Aorta-right atrial tunnel: an interesting type of a congenital coronary artery anomaly.

An 18-year-old girl with an aortico-right atrial tunnel originating from the left sinus of Valsalva, in which the left anterior descending and circumflex coronary arteries arose independently from the different parts of the tunnel, was reported. In the differential diagnosis of continuous murmur, this type of tunnel should be taken into consideration. Surgical approach should be offered.

Aortic flow propagation velocity as an early predictor of high coronary risk in hypertensive patients.

AIM: To assess the value of aortic flow propagation velocity (Vp) in detecting hypertensive patients with coronary risk. METHODS: The study included 120 patients with hypertension. According to the 10-year risk of coronary heart disease the patients were categorized in the three groups: 10-year risk < 10% (I),10 - year risk=%10 - 20 (II), and 10-year risk > 20% (III). The aortic flow propagation velocity (Vp) was measured from descending aorta with color M-mode echoardiography. The slope of the first aliasing contour was accepted as Vp. It was compared with Framingham coronary risk score, carotid intima media thickness and high sensitive C-reactive protein. Twelve patients were excluded from the study due to poor acoustic window. RESULTS: The Vp was significantly lower (p<0.001), carotid intima media thickness and high sensitive C-reactive protein was significantly higher in group III (p=0.002 and p=0.014). The area under ROC curve of Vp, carotid intima media thickness and high sensitive C-reactive protein were 0.890, 0,700 and 0.664, respectively. There was a significant inverse relation between Vp and carotid intima media thickness (r=-0.37; p<0.001). CONCLUSIONS: The aortic flow propagation velocity is a simple, feasible and reproducible marker of atherosoclerosis with an acceptable sensitivity and specificity. There is a need for longitudinal prospective studies to use it routinely.

Conventional and non-conventional coronary risk factors in male premature coronary artery disease patients already having a low Framingham risk score.

BACKGROUND: Individual risk factors and, more importantly, global risk assessment tools such as the Framingham risk score have been used successfully for risk prediction especially in older patients. However, there is paucity of data about the coronary heart disease prediction in premature coronary artery disease patients with a low Framingham risk score. METHODS AND RESULTS: We recruited 102 consecutive young patients without hypertension and diabetes mellitus in the study. All subjects had had chest pain and underwent coronary angiography since non-invasive diagnostic test results suggested ischaemia. Forty-five patients having at least one coronary lesion independent of severity were included in the study group.The remaining fifty-seven subjects without any coronary lesion were used as control group. Conventional and non-conventional risk factors were evaluated both in patients and control subjects. Framingham risk score and absolute 10-year hard CHD events risk were also calculated for each individual. The coronary heart disease group had a significantly higher smoking frequency as compared to the control group.They also had higher plasma levels of triglycerides, apolipoprotein B and apo B/AI ratio but a smaller LDL particle size.We failed to find any independent CHD predictor after logistic regression analysis. However, individual ROC curve analysis of risk factors revealed that apolipoprotein B, triglycerides and apo B/AI ratio have the highest area under the curve for coronary artery disease prediction. CONCLUSIONS: The Framingham risk score may underestimate the true risk of an individual. Incorporating non-conventional risk factors such as apolipoprotein B and apo B/apo AI ratio may provide valuable information in these patients.

Perindopril, atenolol, and amlodipine prevent aortic ultrastructural changes in rats exposed to ethanol.

BACKGROUND: The effects of perindopril, an angiotensin-converting enzyme inhibitor, atenolol, a beta adrenergic receptor blocker, and amlodipine, a calcium channel blocker, were investigated in chronic alcohol administered rats. MATERIAL/METHODS: Adult male Wistar rats (240-320 g) were used in the present study. Alcohol was given to rats on a modified liquid diet for 21 days. Perindopril (2.5 and 5 mg/kg), atenolol (5 and 10 mg/kg), and amlodipine (5 and 10 mg/kg) were injected into rats in different groups intraperitoneally for 21 days. Control rats were pair fed an isocaloric liquid diet containing sucrose as a caloric substitute for alcohol. Saline was injected into the control rats for 21 days. The hearts were removed after the rats were anesthetized by ether, and 1-mm3 samples from the ascending aortas were fixed. Five fields per aorta were examined and photographed with a transmission electron microscope. Blood alcohol levels were also measured spectrophotometrically. RESULTS: Daily alcohol consumption of the rats was in the range of 12.09-15.50 g/kg. Blood alcohol concentrations were 145.63 mg/dl on the 21st day of alcohol consumption. Chronic alcohol consumption caused some marked aortic wall injuries. Perindopril, atenolol, and amlodipine at high doses, but not low doses, produced some significant beneficial effects on alcohol-induced aortic wall damage. CONCLUSIONS: These results imply that perindopril, atenolol, and amlodipine may have protective effects on heavy chronic alcohol consumption-induced aortic wall injury in rats only in high doses.

