Post-operative N-terminal pro-brain natriuretic peptide predicts in-hospital mortality after living donor liver transplantation.

OBJECTIVE: The post-operative serum level of N-terminal pro-brain natriuretic peptide (NT-proBNP) has been found to be associated with post-operative cardiovascular complications and mortality in high-risk surgeries. The usefulness of the post-operative NT-proBNP level as a predictor of mortality after liver transplantation (LT) is unknown. METHODS: The records of patients at a single, tertiary university hospital who had undergone adult living donor liver transplantation (LDLT) with data of post-operative NT-proBNP level values were retrospectively analyzed for in-hospital mortality. The highest post-operative NT-proBNP level from the first 3 days after surgery was included in the study. Receiver operating characteristic curve analysis was performed to assess the best cut-off value of post-operative NT-proBNP, and Cox regression analysis was performed to investigate the effect of NT-proBNP on mortality. RESULTS: A total of 114 LT recipients with a mean Model for End-Stage Liver Disease score of 15.8 were included in the study. In-hospital mortality occurred in 11 (9.6%) of the patients. A history of diabetes mellitus and the post-operative NT-proBNP level were found to be associated with mortality (p=0.011 for diabetes mellitus and p<0.001 for NT-proBNP). The best cut-off value of post-operative NT-proBNP was 1009 ng/L. Cox regression analysis indicated that the NT-proBNP level was a strong predictor of in-hospital mortality (hazard ratio: 24.467, 95% confidence interval: 3.120-191.750; p=0.002). CONCLUSION: The post-operative NT-proBNP serum level independently predicted in-hospital mortality in patients who underwent LDLT. Post-operative NT-proBNP-guided management of LT recipients should be pursued.

The effects of CYP2C9 and VKORC1 gene polymorphisms on warfarin maintenance dose in Turkish cardiac patients.

Aim: Our aim was to examine the effect of CYP2C9 and VKORC1 polymorphisms on warfarin dose requirements in Turkish patients. Materials & methods: 24 warfarin prescribed patients were included and analyzed for eight VKORC1 and 6 CYP2C9 polymorphisms in the study. Results: Patients with CYP2C9 *1/*1 and VKORC1 -1639 GG and GA genotypes required higher warfarin doses in comparison to wild type VKORC1 genotype. Patients with CYP2C9 *1/*3 and VKORC1 -1639 GG genotypes simultaneously, required the lowest dose of warfarin (4.64 mg/day). Patients with CYP2C9 *1/*1 and VKORC1 9041 AA genotype were found to require higher warfarin doses. Conclusion: Our results provide additional evidence to support the hypothesis that CYP2C9 *2, *3, VKORC1 9041 G > A polymorphisms explain considerable proportion of inter-individual variability in warfarin dose requirement.

Postoperative Myocardial Injury Does Not Predict Early and 1-Year Mortality After Living Donor Liver Transplantation.

BACKGROUND: Preoperative cardiac troponin-I (cTnI) elevation has been shown to be a predictor of mortality after liver transplantation. Myocardial injury after non-cardiac surgery (MINS) has been defined as elevation of serum cardiac troponin levels in the perioperative period that does not fulfill the criteria for myocardial infarction. MINS has been shown to be a prognostic factor for in-hospital and long-term mortality, but there is limited data in patients undergoing living-donor liver transplantation (LDLT). In this study, we aimed to evaluate the relationship between MINS and postoperative mortality. MATERIAL AND METHODS: Patients who had undergone adult LDLT at Florence Nightingale Hospital Liver Transplantation Unit between December 2012 and December 2015 were retrospectively analyzed for 30-day in-hospital and 1-year mortality. Myocardial injury was defined as cTnI level above 0.04 ng/mL. Patients (N = 214) were divided into 2 groups according to postoperative cTnI levels. The following were the exclusion criteria: 1. patients under 18 years old, 2. patients undergoing deceased-donor liver transplantation or dual liver-kidney transplantation, 3. cTnI elevation due to other causes (sepsis, renal failure, pulmonary embolism, myocardial infarction), and 4. patients without postoperative troponin levels. RESULTS: MINS occurred in 123 (57.4%) patients after LDLT. There was no difference between the groups according to age, sex, creatinine levels, presence of ischemic heart disease, hypertension, diabetes mellitus, and tobacco use. The presence of MINS did not predict 30-day and 1-year mortality in the study population. CONCLUSION: Myocardial injury detected by serum cTnI elevation was frequent after LDLT; however, it was not associated with 30-day in-hospital and 1-year mortality.

Pulmonary hypertension experience in an expert university hospital.

