Multi-Center Experience of Coronary Artery Perforation During Percutaneous Coronary Intervention: Clinical and Angiographic Characteristics, Management, and Outcomes Between 2010 and 2020.

BACKGROUND: Coronary artery perforations are one of the most feared, rare, and catastrophic complication of percutaneous coronary intervention. Despite the remarkable increase in coronary angiography and percutaneous coronary intervention, there is no large database that collects coronary artery perforation for the Turkish population. Our study aimed to report our experience over a 10-year period for clinical and angiographic characteristics, management strategies, and outcomes of coronary artery perforation during the percutaneous coronary intervention at different cardiology departments in Turkey. METHODS: The study data came from a retrospective analysis of 48 360 percutaneous coronary intervention procedures between January 2010 and June 2020. A total of 110 cases who had coronary artery perforation during the percutaneous coronary intervention were found by angiographic review. Analysis has been performed for the basic clinical, angiographic, procedural characteristics, the management of coronary artery perforation, and outcome of all patients. RESULTS: The coronary artery perforation rate was 0.22%. Out of 110 patients with coronary artery perforation, 66 patients showed indications for percutaneous coronary intervention with acute coronary syndrome and 44 patients with stable angina pectoris. The most common lesion type and perforated artery were type C (34.5%) and left anterior descending (41.8%), respectively. The most observed coronary artery perforation according to Ellis classification was type III (37.2%). Almost 52.7% of patients have a covered stent implanted in the perforated artery. The all-cause mortality rate of coronary artery perforation patients in the hospital was 18.1%. CONCLUSION: The observed rate of coronary artery perforation in our study is consistent with the studies in this literature. However, the mortality rates related to coronary artery perforation are higher than in other studies in this literature. Especially, the in-hospital mortality rate was higher in type II and type III groups due to perforation and its complications. Nevertheless, percutaneous coronary intervention should be done in selected patients despite catastrophic complications.

Dabigatran for stroke prevention in real life in a sample of population from Turkey: D-SPIRIT registry.

OBJECTIVE: The D-SPIRIT registry is designed to investigate the safety and effectiveness of dabigatran etexilate in patients with atrial fibrillation in routine clinical practice. METHODS: D-SPIRIT is the first national, multicenter, prospective, observational, postmarketing registry that investigates the usage of dabigatran in real life. A total of 326 noveloral anticoagulant-eligible patients with atrial fibrillation who have been taking dabigatran etexilate therapy for stroke prevention at least 6 months from 9 different centers were enrolled into the registry. Patients were followed up for 2 years to evaluate the effectiveness and safety of the treatment. All adverse clinical events including bleeding, thromboembolic events, stroke, systemic embolism, transient ischemic attack, myocardial infarction, and all-cause death were recorded. RESULTS: The mean age was 71.1±9.6 years, and 57.4% of the study participants were female. The mean CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack [TIA], vascular disease, age 65-74 years, sex category) score was 3.4±1.6. The cumulative adverse clinical events rate was 6.30% per year. The rate for embolic events including TIA, ischemic stroke, and peripheral embolism was 1.26% per year. The rate for major bleeding was 2.20% per year, and the mortality rate was 0.94% per year. CONCLUSION: This registry obtained an important overview of the current safety and effectiveness of the dabigatran etexilate in Turkey. Our results indicate similar rates of thromboembolic and bleeding events with pivotal phase 3 trial and other real-life registries. However, rate of undertreatment usage of dabigatran etexilate in real life was found to be considerable.

Demographic, Clinical, and Angiographic Characteristics of Atrial Fibrillation Patients Suffering From de novo Acute Myocardial Infarction: A Subgroup Analysis of the MINOCA-TR Study Population.

BACKGROUND: Atrial fibrillation (AF) prevalence in patients with acute myocardial infarction (MI) ranges from 3% to 25%. However demographic, clinical, and angiographic characteristics of AF patients who admitted with de novo MI are unclear. The aim of this study was to investigate the prevalence of patients presenting with de novo MI with AF. METHODS: The study was performed as a sub-study of the MINOCA-TR (Myocardial Infarction with Non-obstructive Coronary Arteries in Turkish Population) Registry, a multicenter, cross-sectional, observational, all-comer registry. MI patients without a known history of stable coronary artery disease and/or prior coronary revascularization were enrolled in the study. Patients were divided into AF and Non-AF groups according to presenting cardiac rhythm. RESULTS: A total of 1793 patients were screened and 1626 were included in the study. The mean age was 61.5 (12.5) years. 70.7% of patients were men. The prevalence of AF was 3.1% (51 patients). AF patients were older [73.4 (9.4) vs. 61.0 (12.4) years, p<0.001] than non-AF patients. The proportion of women to men in the AF group was also higher than in the non-AF group (43.1% vs. 28.7%, p=0.027). Only 1 out of every 5 AF patients (10 patients, 19.6%) was using oral anticoagulants (OAC). CONCLUSIONS: AF prevalence in patients presenting with de novo MI was lower than previous studies that issued on AF prevalence in MI cohorts. The majority of AF patients did not have any knowledge of their arrhythmia and were not undergoing OAC therapy at admission, emphasizing the vital role of successful diagnostic strategies, patient education, and implementations for guideline adaptation.

Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases.

OBJECTIVE: The evolution of non-vitamin K antagonist anticoagulants (NOACs) has changed the horizon of stroke prevention in atrial fibrillation (SPAF). All 4 NOACs have been tested against dose-adjusted warfarin in well-designed, pivotal, phase III, randomized, controlled trials (RCTs) and were approved by regulatory authorities for an SPAF indication. However, as traditional RCTs, these trials have important weaknesses, largely related to their complex structure and patient participation, which was limited by strict inclusion and extensive exclusion criteria. In the real world, however, clinicians are often faced with complex, multimorbid patients who are underrepresented in these RCTs. This article is based on a meeting report authored by 12 scientists studying atrial fibrillation (AF) in diverse ways who discussed the management of challenging AF cases that are underrepresented in pivotal NOAC trials. METHODS: An advisory board panel was convened to confer on management strategies for challenging AF cases. The article is derived from a summary of case presentations and the collaborative discussions at the meeting. CONCLUSION: This expert consensus of cardiologists aimed to define management strategies for challenging cases with patients who underrepresented in pivotal trials using case examples from their routine practice. Although strong evidence is lacking, exploratory subgroup analysis of phase III pivotal trials partially informs the management of these patients. Clinical trials with higher external validity are needed to clarify areas of uncertainty. The lack of clear evidence about complex AF cases has pushed clinicians to manage patients based on clinical experience, including rare situations of off-label prescriptions.

Prevalence and clinical profile of patients with myocardial infarction with non-obstructive coronary arteries in Turkey (MINOCA-TR): A national multi-center, observational study.

OBJECTIVE: Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is a relatively new term that is characterized by clinical evidence of MI with normal or near-normal coronary arteries on coronary angiography (QCA). To date, there have been no population-based studies on the prevalence of MINOCA in Turkey. The aim of this nationwide study was to document the prevalence and demographics of MINOCA in a Turkish population. METHODS: MINOCA-TR is national, multi-center, prospective, all-comer study that was conducted in 32 hospitals. All consecutive patients who were ≥18 years old, diagnosed with MI according to the Third Universal Definition of Myocardial Infarction, and had undergone QCA were included in the study. Patients with stable coronary artery disease, unstable angina pectoris, a history of revascularization, and type 4/5 MI were excluded. RESULTS: A total of 1793 patients who were diagnosed with MI and had undergone QCA were screened between March 2018 and October 2018, of whom 1626 (mean age: 61.5±12.5 years, 70.7% male) were enrolled from 32 centers. The prevalence of MINOCA was 6.7% (n=109) in the overall study population. Compared with non-MINOCA patients, those with MINOCA were younger, had a higher prevalence of the female gender, and had a history of flu. The percentages of current smokers, ST-segment elevated myocardial infarction patients, and those with a history of hypertension, diabetes mellitus, and hyperlipidemia were significantly lower in MINOCA patients (p<0.05, for all). Also, the median left ventricular ejection fraction as seen on echocardiography and the ratio of Killip Class I status at presentation was significantly higher in MINOCA patients than in non-MINOCA patients (p<0.001). Patients with MINOCA received a preload dose of P2Y12 antagonist before QCA less often than non-MINOCA patients (p<0.001). CONCLUSION: The prevalence of MINOCA in Turkey is 6.7% in patients who were admitted with MI. Also, as compared to non-MINOCA patients, the MINOCA patients were exposed to fewer traditional risk factors of coronary artery disease.

The relationship between serum apelin levels and aortic dilatation in bicuspid aortic valve patients.