[Does accompanying metabolic syndrome contribute to heart dimensions in hypertensive patients?]. / Hipertansiyonlu hastalarda metabolik sendrom varliginin kalp boyutlarina katkisi var midir?

OBJECTIVES: Metabolic syndrome (MetS) is associated with increased risk for cardiovascular events. We evaluated heart dimensions in hypertensive patients with MetS. STUDY DESIGN: The study included 75 hypertensive patients (34 males, 41 females; mean age 51+/-9 years) without coronary artery disease. Patients were evaluated in two groups depending on the presence or absence of MetS. Age- and gender-matched 20 healthy subjects (9 males, 11 females; mean age 50+/-5 years) comprised the control group. The diagnosis of MetS was based on the presence of at least three of five MetS criteria. Hypertension was defined as arterial blood pressure exceeding 140/85 mmHg on three consecutive measurements or the use of antihypertensive drugs. Echocardiographic measurements included interventricular septal thickness, left ventricular internal diameter, posterior wall thickness, aortic diameter, left atrial diameter, relative wall thickness, and left ventricular mass. RESULTS: Metabolic syndrome was present in 32 hypertensive patients (42.7%; 18 males, 14 females). The mean number of MetS criteria was 2.6+/-1.0 in the hypertensive group. Compared to the control group, patients with or without MetS exhibited significantly increased interventricular septum and posterior wall thickness, left atrial diameter, relative wall thickness, and left ventricular mass (p<0.05). The only significant difference between the two patient groups was that MetS was associated with a greater left atrial diameter (p=0.019). Left atrial diameter was correlated with the number of MetS criteria (r=0.51; p<0.001). CONCLUSION: Left ventricular dimensions are not influenced by MetS. Rather than MetS, hypertension is primarily responsible for changes in left ventricular dimensions. However, left atrial enlargement is more prominent in patients with MetS, suggesting that each MetS criterion contributes to left ventricular diastolic dysfunction.

Evaluation of plasma adiponectin levels in young men with coronary artery disease.

OBJECTIVE: In this study, we investigated the relation between plasma adiponectin levels and other risk factors in a young patient population. MATERIAL AND RESULTS: We enrolled consecutively 69 young patients (< 45 years) with coronary artery disease in the study group. he patient enrollment period was between February 2003 and November 2004. The control group consisted of 42 age- and sex-matched healthy subjects. Anthropometric, lipid and other variables including adiponectin, fasting glucose and plasma insulin levels were measured in all subjects. Appropriate statistical analyses were performed to determine the differences between the groups, the relation between adiponectin and other parameters and independent factors that predict CAD. There was a statistically significant difference between the groups in terms of lipid parameters (triglycerides, total cholesterol, HDL and LDL cholesterol). Mean plasma adiponectin levels were significantly lower in the patients (P < 0.05). Among the risk factors adiponectin had a significant negative association with the plasma triglyceride level (P < 0.01). Logistic regression analysis revealed triglycerides and adiponectin as independent predictors of CAD. The areas under the ROC curves of adiponectin and triglycerides were not different (P > 0.05). CONCLUSION: We found a decreased plasma adiponectin level in young male patients with coronary artery disease. It may be a novel marker of atherosclerosis in young men.

A new echocardiographic index for assessing left ventricular function and mechanism of mitral regurgitation and its relation to other echocardiographic indices.