OBJECTIVE: Pulmonary artery hypertension (PAH) is characterized by remodeling of the small pulmonary arteries, leading to a progressive increase in pulmonary vascular resistance and right ventricular failure. In this study, we aimed to share our 10 years of experience dealing with pulmonary hypertension (PH) and provide information in real-life settings in terms of demographics, clinical course, PH subgroup distribution, and treatment patterns in patients with PAH in a tertiary center. METHODS: In this retrospective, single-center, observational study, we screened the patients who applied to PH outpatient clinic of Istanbul University Institute of Cardiology due to the suspicion of PAH between 2008 and 2017. While group 1, 4, and 5 PH patients were included, group 2 and 3 PH patients were excluded from the study. RESULTS: Our study group comprised 162 patients (115 females, 71%). The female:male ratio was 2.4. The mean age was 52±16 years. Most (86.4%) of the patients were in group 1 PH (PAH). The rest (13.6%, n=22) of the patients were in group 4 PH (chronic thromboembolic PH). In group 1 PH, 45.7% of patients (n=64) were classified as having idiopathic PAH (IPAH) after excluding the alternative diagnosis using PH diagnostic algorithm. The remaining 54.3% of group 1 PH patients (n=76) had various diseases that caused PAH, which is called associated PAH (APAH); APAH group included PAH associated with congenital heart diseases (n=70), connective tissue disorders (scleroderma, n=4) and portal hypertension (n=2). CONCLUSION: Our data provides important information in real-life settings in terms of demographics, clinical course, PH subgroup distribution, and treatment patterns in patients with PAH in a reference tertiary center in Turkey.

A new gap in the novel anticoagulants' era: undertreatment.

After long years of using warfarin for atrial fibrillation, new oral anticoagulants (NOACs) became available for decreasing the risk of ischemic stroke. Our aim was to observe the physicians prescribing patterns of NOACs. This prospective observational study included patients using NOACs applying consecutively to our outpatient clinic. Physical examination was performed, and patient history, electrocardiogram, transthoracic echocardiography, and biochemical results were collected. Bleeding and ischemic stroke risk scores (HAS-BLED and CHA2DS2-VASc scores) were calculated. We evaluated patients' characteristics, risk factors, concomitant drug usage, and physicians' choices. The study consisted of 174 patients using NOACs (dabigatran 113 patients, rivaroxaban 61 patients), with a mean age of 70.7 ± 8.8 years. The mean HAS-BLED score was 1.74 ± 0.9 and the mean CHA2DS2-VASc score was 3.7 ± 1.2. Fifty-three (30.4%) patients were prescribed low-dose NOAC according to the optimal dose, and 12 (6.8%) patients were prescribed high-dose NOAC according to the optimal dose. We compared optimal dose and undertreatment groups to find out if there was any predicting factor for physicians to use low dose of NOACs, but there was no significant difference between the two groups for age, sex, concomitant chronic disease, and CHA2DS2-VASc and HAS-BLED scores. NOACs were prescribed to patients mostly with high CHA2DS2-VASc score and low HAS-BLED score. Low-dose NOAC usage according to the optimal dose was frequent. Frequent coagulation monitoring and drug incompliance are big deficiencies at atrial fibrillation in use of warfarin. NOACs overcome these difficulties; however, physicians' hesitation to use NOACs with the optimal dosage may be another limitation in real-world practice.

Relationship between increased serum resistin level and severity of coronary artery disease.

Resistin, which is derived from the gene of RSTN, belongs to a family of cysteine-rich secretory proteins called resistin-like molecules (RELMs). Increased serum resistin levels are associated with coronary artery disease (CAD) and the risk of cardiovascular death. Patients (n = 214) with an initial diagnosis of stable angina pectoris, unstable angina pectoris, and myocardial infarction without ST-segment elevation and referred to catheter laboratory for coronary angiography were enrolled in the study. We aimed to investigate the relationship between increased serum resistin level and CAD. The severity of CAD was calculated by the Gensini scoring system. In conclusion, we established a significant correlation between serum resistin levels and CAD (P = .010). Also, serum resistin levels correlated with the Gensini score that represents the severity of CAD angiographically (P = .010).

Atypical chest x-ray calcification in an idiopathic constrictive pericarditis case.

Constrictive pericarditis is an uncommon cause of heart failure. It is a clinical entity caused by thickening, fibrosis, and/or calcification of the pericardium. We present a 50-year-old female patient who was admitted to our institution with a 6-month history of progressive dyspnea on exertion, abdominal swelling, and lower extremity edema. Her chest X-ray revealed an oblique linear calcification in the cardiac silhouette. Transthoracic echocardiography revealed biatrial enlargement. Left ventricular size and systolic function were normal. Cardiac computed tomography revealed the pericardial thickening (>5 mm) and heavy calcification in left atrioventricular groove. Simultaneous right and left heart catheterization showed elevation and equalization of right-sided and left-sided diastolic filling pressures, with characteristic dip, and plateau. Pericardiectomy was performed which revealed a thick, fibrous, calcified, and densely adherent pericardium constricting the heart. The postoperative period was uneventful and was in NYHA functional class I after 3 months.