Coexisting Coronary and Carotid Artery Disease: What We Did, What Happened.

INTRODUCTION: There is no complete consensus on the three surgical methods and long-term consequences for coexisting coronary and carotid artery disease. We retrospectively evaluated the surgical results in this high-risk group in our clinic for a decade. METHODS: Between 2005 and 2015, 196 patients were treated for combined carotid and coronary artery disease. A total of 50 patients were operated on with the staged method, 40 of which had carotid endarterectomy (CEA) priority, and 10 had coronary artery bypass grafting (CABG) priority. CABG and CEA were simultaneously performed in 82 patients; and in 64 asymptomatic patients with unilateral carotid artery lesions and stenosis over 70%, only CABG was done (64 patients). Results were evaluated by uni-/multivariate analyses for perioperative, early, and late postoperative data. RESULTS: In the staged group, interval between the operations was 2.82±0.74 months. Perioperative and early postoperative (30 days) parameters did not differ between groups (P-value < 0.05). Postoperative follow-up time was averaged 94.9±38.3 months. Postoperative events were examined in three groups as (A) deaths (all cause), (B) cardiovascular events (non-fatal myocardial infarction, recurrent angina, congestive heart failure, palpitation), and (C) fatal neurological events (amaurosis fugax, transient ischemic attack, and stroke). When group C events were excluded, event-free actuarial survival rates were similar in all three methods (P=0.740). Actuarial survival rate was significantly different when all events were included (P=0.027). Neurological events increased markedly between months 34 and 66 (P=0.004). CONCLUSION: Perioperative and early postoperative event-free survival rates were similar in all three methods. By the beginning of the 34th month, the only CABG group has been negatively separated due to neurological events. In the choice of methodology, "most threatened organ priority'' was considered as clinical parameter.

Myocardial ischemia in severe aortic regurgitation despite angiographically normal coronary arteries.

Patients with severe aortic regurgitation frequently present with angina pectoris. The exact pathophysiology for angina in aortic regurgitation is not clear. Left ventricular hypertrophy and myocardial blood supply-demand mismatch have been the suggested mechanisms to explain ischemia. However, no conclusive clinical study exists to define the incidence of ischemia in patients with severe aortic regurgitation and normal coronary arteries. We, therefore, investigated the frequency of myocardial ischemia in relation to left ventricular hypertrophy or dilatation in patients with severe aortic regurgitation and normal coronary arteries. We reviewed the medical records of all patients (n = 311) with aortic valve replacement due to aortic regurgitation between 2007 and 2010. We selected subjects with normal coronary arteries (n =182) for the study purpose, and we identified 35 patients who underwent myocardial perfusion scintigraphy prior to the coronary angiography (19 female and 16 male subjects; age 45.0 ± 8.9 years). Left ventricular hypertrophy and dilatation were detected in 9 (26%) and 5 (14%) patients, respectively. Myocardial perfusion scintigraphy showed evidence of ischemia in 10 (29%) patients with normal coronary arteries. The presence of ischemia did not relate to the presence of left ventricular hypertrophy and/or dilatation. As a potential mechanism, aortic regurgitation causes backflow of blood from the aorta into the left ventricle, hence disturbs coronary flow dynamics. In conclusion, myocardial ischemia is common (nearly one-third) among patients with severe aortic regurgitation even in the absence of coronary obstruction, left ventricular hypertrophy and/or dilatation.

The impact of CYP2C9 and VKORC1 genetic polymorphism and patient characteristics upon warfarin dose requirements in an adult Turkish population.

