The Relationship Between Endocan and Serum Inflammatory Markers in Patients with Senile Calcific Aortic Stenosis.

BACKGROUND: Endocan is an indicator of many pathologies accompanied by inflammation, endothelial cell activation, and dysfunction. In this study, we examined the relationship between degenerative aortic sclerosis, which progresses in a similar pathophysiologic mechanism as atherosclerosis, and serum inflammatory markers and endocan levels. METHODS: A total of 155 patients without known coronary artery disease, aged between 65 and 80 years, were consecutively included in the prospective cross-sectional study. The study population was analyzed in 4 different groups. The control group consisted of patients with normal aortic valve structure, while patients with aortic stenosis were classified as mild aortic stenosis (2-2.9 m/s), moderate aortic stenosis (3-3.9 m/s), and severe aortic stenosis (≥ 4 m/s) according to their aortic velocity. While there were 39 patients in the control group, there were 58, 24, and 34 patients in the mild, moderate, and severe aortic stenosis groups, respectively. RESULTS: There was no statistically significant difference between the groups in terms of patient distribution and characteristics. History of dyspnea and angina was correlated with the severity of aortic stenosis (P <.001). In this study, no statistically significant correlation was found between serum endocan levels and the severity of aortic stenosis (control group: 17.3 ± 6.3 ng/mL, mild aortic stenosis: 17.6 ± 8.7 ng/mL, moderate aortic stenosis: 16.3 ± 3.8 ng/mL, severe aortic stenosis: 15.2 ± 5.9 ng/mL, P =.396). However, it was figured out that there was a positive correlation between endocan levels and hemoglobin (Hg) (r = 0.308, P =.001), platelet (PLT) (r = 0.320, P <.001), and albumin (Alb) (r = 0.206, P =.026). CONCLUSION: In this study, no significant correlation was found between serum endocan levels and the severity of aortic stenosis. On the other hand, there was a positive correlation between endocan levels and Hg, PLT, and Alb.

Prognostic Nutritional Index as a Predictor of No-Reflow Occurrence in Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention.

Nutritional status and its index (Prognostic Nutritional Index, PNI) is an important prognostic factor for ST-segment elevation myocardial infarction (STEMI). The present study investigated whether PNI it is associated with no-reflow in patients with STEMI. In this retrospective study, 404 patients with STEMI and underwent primary percutaneous coronary intervention (pPCI) were consecutively included, between January 2016 and December 2018. No-reflow phenomenon (NRP) was detected in 103 (25.4%) patients. In multivariate logistic regression analysis C-reactive protein (CRP) (odds ratio (OR): 1.693, 95% confidence interval (CI): 1.126-2.547, P = .011), left ventricle ejection fraction (LVEF) (OR: 0.777, 95% CI: 0.678-0.891, P < .001), SYNTAX score (OR: 1.114, 95% CI: 1.050-1.183, P = .001), low density lipoprotein cholesterol (LDL-C) (OR: 1.033, 95% CI: 1.013-1.055, P = .002), hemoglobin level (OR: 0.572, 95% CI: 0.395-0.827, P = .003), PNI (OR: 0.554, 95% CI: 0.448-0.686, P < .001) were associated with NRP. The area under curve of PNI was significantly higher than albumin (z = 4.747, P < .001) and lymphocyte values (z = 3.481 P < .001). PNI was associated with no-reflow occurrence and mortality. So, PNI may be useful to predict NRP risk in patients with STEMI before pPCI.

Elevated levels of short-term blood pressure variability: A marker for ascending aortic dilatation in hypertensive patients.