OBJECTIVE: The bicuspid aortic valve (BAV) is the most common congenital heart disease. The process of aortic dilatation is not completely clear in patients with the BAV. Apelin is a peptide found at high levels in vascular endothelial cells which has a role in vascular regulation and cardiovascular function. The aim of this study was to determine the relationship between serum apelin levels and ascending aortic dilatation in adult patients with BAV. DESIGN: This cross-sectional study included 62 patients with isolated BAV and to an age, gender, and body mass index-matched control group of 58 healthy volunteers with tricuspid aortic valve. Transesophageal echocardiography was performed on all patients to determine the type of BAV. Aortic diameters of the aortic root, sinus valsalva, sinotubular junction, and ascending aorta were evaluated with echocardiography. Patients with BAV were divided into two subgroups according to the aortic diameters, as the nondilated BAV group and the dilated BAV group. Serum apelin level was analyzed with ELISA method. RESULTS: The serum apelin levels of the BAV patients were significantly lower than those of the control group (833.5, 25th-75th percentile (713.5-1745) pg/dL vs 1669 (936-2543) pg/dL; P = 0.006). In the subgroup analysis, serum apelin level was significantly different between the nondilated BAV group and the dilated BAV group [977 (790-2433) pg/dL vs 737 (693-870) pg/dL, P < 0.05] and between the dilated BAV group and the control group [737 (693-870) pg/dL vs 1669 (936-2543) pg/dL, P < 0.001]. In multivariate logistic regression analysis apelin [7.27 (95% CI: 1.73-30.42), P = 0.007] and age [1.05 (95% CI: 0.99-1.20), P = 0.049] were determined as independent predictors for ascending aortic dilatation. CONCLUSION: Low serum apelin level was associated with dilatation of ascending aortic in BAV patients. However, apelin was not relevant to BAV without aortic dilatation.

Assessment of bicuspid aortic valve phenotypes and associated pathologies: A transesophageal echocardiographic study.

OBJECTIVE: We investigated the frequency of different bicuspid aortic valve disease (BAV) phenotypes,the associated valvular pathologies, and the aortopathy phenotypes, using 2-dimensional (2D) transthoracic, 2D transesophageal echocardiography (TEE) and 3-dimensional (3D) TEE. METHODS: A total of 154 patients with BAV were included. Five BAV phenotypes were detected. To better define valvular pathologies, binary classifications of BAV were used: BAV with antero-posterior commisural line (BAV-AP) and right-left commissural line (BAV-RL). Aortopathy phenotype was classified according to the involved tract(s). RESULTS: Of the patients, 53.2% had type 1, 16.2% type 2, 15.6% type 3, 1.3% type 4, and 13.6% had type 5 BAV. The prevalence of BAV-AP and BAV-RL was 68.2% and 31.8%, respectively. No difference was detected with respect to aortic regurgitation between BAV-AP and BAV-RL (p=0.9), but the BAVRL group had an increased propensity to have a stenotic aortic valve (p=0.003). The indexed aortic diameter was larger in BAV-AP cases than BAV-RL at the sinus of Valsalva (p=0.008). In patients with dilatation of the root and tubular portion, a predominance of BAV-AP versus BAV-RL was observed (85% vs 15%). A markedly low prevalence of the root phenotype (3.2%) was observed. In 90.1% of the patients, 2D TEE was sufficient to classify BAV phenotypes; further 3D imaging was needed in 9.9% of the cases. CONCLUSION: There may be racial differences in the frequency of valvular and aortopathy phenotypes in patients with BAV. BAV phenotypes differ with respect to aortic stenosis and aortopathy phenotypes. TEE may have good diagnostic utility in differentiating BAV phenotypes.

Assessment of Contributors of Aortopathy and Subclinical Left Ventricular Dysfunction in Normally Functioning Bicuspid Aortic Valves.

