By multivariate analysis, PWD (OR: 1.13, 95% CI: 1.02-1.25; p=0.017), LA volume index (OR: 1.19, 95% CI: 1.02-1.37; p=0.021), left intra-atrial (OR: 1.12, 95% CI: 1.01-1.24; p=0.041), and interatrial EMD (OR: 1.08, 95% CI: 1.01-1.16; p=0.026) were found as independent predictors of PD. CONCLUSION: Atrial conduction times were longer and correlated with the severity of disease in PD patients. Prolonged inter- and intra-atrial-EMD intervals were also found as independent correlates of PD. These findings may suggest an increased predisposition to atrial fibrillation in PD.

Renal function in patients with mechanical prosthetic valves : Long-term effects of anticoagulation and over-anticoagulation with warfarin.

BACKGROUND: Warfarin-related nephropathy (WRN) is a complication of warfarin over-anticoagulation that is associated with acute and/or chronic renal dysfunction and increased mortality. The long-term effects of warfarin on renal function has not been adequately studied in patients with a mechanical prosthetic valve (MPV). AIM: To study the time-dependent effects of over-anticoagulation on renal function in patients with a MPV. METHODS: A total of 193 patients who underwent MPV implantation and were followed up in this study were eligible for inclusion. Time above therapeutic international normalized ratio (INR) range (TATR) was calculated by dividing the number of INR measurements above target in a year by the total number of INR measurements within a year. Patients were divided into quartiles according to average TATR at 60 months. RESULTS: At 60 months more patients within the 4th quartile had a ≥20% reduction in the estimated glomerular filtration rate (eGFR, 25.0%, p = 0.04) and chronic kidney disease (CKD, 33.0%, p = 0.07) compared to patients within the 1st quartile. High TATR remained a significant determinant for reduction in eGFR (odds ratio OR: 7.50, 95% confidence interval CI:1.55-36.32) and CKD (OR:5.15, 95% CI: 1.26-20.62) after adjusting for other variables. Longitudinal analysis revealed that the change in eGFR was related to the duration of warfarin use (p < 0.001) and the interaction between the duration of warfarin use and TATR (p = 0.03). Similar findings were observed in patients without CKD at baseline, but not in those with CKD before the index operation. CONCLUSION: Anticoagulation over targeted INR values is associated with a steeper decline in eGFR and an increased frequency of CKD in patients with a MPV.

Systemic inflammatory activation in patients with acute coronary syndrome secondary to nonatherosclerotic spontaneous coronary artery dissection.

OBJECTIVE: Pathological studies have suggested that local inflammation, particularly eosinophilic infiltration of the adventitia, could be related to nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD). However, the role of systemic inflammation in the pathogenesis of NA-SCAD remains unknown. Our aim was to investigate systemic inflammatory activation in patients with an acute coronary syndrome (ACS) secondary to NA-SCAD. METHODS: The institutional electronic medical database was reviewed, and 22 patients with NA-SCAD-ACS were identified after the review. Furthermore, 30 random patients with CAD-ACS and 30 random subjects without any history of CAD or ACS with demographic and clinical characteristics similar to those of NA-SCAD-ACS patients were identified from the institutional database to be included in the study. RESULTS: Patients with NA-SCAD-ACS and those with CAD-ACS both had higher white blood cell and neutrophil counts than controls. Neutrophil-lymphocyte ratio (NLR) and C-reactive protein (CRP) levels were only significantly higher in the NA-SCAD-ACS group [2.01 (1.54-6.17) for NLR and 0.70 (0.13-2.70) for CRP] than in the controls [1.55 (1.27-2.13), p=0.03 for NLR and 0.15 (0.10-0.43), p=0.049 for CRP]; however, there were no differences between the NA-SCAD-ACS and CAD-ACS groups [1.91 (1.41-2.78) for NLR and 0.41 (0.09-1.10) for CRP, p>0.05 for both comparisons] regarding all tested parameters. CONCLUSION: The degree of inflammatory activation in NA-SCAD-ACS patients was similar to, or even greater than, that in CAD-ACS patients; thus, suggesting a role of inflammation in the pathophysiology of NA-SCAD-ACS.