Background: Ascending aortic aneurysms are one of the primary causes of mortality. However, not much is known about the etiologies of aortic aneurysm. Recently, in hypertensive (HT) patients, blood pressure variability (BPV) has been recommended as a remarkable risk factor for adverse cardiovascular outcomes. This study aimed to explore the association between short-term BPV and ascending aortic dilatation (AAD).Methods: In this study, a total of 53 HT patients with AAD (aortic size index [ASI] ≥21 mm/m2) and 126 HT patients with a normal ascending aortic diameter (ASI <21 mm/m2) were included. Baseline, echocardiographic, and 24-h ambulatory blood pressure (BP) monitoring results were compared between groups. Standard deviation (SD) and coefficient of variation (CV) of BP were used to determine short-term BPV.Results: Except for daytime SBP values, daytime, nighttime, and 24-h mean systolic (SBP) and diastolic (DBP) BP levels were similar between groups. Compared with the HT patients with normal AA, daytime SBP, daytime SD of SBP, 24-h SD of SBP, daytime CV of SBP, and 24-h CV of SBP were significantly higher in HT patients with AAD. Compared with the HT patients with normal AA, the frequency of nondipper pattern was higher and dipper pattern was lower in HT patients with AAD. In multivariate logistic regression analysis, the daytime CV of SBP, daytime SD of SBP, 24-h SD of SBP, daytime SBP, and left ventricular mass index were independently associated with AAD. In receiver operating characteristic curve analysis, the daytime CV of SBP levels of >12.95 had a sensitivity of 61% and a specificity of 59% (area under the curve, 0.659; 95% CI, 0.562-0.756; P= .01); moreover, daytime SD of SBP > 16.4 had sensitivity of 62% and specificity of 61% (AUC, 0.687; 95% CI, 0.591-0.782; P< .001).:Conclusion Increased short-term BPV is independently associated with AAD and may be recommended as a remarkable factor risk for AAD in HT patients.

A rare complication of transcatheter aortic valve replacement: Free-floating nose cone.

Presently described is a case in which the tip of the delivery catheter system (nose cone) has been broken during catheter removal after valve deployment in a femoral transcatheter aortic valve replacement procedure and the successful management of this rare complication.

Importance of the heart borders as a fluoroscopic clue for cardiac tamponade.

Every catheter laboratory is equipped with an X-ray system designed to provide fluoroscopic imaging of the heart. Although cardiac catheters are well visualized in all X-ray imaging, the soft tissue of myocardium is not. Therefore the imaging of the cardiac chambers is indirect through relation to the cardiac silhouette. However, fluoroscopy can be used to detect complications from the invasive procedures in the cardiac catheterization laboratory, such as cardiac tamponade where the excursion of the cardiac silhouette decreases, and visceral and parietal pericardium are seen separated by the blood of accumulation in the pericardial cavity. Even if a transthoracic or intracardiac echocardiography guidance is immediately available, early fluoroscopic detection of tamponade should be remembered during the invasive procedures in the cardiac catheterization laboratory.

Monocyte to HDL Cholesterol Ratio Predicts Coronary Artery Disease Severity and Future Major Cardiovascular Adverse Events in Acute Coronary Syndrome.

BACKGROUND: We aimed to investigate the usefulness of monocyte to HDL cholesterol ratio (MHR) in predicting coronary artery disease severity and future major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS). METHODS: 2661 patient with ACS were enrolled and followed up during median 31.6 months. RESULTS: MHR were significantly positively correlated with neutrophil to lymphocyte ratio (r=0.438), CRP (r=0.394), Gensini (r=0.407), and SYNTAX score (r=0.333). During in-hospital and long-term follow-up, MACE, stent thrombosis, non-fatal MI, and mortality occurred more frequently in the third tertile group. Kaplan-Meier analysis revealed the higher occurrence of MACE in the third tertile group compared with other tertiles. Adjusting for other factors, a MHR value in the third tertile group was determined as an independent predictor of in-hospital and long-term MACE. CONCLUSIONS: MHR as a novel inflammation-based marker seemed to be an independent predictor of severity of coronary artery disease and future cardiovascular events in patients with ACS. MHR may utilise the identification of patients who are at higher risk for MACE and individualisation of targeted therapy.

Massive Myocardial Staining and Thebesian Venous Opacification during Complicated Coronary Angiography.

Myocardial staining is a complication of coronary angiography or intervention procedures and consists of extravasations of contrast material into the myocardium. The powerful injection of contrast (myocardial staining) is caused by the improper positioning of the angiography or guiding catheter and can lead to refractory ventricular tachyarrhythmias and occasionally cardiac death. It results in small puffs of dye extravasating into pericoronary space (epicardial or myocardial).We presented an interesting image of a massive myocardial staining and dense coronary and thebesian venous opacification during complicated right coronary angiography. This case illustrates the value of careful manipulation and positioning of the coronary catheter during coronary angiogram.

Platelet to Lymphocyte Ratio as a Prognostic Marker of In-Hospital and Long-Term Major Adverse Cardiovascular Events in ST-Segment Elevation Myocardial Infarction.