In this study, we investigated the contribution of vitamin K epoxide reductase (VKORC1) and cytochrome P450 2C9 (CYP2C9) genotypes, age, and body surface area (BSA) on warfarin dose requirements and in an adult Turkish population. Blood samples were collected from 100 Turkish patients with stable warfarin dose requirements and an international normalized ratio (INR) of the prothrombin time within the therapeutic range. Genetic analyses for CYP2C9 genotypes (*2 and *3 alleles) and VKORC1 -1639 G>A polymorphism were performed and venous INR determined. The mean warfarin daily dose requirement was higher in CYP2C9 homozygous wild-type patients, compared to those with the variant *3 allele (P < 0.05), similar to those with the variant *2 allele (P > 0.05) and highest in patients with the VKORC1 -1639 GG genotype compared to those with the GA genotype and the AA genotype (P < 0.01). The time to therapeutic INR was longer in CYP2C9 homozygous wild-type patients compared with those with the variant *2 and *3 alleles (P < 0.01), and longer in patients with the VKORC1 (position -1639) GG genotype compared with those with the GA genotype and the AA genotype (P < 0.01). The multivariate regression model including the variables of age (R (2) = 4.4%), BSA (R (2) = 27.4%), CYP2C9 (R (2) = 8.1%), and VKORC1 genotype (R (2) = 34.1%) produced the best model for estimating warfarin dose (R (2) = 60.4%). VKORC1 genotype and CYP2C9 polymorphism affect daily dose requirements and time to therapeutic INR in Turkish patients receiving warfarin for anticoagulation.

An approach to cultural adaptation and validation: the Intermittent Claudication Questionnaire.

The objective of this study was to perform a cultural adaptation and define the validity of the Turkish version of the Intermittent Claudication Questionnaire (ICQ) in order to provide a practical instrument for the evaluation of the impact of intermittent claudication (IC) on patients' quality of life and response to therapy. A standard 'forward-backward' translation method was used to translate the questionnaire into Turkish. Reliability was assessed by internal consistency of the questionnaire reporting Cronbach's alpha coefficient, test-retest reliability that was assessed with the intraclass correlation between instrument scores over time and with the Spearman-Brown coefficient as a variant of split-half reliability. Validity was examined by correlation of the ICQ with the scores of the SF-36 and its eight domains. Eighty-four patients (mean age, 60.7 +/- 7.3 years; male, 57%) were given the ICQ and a final completion rate of 98.8% (83 patients) was reached. The mean total ICQ score was 39.1 +/- 21.8 (SD) (0-100) for the first application of the questionnaire. Thirty patients out of the eligible 83 completed the questionnaire at two time points with a 1-day interval. For the retest, the total ICQ score was 40.6 +/- 26.1 (4.7-97.2). The total SF-36 score of all the study patients was 33.8 +/- 20.7 (3.0-81.0). Cronbach's alpha was 0.95; the Spearman-Brown coefficient was 0.92; and the intraclass correlation coefficient for the two measurements was 0.91. For the total score and for the scores of domains except the emotional role domain, the correlations were high and all the correlations were statistically significant. In conclusion, the Turkish version of the ICQ, which is a disease-specific, self-administered, and practical instrument, is reliable and valid. We recommend its use to assess the effect of IC on the quality of life of patients in clinical trials and in daily clinical practice.

Revascularization of multiple bypassable extended right coronary arteries.

BACKGROUND: Extended right coronary arteries are not uncommon in coronary surgery. They can be revascularized optionally either by conventional single or complete multiple bypassing. However, there are still no objective data showing the superiority or appropriateness of one of these methods over the other. METHODS: Extended right coronary arteries were identified by preoperative angiographic scoring and randomized to multiple-bypassing (group A; n = 32) or single-bypassing (group B; n = 32) groups. Four parameters that show the completeness of right coronary territory revascularization were evaluated and compared between the 2 groups. RESULTS: Although overall perioperative ischemic events seemed to increase in the single-bypass group (P =.0059), half of them were reversible, and there were no statistical differences between the definitive perioperative ischemic event rates, namely, infarction rates, and the remaining 3 parameters of the groups. Logistic regression analysis showed that preoperative left ventricular dysfunction (ejection fraction <50%) was the most significant predictor of these perioperative ischemic events. Hence, the subgroups of patients with left ventricular dysfunction were also evaluated (subgroup A, n =13; subgroup B, n = 12). Overall perioperative ischemic event (P =.001), definitive perioperative ischemic event (infarction; P =.0324), and consequent right ventricular dysfunction (P =.0324) rates were significantly higher in the single-bypass subgroup. Postoperative reperfusion status and graft patency rates of the right coronary territory did not change with the different revascularization methods. CONCLUSIONS: Complete revascularization of extended right coronary arteries did not seem advantageous over its conventional operation in patients with normal ventricular function; however, in patients with poor ventricular function (ejection fraction <50%), it prevented perioperative ischemic events in the right coronary territory and the consequent functional impairment that appeared with conventional operation.