OBJECTIVE: Mitral regurgitation (MR) is a progressive disease of the mitral valve, which can be primary or functional. The assessment of left ventricular function in MR is still troublesome. In this study, we evaluated the validity of a new parameter, total dt, in patients with MR. METHODS: Forty patients with severe MR constituted the study group. According to the transesophageal echocardiographic evaluation, the patients were dichotomized into two groups: (1) Primary MR; n = 21, (2) Functional MR; n = 19. The total dt was defined as the sum of time intervals from 1 msto 3 ms (positive dt) and from 3 ms to 1 ms (negative dt) on the CW Doppler recording of MR jet. It was compared to other indices of left ventricular function and left ventricular geometry, including ejection fraction, fractional shortening, myocardial performance index, coaptation distance, left ventricular volume and diameter, sphericity index, and parameters of diastolic function. RESULT: The total dt correlated with myocardial performance index, coaptation distance, and sphericity index. It could differentiate between primary and functional MR with an area under curve of 0.878, followed by myocardial performance index with 0.860. The total dt > 104 ms was 79% sensitive and 81% specific for discrimination. CONCLUSION: The total dt is useful for assessing left ventricular function and also for differentiating primary MR from functional MR.

Heart rate variability in patients with allergic rhinitis.

Considering the role of autonomic imbalance in the pathogenesis of hypersensitivity reactions, we evaluated the autonomic system through time-domain analysis of heart rate variability (HRV) in patients with allergic rhinitis. Twenty-four patients with allergic rhinitis and 22 healthy subjects (mean age, 41 +/- 8 years and 37 +/- 9 years, respectively) were enrolled in the study. The diagnosis of allergic rhinitis was based on the history, symptoms, and skin prick tests results. Twenty-four-hour ambulatory electrocardiographic recordings were obtained, and the time-domain indices were analyzed. Analysis of HRV revealed that the SD of normal RR intervals, SD of successive differences in normal cycles, and HRV triangular index were not significantly different between the groups, but the root mean square successive difference, number of RR intervals exceeding 50 milliseconds, and percentage difference between adjacent normal RR intervals exceeding >50 milliseconds were significantly greater in the study group, compared with the control group. Our findings showed that HRV indices, which predict parasympathetic predominance, were increased in patients with allergic rhinitis. This finding shows that vagal activation is present not only in the nose but also in other systems, including the cardiovascular system.

Cardiac autonomic functions are altered in patients with acute leukemia, assessed by heart rate variability.

Acute leukemia is one of the leading malignancies worldwide. Although neuropathy was reported as one of the complications of leukemia, there is a little data about the autonomic involvement. This study was designed to investigate the cardiac autonomic disturbances in acute leukemias by using time-domain indices of heart rate variability (HRV). Newly diagnosed 36 patients with acute leukemia (14 acute lymphoblastic leukemia and 22 acute myeloblastic leukemia) and gender- and age-matched 32 healthy subjects as controls were enrolled in this study. The diagnosis of leukemia was established by whole blood count, peripheral smears and bone marrow aspirations. In order to rule out the effect of any medication on HRV, the patients were selected from those who had not received any antineoplastic agent yet. For assessing the cardiac autonomic functions, HRV obtained from 24-hr Holter monitor recordings was used. The age, gender and serum ferritin levels were similar, while hemoglobin levels were lower in the leukemia group. The comparison of the leukemia group and control group revealed that HRV decreased in patients with acute leukemia, which reflects sympathetic dominance in acute leukemia. This is the first study that shows altered cardiac autonomic functions in patients with acute leukemias who are not on any therapeutical intervention. The altered cardiac autonomic functions may be a sign of paraneoplastic neuropathy in patients with acute leukemia.

[Relationship between coronary risk calculation and distribution of the coronary artery lesions and risk factors]. / Koroner risk katsayisi ile koroner anjiyografik olarak damar tutulumu ve risk faktörleri arasindaki iliski.

OBJECTIVES: Early diagnosis and treatment of coronary artery disease is gaining more importance because of its increasing incidence. The calculation of coronary risk score is one of the most important approaches. The aim of the study is to find out the relation between coronary risk score and vessel distribution of the coronary heart disease. METHODS: The study included 49 patients (mean age = 63+/-8 years; 36 males) whose coronary disease was proven by coronary angiography. The severity of the disease is established according to the number of the vessels with >50% stenosis. RESULTS: According to the results; age (p=0.548), gender (p=0.116), uric acid (p=0.091), and smoking (p=0.718) are not effective on diseased vessel distribution. Similarly, total coronary risk score and vessel involvement was not correlated (p=0.115). The ten year coronary risk and vessel involvement was not in good correlation, too (p=0.523). Low-density lipoprotein (LDL)-cholesterol levels were lower in patients with multiple vessel disease but the statistical significance was borderline (p=0.051). High-density lipoprotein (HDL)-cholesterol levels were lower in multiple vessel disease (p=0.004). Both LDL-cholesterol and HDL-cholesterol scores were decreasing with increased number of involved vessels (p=0.035, p=0.001). Multivariate analysis revealed that blood pressure score, and HDL cholesterol score were directly related and LDL-score were inversely related to the number of the involved vessels. The height and vessel involvement was also in good correlation (p=0.024). CONCLUSION: The LDL-cholesterol, HDL-cholesterol, diastolic blood pressure and height are affective on the number of the involved vessels. The total coronary risk scores are not correlated with the severity and distribution of the disease.