We assessed the prognostic value of the platelet to lymphocyte ratio (PLR) on in-hospital and long-term major adverse cardiovascular events (MACEs) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) in a large prospective study. Patients (n = 1938) admitted with acute STEMI within 12 hours of symptom onset and who underwent pPCI between January 2010 and January 2015 were followed up for 31.6 ± 16.2 months. During the in-hospital and long-term follow-up period, MACE, the prevalence of stent thrombosis, nonfatal myocardial infarction, and mortality were higher in the third PLR tertile group. A PLR in the third tertile had 2.4-fold increased risk of in-hospital MACE and 2.8-fold risk of long-term MACE. The PLR was significantly and positively correlated with peak creatine kinase MB (CK-MB) levels (r = 0.562, P < .001) and Gensini score (r = 0.408, P < .001). Kaplan-Meier analysis of long-term MACE-free survival revealed a higher occurrence of MACE in the third PLR tertile group compared to the other tertiles. In conclusion, the PLR may be a marker of inflammatory and prothrombotic status and predicted in-hospital and long-term MACE in a population with STEMI.

Non-O blood groups can be a prognostic marker of in-hospital and long-term major adverse cardiovascular events in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: Recent studies have suggested ABO blood type locus as an inherited predictor of thrombosis, cardiovascular risk factors, myocardial infarction. However, data is scarce about the impact of non-O blood groups on prognosis in patients with ST-elevation myocardial infarction (STEMI). Therefore, we aimed to evaluate the prognostic importance of non-O blood groups in patients with STEMI undergoing primary percutaneous coronary intervention (pPCI) METHODS: 1835 consecutive patients who were admitted with acute STEMI between 2010 and 2015 were included and followed-up for a median of 35.6months. RESULTS: The prevalence of hyperlipidemia, total cholesterol, LDL, peak CKMB and no-reflow as well as hospitalization duration were higher in patients with non-O blood groups. Gensini score did not differ between groups. During the in-hospital and long-term follow-up period, MACE, the prevalence of stent thrombosis, non-fatal MI, and mortality were higher in non-O blood groups. In multivariate logistic regression analysis, non-0 blood groups were demonstrated to be independent predictors of in-hospital (OR:2.085 %CI: 1.328-3.274 p=0.001) and long term MACE (OR:2.257 %CI: 1.325-3.759 p<0.001). Kaplan-Meier analysis according to the long-term MACE free survival revealed a higher occurrence of MACE in non-O blood group compared with O blood group (p<0.001, Chi-square: 22.810). CONCLUSION: Non-O blood groups were determined to be significant prognostic indicators of short- and long-term cardiovascular adverse events and mortality in patients with STEMI undergoing pPCI. In conjunction with other prognostic factors, evaluation of this parameter may improve the risk categorization and tailoring the individual therapy and follow-up in STEMI patient population.

Impact of Aortic Stiffness Evaluated by Aortic Pulsatility on Fractional Flow Reserve.

BACKGROUND: Fractional flow reserve (FFR) is a highly reproducible, accurate and lesion-specific index to indicate inducible ischemia for a particular coronary artery lesion. Invasively measured aortic pulsatility (AP) is an indicator of aortic stiffness. In this study we aimed to evaluate the possible impact of AP in terms of aortic stiffness on FFR measurement. METHODS: In this study, we reviewed the FFR evaluation of 90 patients who had intermediate lesions (40-70% stenosis measured with quantitative coronary analysis) at the left anterior descending artery (LAD). AP was calculated as the ratio of aortic pulse pressure (systolic-diastolic pressure) to mean pressure. RESULTS: Aortic systolic pressure, aortic diastolic pressure, aortic pulse pressure and also aortic pulsatility did not differ significantly between patients with FFR ≤ 0.80 and FFR > 0.80 (p = 0.44, p = 0.28, p = 0.93 and p = 0.41, respectively). In subgroups arranged according to the degree of luminal narrowing (40-50%, 51-60%, and 61-70%), we did not observe significant correlation between AP and FFR value in subgroups with 40-50% and 51-60% lesions (r = 0.03, p = 0.95 and r = 0.07, p = 0.69, respectively). However, a statistically significant negative correlation between FFR value and AP in the subgroup of patients with 61-70% lesions was detected (r = -0.54, p = 0.04). CONCLUSIONS: These findings suggested that aortic stiffness might have a possible impact on FFR measurement in coronary lesions of 61-70% stenosis evaluated quantitatively. KEY WORDS: Aortic pulsatility; Fractional flow reserve; Stiffness.

Association of prediabetes with diffuse coronary narrowing and small-vessel disease.