BACKGROUND: Left ventricular (LV) function and the dimensions of aortic valves from normally functioning bicuspid aortic valve (BAV) patients were compared with those of healthy control patients. A comparison between patients with antero-posterior BAV (BAV-AP) or right-left BAV (BAV-RL) was also performed, and the determinants of aortopathy and LV function were investigated. METHODS: Sixty-eight patients with aortic velocities <2 m/s and trivial or mild aortic regurgitation were included in the study. All patients underwent transesophageal echocardiography to diagnose BAV and identify associated phenotypes. Twodimensional (2D), Doppler echocardiographic evaluation, and strain imaging were also performed, and the results compared with those obtained from 55 age- and gender-matched healthy controls. RESULTS: The LV ejection fractions were similar between BAV patients and healthy controls, while LV global longitudinal strain (LVGLS) (p = 0.03) and LV global circumferential strain (LVGCS) (p = 0.02) were significantly lower among BAV patients. Aortic velocities and aortic dimensions at theannulus, sinus of Valsalva and sinotubular junction were significantly greater in BAV patients (all p <0.001). The diameter of the tubular ascending aorta (AA) was correlated with age (r = 0.55, p <0.001), septal E/e' (r = 0.4, p = 0.003), and LV mass index (r = 0.29, p = 0.024). Multivariate analyses revealed that the primary determinant of the AA diameter in BAV patients was age (ß = 0.38, p = 0.04), and enlargement of the AA was independent of the diastolic properties of the left ventricle and LVGLS. No significant differences were observed among the 2D or Doppler echocardiography parameters, nor among strain measurements, between BAV-AP (n = 47) and BAV-RL (n = 21) phenotypes. CONCLUSIONS: Subclinical myocardial dysfunction was observed in BAV patients with normal aortic valve function. LV dysfunction was independent of age, aortic velocity and AA diameter, which suggested the presence of intrinsic myocardial disease. Aging contributes to aortic dilatation in normally functioning BAV.

Early Reverse Cardiac Remodeling Effect of Laparoscopic Sleeve Gastrectomy.

BACKGROUND: This study evaluated the early postoperative benefits of laparoscopic sleeve gastrectomy (LSG) on the left ventricular (LV) function and left atrial (LA) structural, mechanical, and electrical functions in severely obese patients. METHODS: Thirty-two patients with severe obesity who were consecutively scheduled for LSG and 30 healthy controls were included in the study. LV global longitudinal strain (LGS), peak atrial longitudinal strain (PALS), and strain rates (S-Sr, E-Sr, and A-Sr) of the lateral and septal LA walls, and intra- and interatrial dyssynchrony periods for all subjects were evaluated using strain echocardiography. The measurements were repeated in patients 1 month after surgery. RESULTS: LGS of the LV was significantly depressed in the patient group compared with the control group (p < 0.001). LA peak septal and lateral wall strain values were significantly lower in patients than in controls (both p values <0.001). LA intra- and interatrial dyssynchrony periods were longer in patients than in controls (p = 0.012 and p = 0.004, respectively). LGS significantly improved after LSG (p < 0.001). Significant reductions were noted in the LA antero-posterior diameter (p < 0.001), LA volume index (LAVI, p = 0.001), and in the mitral velocity to the early diastolic velocity of the mitral annulus ratio (E/e' ratio, p = 0.046). The PALS of the septal and lateral LA walls significantly increased (p = 0.001 and p < 0.001, respectively). S-Sr, E-Sr, and A-Sr values of the septal LA wall (p = 0.049, p < 0.001, and p = 0.001, respectively) and the lateral LA wall (p = 0.009, p = 0.007, and p = 0.002, respectively) significantly improved postoperatively. Intra- and interatrial dyssynchrony significantly decreased (p = 0.001 and p < 0.001, respectively). Weight loss positively correlated with changes in LGS (R = 0.39, p = 0.039), LAVI (R = 0.39, p = 0.034), intra-atrial dyssynchrony (R = 0.45, p = 0.021), interatrial dyssynchrony (R = 0.42, p = 0.038), septal LA wall peak strain (R = 0.44, p = 0.027), lateral LA wall peak strain (R = 0.46, p = 0.017), septal LA wall A-Sr (R = 0.43, p = 0.028), and lateral LA wall A-Sr (R = 0.46, p = 0.019). The comparison of postoperative findings of the patients with controls revealed that the LA diameter, both LA volume and volume index (LAVI), E/e' ratio, S-Sr and E-Sr of both lateral and septal LA walls, intra- and interatrial LA dyssynchrony of the patient group became similar to the control group (all p value >0.05). Postoperative A-Sr values of both LA walls (both p value <0.001) were higher in patients than controls. CONCLUSION: The benefits of LSG on LV and LA function may be observed even in the early postoperative phase. The resulting weight loss correlates with LV and LA reverse remodeling in severely obese patients.

Design and rationale of dabigatran's stroke prevention in real life in Turkey (D-SPIRIT).