[The value of augmentation index and myocardial performance index obtained from cardiac catheterization pressure recordings in predicting coronary artery disease]. / Kardiyak kateterizasyona ait basinç kayitlarindan elde edilen artirma indeksi ve miyokardiyal performans indeksinin koroner arter hastaligini öngörme degerleri.

OBJECTIVE: The aim of the study was to determine the relation between some parameters, which can be obtained from cardiac catheterization pressure records, and coronary artery disease. METHODS: The study included 65 patients, in whom coronary angiography was performed by the cardiologists of the study. The parameters could be obtained in 40 patients (59+/-6 years; 28 male), and statistical analysis included the data of these patients. From the pressure recordings, myocardial performance index (MPI), isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT), ejection time (ET), augmentation wave amplitude (AW), augmentation wave time (AWT) and augmentation index (AI) were measured manually. Coronary artery disease was defined as the presence of any lesion, without regarding the degree of narrowing. The parameters were evaluated with respect to relation with presence of coronary artery disease (Mann-Whitney U test), relation with risk factors for atherosclerosis (Mann-Whitney U test and Chi square test) and capability of predicting coronary artery disease (area under ROC curve, AUC). Statistical significance was set at 0.05. RESULTS: The presence of coronary artery was significantly related to AI, AWT, AW, IVCT and MPI (p<0.001 for all). The most sensitive parameters for coronary artery disease were AI (sensitivity 94%, AUC -0.846, p<0.001) and AW (sensitivity 94%, AUC -0.848, p<0.001), while the most specific one was AWT (specificity 82%, AUC -0.833, p<0.001). The MPI and IVCT were weakly related with risk factors, while IVRT had stronger relation. The parameters of augmentation wave were significantly related with high density lipoprotein cholesterol, whereas the relation with low density lipoprotein cholesterol was weak. CONCLUSION: The parameters, which are obtained from cardiac catheterization pressure recordings, are related with coronary artery disease. They may be useful for predicting future coronary artery disease especially in patients with normal coronary angiogram. It is useful to add these parameters into the reports of coronary angiograms.

The prevention of myocardial ultrastructural changes by perindopril, atenolol and amlodipine in chronic alcohol administered rats.

The effects of perindopril, an angiotensin converting enzyme inhibitor, atenolol, a beta adrenergic receptor blocker and amlodipine, a calcium channel blocker were investigated in chronic alcohol administered rats. Adult male Wistar rats (240-320 g) were used in the present study. Alcohol was given to rats by a modified liquid diet for 21 days. Perindopril (2.5 and 5 mgkg(-1)), atenolol (5 and 10 mg kg(-1)) and amlodipine (5 and 10 mg kg(-1)) were injected to rats in different groups intraperitoneally for 21 days. Control rats were pair fed by an isocaloric liquid diet containing sucrose as a caloric substitute for alcohol. Saline was injected to control rats for 21 days. Rats were anesthetized with ether. Their hearts were removed and 1 mm3 samples from left ventricles were fixed. Five fields per heart were examined and photographed with transmission electron microscope. Blood alcohol levels were also measured spectrophotometrically. Daily alcohol consumption of the rats was in a range of 12.09-15.5 g kg(-1). Blood alcohol concentrations were found as 145.63 mg dl(-1) at 21st day of alcohol consumption. Chronic alcohol consumption caused some marked myocardial injuries. Perindopril and atenolol but not amlodipine produced some significant beneficial effects on alcohol-induced myocardial damages. Our results imply that perindopril and atenolol but not amlodipine have protective effects on heavy chronic alcohol consumption-induced myocardial injury in rats.

A simple different method to use proximal isovelocity surface area (PISA) for measuring mitral valve area.