BACKGROUND: A significant number of patients may not benefit from conventional techniques of myocardial revascularization due to diffuse coronary artery disease (CAD) or small coronary arterial sizes because of smaller arteries causing anastomotic technical difficulties and poor run-off. Diabetic patients have a more severe and diffuse coronary atherosclerosis with smaller coronary arteries limiting the possibility to perform a successful and complete revascularization, but this has not been examined in prediabetics. OBJECTIVE: To evaluate whether there is an association between prediabetes and the coronary arterial size. METHODS: We prospectively studied 168 consecutive patients with CAD and 172 patients with normal coronary artery anatomy (NCA). Patients were divided into three groups according to hemoglobin (Hb) A1c levels as "normal," "prediabetic," and "diabetic" groups, and the coronary artery sizes and Gensini scores were analyzed. RESULTS: There were 78 female patients and 90 male patients in the CAD group, and 87 female patients and 85 male patients in the NCA group. There was a statistically significant difference in distal and proximal total coronary arterial size among the CAD and NCA groups for both genders. There was a positive correlation between the HbA1c subgroups and Gensini score (Spearman's ρ: 0.489, p<0.001 in female group; Spearman's ρ: 0.252 p=0.016 in male group). CONCLUSION: We found that prediabetic patients have a smaller coronary size and diffuse coronary narrowing for both genders, particularly in distal coronary arterial tree of left anterior descending coronary artery. The early detection of prediabetes in daily cardiology practice may provide more appropriate coronary lesion for percutaneous or surgical revascularization.

Right ventricular functions in patients with slow coronary flow.

OBJECTIVE: The objective of this study was to evaluate right ventricular systolic and diastolic functions with the use of conventional and tissue Doppler echocardiography in patients with slow coronary flow (SCF). METHODS AND RESULTS: Patients who were detected to have SCF but otherwise normal epicardial coronary arteries between October 2010 and July 2011 were included in our study. The control group was selected from the patients with normal coronary arteries but no SCF. All patients underwent echocardiography to evaluate left and right cardiac functions with conventional methods and tissue Doppler imaging. The study consisted of 86 patients [59 (68.6%) males, mean age: 54 +/- 10 years) with SCF. Sixty-six subjects [42 (63.6%) males, mean age: 55 +/- 8 years] with normal coronary arteries without SCF constituted the control group.Tissue Doppler findings of left ventricular systolic and diastolic functions were significantly disturbed in the SCF group (myocardial performance index: 0.37+/- 0.02 vs. 0.28 +/- 0.02, P<0.001; E/A ratio: 0.9 +/-0.1 vs. 1.1 0.1, P < 0.001). However, when the right ventricular functions were considered, no significant difference was observed between the 2 groups (myocardial performance index: 0.25 +/- 0.10 vs. 0.25 +/- 0.10, P = 0.9; E/A ratio: 0.50 +/- 0.06 vs. 0.50 +/- 0.08, P= 0.3; TAPSE: 26.2 +/- 2.2 vs. 25.9 +/- 2.2, P = 0.6). CONCLUSIONS: Preserved right ventricular diastolic and systolic functions in contrast to the impaired left ventricular functions in patients with SCF was the main finding of our study. The exact mechanisms of this new finding should be investigated by further studies.

Plasma levels of tumor necrosis factor-alpha and its receptors in patients with mitral stenosis and sinus rhythm undergoing percutaneous balloon valvuloplasty.

This study aimed to determine whether plasma levels of tumor necrosis factor-alpha (TNF-alpha) and soluble TNF receptor (sTNF-R) increases in rheumatic mitral stenosis (MS) patients with sinus rhythm and to examine the effect of percutaneous mitral balloon valvuloplasty (PMBV) on these parameters. Twenty-six patients with MS and sinus rhythm (study group, 20 female, mean age 33 +/- 8 years), who were scheduled for PMBV, and a well-matched control group consisting of 21 healthy volunteers (15 female, mean age 35 +/- 6 years) were enrolled in the study. Tumor necrosis factor-alpha and sTNF-R levels were compared between study patients and controls, and between peripheral and left atrium (LA) blood. Changes in TNF alpha and sTNF-R levels 24 h and 4 weeks after PMBV were analyzed. Significantly higher baseline TNF-alpha and sTNF-R levels were noted in the study group. In the study group, TNF-alpha and its receptors were also found to be higher in LA blood than in baseline peripheral blood. After PMBV, mitral valve area (MVA) increased and transmitral pressure gradient decreased significantly. At the 24th hour after PMBV, the TNF-alpha level decreased from 29.61 +/- 12.22 pg/ml to 22.42 +/- 8.81 pg/ml (P < 0.0001) and at the 4th week, from 22.42 +/- 8.81 pg/ml to 18.92 +/- 7.37 pg/ml (P < 0.0001). Similar reductions were observed in the sTNF-R level. Regression analysis between the difference in sTNF-R level measured 24 h after and before PMBV and the difference in MVA measured 24 h after and before PMBV showed a significant direct relationship between these variables. This study suggests that isolated rheumatic MS without atrial fibrillation is accompanied by increased TNF-alpha and sTNF-R level. The successful PMBV establishes a significant reduction in TNF-alpha and its receptors, probably due to improved postprocedural hemodynamic parameters.