OBJECTIVE: The D-SPIRIT registry is designed to investigate the safety and efficacy of dabigatran etexilate in patients with nonvalvular atrial fibrillation (NVAF) and to collect data on outcomes in clinical practice. METHODS: The D-SPIRIT is a national, prospective, observational, post-marketing registry involving patients with NVAF who have been taking dabigatran etexilate therapy for stroke prevention for a minimum of 6 months prior to enrollment. The registry will collect and analyze data from routine care, enrolling up to 600 patients in 9 centers. Patients will be followed up for 2 years to evaluate effectiveness and safety. A sample size of 600 subjects is proposed based on the following assumptions; Two-sided significance level of 0.05 (1-sided significance level of 0.025), ischemic stroke incidence rate of 0.768%-1.111%, hemorrhagic stroke incidence rate of 0.109%-0.130%, transient ischemic attack incidence rate of 0.722%-0.623%, therapy discontinuation incidence rate of 40% at day 730, and duration of enrollment period of 12 months with non-uniformed enrollment rate. Ethics approval was given by Dokuz Eylül University Ethics Committee of Clinical Research (2014/54) and approved by the Turkish Ministry of Health. CONCLUSION: Potential results of D-SPIRIT registry will add data from clinical practice to those from the RE-LY trial to expand knowledge of dabigatran etexilate treatment in patients with NVAF.

Evaluating functional capacity, and mortality effects in the presence of atrial electromechanical conduction delay in patients with systolic heart failure.

OBJECTIVE: Atrial functions are relatively suppressed in heart failure (HF). We aimed to investigate the associations of intra- and inter-atrial electromechanical conduction delay (EMCD) with functional class and mortality over a 12-month follow-up period. METHODS: The prospective study included 65 patients with systolic HF and 65 healthy subjects with normal sinus rhythm. Left ventricular (LV) systolic functions and left atrial (LA) dimensions and volumes were evaluated by transthoracic echocardiography. Tissue Doppler imaging (TDI) signals at the lateral border of the mitral annulus (lateral PA'), septal mitral annulus (septal PA'), and tricuspid annulus (tricuspid PA') were measured. Intra- and inter-atrial EMCD were calculated. RESULTS: Mitral inflow velocities were studied using pulsed-wave Doppler after placing the sample volume at the leaflets' tips. The peak early (E wave) and late (A wave) velocities were measured. The septal annular E/E' ratio was relatively higher and lateral, septal, and right ventricular S, E', and A' waves were significantly lower in the HF group than in the control group (12.49±6.03 - 7.16±1.75, pE/E' <0.0001). Intra-atrial EMCD was detected as 117.5 ms and inter-atrial EMCD as 127.5 ms in patients with prolonged atrial EMCD. A significant increase was found in prolonged intraand inter-atrial EMCD according to functional capacity increase (p=0.012 and p=0.031, respectively). The incidence of mortality was significantly higher in patients with prolonged atrial EMCD (p=0.025), and 5 patients in the HF group died during the study over the 12-month follow-up period. CONCLUSIONS: In this study, we found a relationship between prolonged atrial conduction time and increased functional class and mortality in patients with systolic HF.

Predictors of Future Atrial Fibrillation Development in Patients with Hypertrophic Cardiomyopathy: A Prospective Follow-Up Study.

BACKGROUND: We evaluated whether left atrial (LA) phasic functions, P-wave dispersion (PWD), and plasma NT-proBNP levels could predict future development of atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM). METHODS: Seventy patients with HCM were evaluated. The LA phasic functions including the LA total emptying volume (LATEV), LA total emptying fraction (LATEF), LA active emptying volume (LAAEV), LA active emptying fraction (LAAEF), LA passive emptying volume (LAPEV), and LA passive emptying fraction (LAPEF) were evaluated. P-wave dispersion was calculated. Plasma NT-proBNP levels were measured on the same day with echocardiographic study. RESULTS: Patients were followed up 53.09 ± 1.87 months. Patients who developed AF (n = 18) had significantly higher PWD values, NT-proBNP levels, LAVI, E/E' av, and resting LVOT gradients and significantly lower LATEF and LAAEF. In multivariate analysis, LATEF (P = 0.002), LAAEF (P = 0.007), logNT-proBNP level (P = 0.022), and PWD (P = 0.018) were associated with AF development. The results of receiver operating characteristic analysis revealed that a LATEF cutoff value 49% with 72% sensitivity and 81% specificity, a LAAEF cutoff value of 36% with 72% sensitivity and 71% specificity, and an NT-proBNP cutoff value of 720 pg/mL predicted future AF development with 72% sensitivity and 60% specificity. A PWD cutoff value of 47.5 msecond predicted future AF development with 78% sensitivity and 72% specificity. CONCLUSION: In patients with HCM, LA phasic functions, PWD, and NT-proBNP levels predict future development of AF. Assessment of LA phasic functions during routine echocardiographic evaluation and measuring NT-proBNP levels and PWD values of patients with HCM during daily practice may provide important data in predicting those at high risk of AF occurrence.