BACKGROUND: Angle-correction is an important limiting factor for using proximal isovelocity surface area (PISA) method in measuring mitral valve area (MVA). In this study, we derived a novel formula, which simplifies the angle-correction, and tested its use in patients with mitral stenosis (MS). METHODS: The study included 30 MS patients without concomitant aortic or mitral regurgitation. We used mathematical equations and established a relation between the angle and its corresponding border, 'a', by using linear regression analysis. It was found that MVA is equal to [(1.11*a2 + 0.95)* r2 (Val/Vmax)]. We compared this formula with plain angle-corrected and solid angle-corrected PISA methods, planimetry (reference method) and pressure-half time method by linear regression analysis. RESULTS: All methods were in significant relation with the reference method, two-dimensional planimetry. We found that there is a good relation between our method and planimetry (r = 0.79, p < 0.001), pressure half-time method (r = 0.85, p < 0.001), angle-corrected PISA method (r = 0.99, p < 0.001), and solid angle-corrected PISA method (r = 0.88, p < 0.001). The time duration of the new method was shorter (p < 0.001). CONCLUSION: Our method is an easy way for applying angle-corrected PISA method to mitral valve area measurement in patients with mitral stenosis. Absence of the need for estimating the angle is the major advantage.

Utility of myocardial performance index measured by left ventricular catheterization.

BACKGROUND: Myocardial performance index (MPI) is a valuable index of global ventricular performance. It is almost always measured by Doppler echocardiography. The purposes of this study were (I) to compare MPI measured by catheterization (MPIc) and that measured by Doppler echocardiography (MPId), and (2) to compare it with the functional status. MATERIALS AND METHODS: The study included 80 patients who had undergone left heart catheterization. The MPIc was measured from the pressure recordings obtained at left ventricle and aorta. RESULTS: Mean MPId and MPIc were 0.40 +/- 0.12 and 0.42 +/- 0.12, respectively. Mean left ventricular end diastolic pressure (LVEDP) was 13 +/- 5 mm Hg. Mean heart rate was 77 +/- 11 beats/min. Mann-Whitney U test revealed that MPIc could discriminate between the functional statuses of the patients. The regression analysis revealed that there is a good correlation between MPIc and MPId, LVEDP or heart rate. There was no significant difference between MPIc and MPId (p > 0.05). CONCLUSION: The present data show that (I) the MPIc has a strong correlation with MPId; (2) it is a good discriminator of functional status. It may provide an additional information regarding the left ventricular performance in patients who underwent the cardiac catheterization.

Elongation index as a new index determining the severity of left ventricular systolic dysfunction and mitral regurgitation in patients with congestive heart failure.

The shape of the left ventricle is an important echocardiographic feature of left ventricular dysfunction. Progression of the mitral regurgitation and consequent left ventricular remodeling is unpredictable in heart failure. Elongation index is an index of left ventricular sphericity. The surface area of the elongated ventricle is larger than that of a spherical one. The objective of this study was to assess the relation between elongation index and the degree of mitral regurgitation along with noninvasive indices of left ventricular function. Thirty-two patients (21 male, 11 female, mean age: 57 +/- 6 yrs) with congestive heart failure and mitral regurgitation were included. Patients were stratified into three groups according to vena contracta width as having mild (n = 11), moderate (n = 11) and severe mitral regurgitation (n = 10). The elongation index (EI) was considered as equal to {[(left ventricular internal area-measured) - (theoretical area of the sphere with measured left ventricular volume)]/(theoretical area of the sphere with measured left ventricular volume)}. Ejection fractions by the modified Simpson rule, dP/dt and sphericity index (SI) were also recorded. The relationship between (EI), ejection fraction, dP/dt and SI reached modest statistical significance (p < 0.05). When the EI and SI were compared, the correlation was also significant (p < 0.01). The areas under the receiver operator curve of EI and SI for discriminating dP/dt < 1000 mm Hg/s were 0.833 and 0.733, respectively. In conclusion, the elongation, which defines the shape of the left ventricle, might be related to the systolic function of the left ventricle and the degree of the mitral regurgitation. Further studies are needed to demonstrate its use in other clinical entities.

The effect of tirofiban and clopidogrel pretreatment on outcome of old saphenous vein graft stenting in patients with acute coronary syndromes.