Evaluation of atrial vulnerability immediately after radiofrequency catheter ablation of accessory pathway in patients with Wolff-Parkinson-White syndrome.

PURPOSE: The intrinsic atrial vulnerability is proposed as one of the mechanisms of paroxysmal atrial fibrillation (PAF) in Wolff-Parkinson-White (WPW) syndrome. In this study, we examined the early changes in atrial refractoriness and intra- and inter-atrial conduction times after radiofrequency (RF) catheter ablation of accessory pathway (AP). METHODS: Twenty-four consecutive patients with WPW syndrome and documented AV reciprocating tachycardia but without history of PAF (fourteen male, mean age 39 +/- 9.5 years) and 27 control subjects (six female, mean age 51.4 +/- 10.1 years) with AV nodal reentrant tachycardia (AVNRT) who underwent ablation of the slow AV nodal pathways were enrolled into the study. Regional atrial effective refractory periods (AERPs), AERP dispersion, and intra- and inter-atrial conduction times were obtained before and 30 min after ablation and were compared between two groups. In the study group, patients with and without inducible AF were also compared regarding these parameters. RESULTS: In the study group, AERPs in higher right atrium and right posterolateral atrium were significantly increased, and AERP dispersion, intra-atrial, and inter-atrial conduction times were significantly decreased after ablation; AERP in distal coronary sinus was unchanged. In control group, no significant difference was observed in these parameters. Inducibility of AF was significantly reduced following ablation of AP in the study group (from seven to zero of 24 patients, p = 0.016). Comparison between patients with (n = 7) and without (n = 17) AF revealed that left atrium diameter was larger, AERPs in the right posterolateral atrium before and after ablation, and ERP of AP were shorter in AF group. CONCLUSION: In WPW syndrome patients, RF catheter ablation of AP results in an 'immediate' decrease in atrial vulnerability. Since inducibility of AF becomes more difficult in this less vulnerable atrium, the AP itself may play an important role in the development of AF.

Coagulation, fibrinolytic system activation and endothelial dysfunction in patients with mitral stenosis and sinus rhythm.

Anticoagulation treatment can prevent systemic embolism in patients with mitral stenosis (MS) and atrial fibrillation (AF), but this treatment is under debate if patients are in sinus rhythm. The authors aimed to determine the hemostatic changes in patients with MS and sinus rhythm. Forty-six patients (28 in sinus rhythm and 18 in AF) with mitral stenosis were enrolled in this study. They studied systemic venous fibrinogen, D-dimer, antithrombin-III, tissue plasminogen activator (tPA), plasminogen activator inhibitor-I (PAI-I), von Willebrand factor (vWF), and platelet factor 4 (PF 4) in these patients. The patients were first classified according to their rhythm as sinusal and AF, and then according to the presence of left atrial spontaneous echo contrast (LASEC). Fibrinogen, D-dimer, antithrombin-III, vWF, and PF 4 levels were significantly greater in patients with MS and sinus rhythm or atrial fibrillation compared to the control group (p < 0.05). Whether the rhythm was sinus or AF, fibrinogen, D-dimer, antithrombin-III, vWF, and PF 4 levels were significantly higher in patients with LASEC than in the control group (p < 0.05). Only PF 4 was higher in the AF group than in those with sinus rhythm (p < 0.05). As to plasminogen activator and PAI-I levels, only tissue plasminogen activator levels were found to be higher in the AF group than in those with sinus rhythm and the control group (p < 0.05). In patients with mitral stenosis and sinus rhythm, if LASEC is present, coagulation activation, platelet activation, and endothelial dysfunction are similar in patients with AF, and anticoagulation should be considered in these patients.