Galectin-3 levels in patients with hypertrophic cardiomyopathy and its relationship with left ventricular mass index and function.

OBJECTIVE: Cardiac fibrosis is an important contributor to adverse left ventricular (LV) remodeling and arrhythmias in patients with hypertrophic cardiomyopathy (HCM). Galectin-3 (Gal-3) is a novel marker of cardiac fibrosis and inflammation. In this study, we investigated Gal-3 levels in patients with HCM and controls and assessed the relationship between Gal-3 level and echocardiographic indices using strain echocardiography in patients with HCM. METHODS: Forty patients with HCM in sinus rhythm and 35 healthy controls were prospectively enrolled in this case-control study. The HCM diagnosis was based on two-dimensional echocardiographic demonstration of a hypertrophied and non-dilated left ventricle (LV) with a wall thickness ≥15 mm in one or more LV myocardial segments in the absence of any cardiac or systemic disease capable of inducing LV hypertrophy. Patients with one of the followings were excluded: coronary artery disease, atrial fibrillation episodes on 24-h Holter electrocardiogram (ECG) monitoring, history of an invasive intervention to alleviate an LV outflow (LVOT) obstruction, inadequate image quality, renal disease, diabetes mellitus, hyperlipidemia, liver cirrhosis, and pulmonary fibrosis. Global LV longitudinal, circumferential strain and strain rates, peak torsion, and LV mass index (LVMI) of all subjects were assessed by echocardiography. Gal-3 levels were measured in all subjects. RESULTS: Left ventricular global longitudinal strain (-13.37±4.6% vs. -18.93±2.5%, p<0.001) and strain rate (0.66±0.22 s-1 vs. 1.08±0.14 s-1, respectively; p<0.001) values were lower in patients with HCM than in controls. Gal-3 levels were significantly higher in patients with HCM than in controls (16.9±6.64 ng/mL vs. 13.21±3.42 ng/mL, p=0.005). Gal-3 levels were associated with the thickness of the interventricular septum (r=0.444, p=0.004) and LVMI (r=0.365, p=0.021); however, they were not associated with LV global longitudinal strain (p=0.42) or strain rate (p=0.28). CONCLUSION: Gal-3 levels increased and were correlated with the degree of LV hypertrophy in patients with HCM. Gal-3 is not a good marker of decreased myocardial LV diastolic and systolic functions in these patients.

Evaluation of Trastuzumab-induced early cardiac dysfunction using two-dimensional Strain Echocardiography.

AIM: Trastuzumab, a chemotherapeutic agent used in the treatment of breast cancer. has been shown to induce subclinical left ventricular (LV) dysfunction during a three to six month period as evidenced by strain echocardiographic examination without any change occurring in the ejection fraction of LV. The present study evaluated the presence of subclinical LV dysfunction using strain echocardiography 1 day and 7 days after the initiation of trastuzumab therapy. MATERIAL AND METHODS: The patients with breast cancer receiving adjuvant trastuzumab therapy underwent 2-dimensional, tissue Doppler, and strain echocardiographic examination at baseline and 1 day and 7 days after therapy. LV global longitudinal strain (GLS), global circumferential strain (GCS) values, and other echocardiographic parameters were calculated. RESULTS: A total of 40 females, mean age 50+/-10 years, were evaluated. Of these patients, 97% received anthracycline and 73% received radiotherapy before the initiation of trastuzumab therapy. No change was observed in any of the echocardiographic parameters 1 day after the initiation of trastuzumab therapy (p>0.05). The LV ejection fraction, tissue Doppler parameters, and GCS values did not show any changes 7 days after the initiation of therapy, whereas significant decreases were observed in GLS value (19.2+/-4.0% vs. 17.2+/-3.4, p=0.001) and systolic annular velocity of the lateral LV wall (S' velocity) (10.5+/-3.2 vs. 8.6+/-2.2, p=0.002). CONCLUSION: Trastuzumab therapy is associated with subclinical LV dysfunction as early as 7 days after initiation of the therapy as evidenced by the decreases in GLS value of LV and systolic annular velocity of the lateral LV wall.

Diagnostic value of combining heart rate recovery and P-wave changes with exercise-induced changes in the ST segments for prediction of myocardial ischaemia.