In spite of developments in interventional cardiology, the success rate of saphenous vein graft stenting is still low in patients with acute coronary syndromes. In this study, we aimed at finding out the effect of pretreatment with Tirofiban, a glycoprotein IIb/IIIa inhibitor, and clopidogrel, an adenosine diphosphate antagonist, on the outcome of saphenous vein graft stenting in patients with acute coronary syndrome. A total of 47 patients, who had lesions in saphenous vein grafts and acute coronary syndrome, could be randomized to treated group (n = 24), who received Tirofiban and clopidogrel for 48 hours before the intervention, and untreated group (n = 23), who did not receive Tirofiban and clopidogrel. In the untreated group, the intervention was performed just after the coronary angiography. All patients underwent stenting as the standard intervention. The groups were compared by Mann-Whitney's U-test or Chi-Square test. The level of statistical significance was set at 0.05. There were no significant differences regarding age, gender, and atherosclerotic risk factors between the two groups. In treated group, precutaneous coronary intervention was successful in all patients and no-reflow phenomenon occurred in only one patient. The rate of no-reflow or slow-flow phenomenon was significantly lower in treated group (one patient vs 9 patients, p = 0.004). One patient in untreated group experienced ventricular fibrillation, which was converted to sinus rhythm after defibrillation. During short-term follow-up, there were no acute myocardial infarction, coronary bypass surgery or death in both groups. There was no major bleeding. Minor bleeding was more frequent in treated group, but it did not achieve statistical significance (3 vs 1; p = 0.322). In conclusion, pretreatment with tirofiban and clopidogrel before percutaneous coronary intervention might result in better immediate outcomes in old saphenous vein grafts without any significant increase in bleeding complications.

Left atrial functions after myocardial infarction.

Acute myocardial infarction results in not only left ventricular but also left atrial dysfunction. Left atrial function is important for optimal filling of the left ventricle. In this study, we aimed at evaluating left atrial functions 6 months after acute myocardial infarction in three different patient groups (thrombolytic therapy, primary percutaneous intervention, or no reperfusion strategies). Between October 2002 and May 2003, 48 patients with ST elevation myocardial infarction who were either administered thrombolytic therapy (group T, n=16), underwent primary angioplasty (group A, n=20), or underwent no reperfusion therapy (group C, n=12) at our unit were enrolled into the study. Echocardiography was performed in these patients 6 months after acute myocardial infarction. Left atrial contractility was assessed by atrial ejection force. Left atrial contribution was assessed by atrial fractional shortening and left atrial volume was calculated. The left atrial volume was significantly higher in group C (P<0.05), but there was no significant difference between groups A and T (P>0.05). Patients in group C had significantly lower atrial ejection force values compared with the other groups (P<0.05). Atrial fractional shortening was not significantly different among the three groups (P>0.05). Atrial ejection force, which is an indicator of left atrial contractility, is better with either angioplasty or thrombolysis. Left atrial volume is higher in patients who were not treated with reperfusion strategies. Further studies are needed to explain the mechanism involved.

A novel method to estimate pulmonary artery wedge pressure using the downslope of the Doppler mitral regurgitant velocity profile.

Continuous-wave (CW) Doppler recording of mitral regurgitation (MR) is a reflection of the left ventriculoatrial pressure gradient. Accordingly, this jet may yield information about pulmonary artery wedge pressure (PAWP). In this study, we derived and then evaluated a novel method for prediction of PAWP. Patients (n=80) with moderate to severe MR and left ventricular dysfunction were included in the study. Transthoracic echocardiography was performed in patients during pulmonary artery pressure monitoring. A satisfactory CW Doppler recording of MR was obtained in 63/80 (78%). On the late descending portion of the CW recording, the time from a velocity of 4 m/sec to the end of the jet was defined as t1, and from 3 m/sec to the end of the jet as t2. Mathematical derivation of t1/t2 as a predictor of PAWP, was performed based on Weiss' derivation. If t1/t2 was <1.30, the PAWP was normal. If t1/t2 > 1.44, the PAWP was > 16 mmHg. With this new mathematical derivation, it appears that the downslope of the CW Doppler MR waveform may be able to distinguish a normal from elevated PAWP.

Stenting the undeployed stent.

Undeployment of a stent which poses a potential risk for future events may become a serious problem in the catheter laboratory. Herewith, we present a case in which we successfully stented an undeployed stent in the distal right coronary artery.