BACKGROUND: In patients admitted to outpatient clinics with chest pain, changes in the ST-segments of electrocardiogram (ECG) readings are the most widely used criteria during treadmill ECG tests to determine myocardial ischaemia, despite its poor accuracy. In this study, we evaluated the benefit of combining elongation of P-wave duration (Pdur) and abnormal heart rate recovery (HRR) parameters in addition to changes in the ST-segments for the detection of myocardial ischaemia with treadmill ECG testing. METHODS: Patients (n = 369) with chest pain who underwent both a treadmill ECG test and myocardial perfusion scintigraphy (MPS) were enrolled. P-wave duration was measured at rest and at the end of the first minute of the recovery phase and elongation of the P-wave was calculated. Abnormal HRR was defined as the failure of a decreasing HR at the end of the first minute of the recovery phase >10% of the maximum HR reached during treadmill ECG testing. The sensitivity, specificity, positive and negative predictive values, diagnostic accuracy values, and likelihood ratios (LRs) of changes in the ST-segments, P-wave elongation, abnormal HRR, and the combination of these three variables for predicting myocardial ischaemia detected by MPS, were calculated separately-in patients without previous coronary artery disease (CAD) and in those with CAD. RESULTS: Elongation of Pdur by 20 ms or longer and abnormal HRR during treadmill ECG test were more common in patients with reversible perfusion defects in MPS than in those without perfusion defects (both P < 0.001). When patients were divided into two groups according to the presence or absence of a history of CAD, the addition of elongation of Pdur 20 ms and abnormal HRR to the development of significant changes in the ST-segments detected myocardial ischaemia with 46.7% sensitivity, 97.8% specificity, 67.2% negative predictive value, 88.9% positive predictive value, and 70% diagnostic accuracy in 77 patients with previous CAD. The LR+ of the combination of the three variables was 12.27. The addition of elongation of Pdur 20 ms and abnormal HRR to the development of significant changes in the ST-segments detected myocardial ischaemia with 52.7% sensitivity, 98.7% specificity, 89.9% negative predictive value, 90.6% positive predictive value, and 90% diagnostic accuracy in 292 patients without previous CAD. The LR+ of the combination of the three variables to detect myocardial ischaemia was calculated to be 41.48 in patients without a history of CAD. CONCLUSIONS: The addition of elongation of Pdur and abnormal HRR to the conventionally used criterion of changes in the ST-segments in patients with suspected myocardial ischaemia increased the specificity and positive and negative predictive values of treadmill ECG testing for detecting myocardial ischaemia, which might reduce the need for other expensive noninvasive techniques. The diagnostic utility of adding these two parameters was more obvious in patients with no history of CAD.

Chronic Papillary Muscle Rupture: 14-Year Survival without Surgical Treatment.

UNLABELLED: Papillary muscle rupture is a life-threatening complication of myocardial infarction which is usually refractory to medical treatment. We present a very rare case of a 65-year-old woman who had a myocardial infarction and posteromedial papillary muscle rupture which was only treated with medical therapy, including her corresponding 14-year follow-up. However, surgical intervention is still strongly recommended because the prognosis of acute papillary muscle rupture associated with myocardial infarction remains poor. KEY WORDS: Complication; Myocardial infarction; Papillary muscle rupture; Survival.

Isolated Congenital Unilateral Agenesis of the Left Pulmonary Artery with Left Lung Hypoplasia in an Asymptomatic Adult Patient.

UNLABELLED: The congenital unilateral agenesis of pulmonary artery is a congenital cardiovascular anomaly rarely seen in adulthood. A 21-year-old asymptomatic male was admitted to our hospital to obtain a routine health report to accompany a job application. Posteroanterior chest radiograph revealed a mediastinal shift to the left, with increased radiopacity in the left lung and increased radiolucency in the right lung. Thoracoabdominal computed tomography revealed hypoplasia of the left pulmonary artery. Transthoracic echocardiography excluded any accompanying cardiac abnormalities. Pulmonary angiography was undertaken and confirmed diffuse hypoplasia of the left pulmonary artery while right pulmonary artery was significantly enlarged. The patient's pulmonary artery pressure was within the normal limits, after which he decided to be carefully followed-up. KEY WORDS: Cardiovascular anomaly; Hypoplasia; Pulmonary artery.

Predictors of Atrial Fibrillation Risk in Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a genetic cardiovascular disease that predisposes individuals to the development of arrhythmias. The most common sustained arrhythmia is atrial fibrillation (AF). Compared with the general population, patients with HCM are more prone to the development of AF. To avoid embolic complications and the clinical deterioration caused by the development of AF in HCM, identifying patients with a tendency toward AF might affect the management of HCM. In this review, we evaluated the predictors of AF development in patients with HCM.

Relationships between P wave dispersion, atrial electromechanical delay, left atrial remodeling, and NT-proBNP levels, in patients with hypertrophic cardiomyopathy.

BACKGROUND: We evaluated the associations among the well-known atrial fibrillation (AF) predictors including P-wave dispersion (PWD), intra- and inter-atrial electromechanical dyssynchrony (EMD), left atrial (LA) phasic functions, and plasma N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) levels, in patients with hypertrophic cardiomyopathy (HCM). METHODS: Seventy patients with HCM and age and sex matched 70 subjects were enrolled. PWD, LA total emptying fraction (LATEFr), active emptying fraction (LAAEFr), passive emptying fraction (LAPEFr), expansion index (LAEI) intra- and inter-atrial EMD were calculated. Levels of NT-proBNP of all subjects were determined. RESULTS: Higher PWD (p = 0.006), significantly decreased LAEI (p < 0.001), LATEFr, and LAPEFr (both p values < 0.001) values and significantly increased inter-atrial (p < 0.001), LA (p = 0.001), and right atrial dyssynchrony (p < 0.001) were observed in the HCM group compared to controls. PWD was negatively correlated with LAEI (r = -0.236, p = 0.005) and LATEFr (r = -0.242, p = 0.04), however not with LAPEFr (p = 0.7), or LAAEFr (p = 0.3). Except for the LA lateral wall PA' (r = 0.283, p = 0.02), PWD was not correlated with any atrial EMD parameter. Inter-atrial dyssynchrony was related to LAEI (r = -0.272, p = 0.001), LATEFr (r = -0.256, p = 0.03), and LAPEFr (r = -0.332, p = 0.006), but not, however, to LAAEFr (p = 0.4). The plasma NT-proBNP levels of patients were not correlated with either PWD (p = 0.927) or inter-atrial dyssynchrony (p = 0.102). CONCLUSIONS: PWD and inter-atrial dysynchrony seem to independently promote AF, although both are associated with LA reservoir function in HCM populations. The NT-proBNP level is not associated with these two AF predictors in patients with HCM. NT-proBNP seems to be a poor marker of atrial electrical remodeling in HCM patients.

The left atrial phasic functions and the relationship with plasma N-terminal pro-B-type natriuretic peptide levels and symptomatic states in patients with hypertrophic cardiomyopathy.

OBJECTIVE: We aimed to evaluate left atrium (LA) phasic functions and relation with N-terminal pro-B- type natriuretic peptide (NT-proBNP) levels and symptomatic states of the patients with hypertrophic cardiomyopathy (HCM). METHODS: Left atrial volume was calculated at end-systole (Vmax), end-diastole and pre-atrial contraction by echocardiography in 75 patients with HCM and 75 control subjects. Left atrial ejection fraction (LAEF), expansion index (LAEI), active emptying volume index (LAAEVI) and fraction (LAAEFr), passive emptying volume index (LAPEVI) and fraction (LAPEFr) were calculated. NT-proBNP levels were measured. RESULTS: Left atrial active emptying volume (LAAEV) positively correlated with Vmax (r=0.343, p=0.003) up to a point, but then reached a plateau with larger LA volumes in HCM group. The LAAEFr was the only variable which was similiar between asymptomatic patients and controls, but was significantly decreased in symptomatic patients (p<0.05). NT-proBNP was correlated with LAEF (r=-0.32, p=0.005), LAEI (r=-0387, p=0.001), and LAAEFr (r=-0.25, p=0.035) but not related with LAPEFr (p=0.4). In receiver operating characteristic curve analysis an NT-proBNP cut-off value of 1415 pg/mL identified reduced LAEF with 87% specificity and 59% sensitivity [AUC=0.77 (95% CI: 0.65-0.89), p=0.004], a cut-off value of 820 pg/mL predicted impaired LAEI with 81% specificity ve 67% sensitivity [AUC=0.78 (95% CI: 0.66-0.9), p<0.001]; while a cut-off value of 1320 pg/mL predicted impaired LAAEFr with 76% specificity and 67% sensitivity [AUC=0.79 (95% CI: 0.68-0.91), p=0.02]. CONCLUSION: In HCM, LA phasic functions alter according to the Frank-Starling mechanism indicating occurrence of a secondary atrial myopathy. Impairment of LA booster pump function seems to be associated with appearance of symptoms and NT-proBNP levels predict the deterioration of LA reservoir and pump functions in HCM population.