Descriptive Analysis of Sphenovomerine Suture and Its Importance in Neurosurgery.

PURPOSE: Articulation of rostrum of sphenoid bone with alae of vomer forms a schindylesis type of joint. The circumference of this joint, called sphenovomerine suture (SVS), is very important in establishing a reliable surgical field in the endoscopic transsphenoidal pituitary surgery. Because of its vital role in endoscopic transsphenoidal pituitary surgery, this radio-anatomical study was designed to establish the morphological properties of SVS. METHODS: In this study, the authors examined SVS in 235 patients (121 females and 114 males) on the computed tomography images of the paranasal sinus and made 4 measurements to describe SVS. RESULTS: The mean distance between superior margin of the upper labial philtrum and top of SVS was 6.66 ±â€Š0.43 cm for females and 7.44 ±â€Š0.54 cm for males. The distance between the top of SVS and dorsum sellae was 3.08 ±â€Š0.33 cm for females and 3.19 ±â€Š0.32 cm for males, the alae of vomer angle in the upper surface was 74.22 ±â€Š20.06° for females and 74.23 ±â€Š19.68° for males. The distance between the most lateral points of 2 alae of vomer was 0.99 ±â€Š0.17 and 1.01 ±â€Š0.19 cm for females and males, respectively. CONCLUSIONS: For an easy and successful operation, removal of the SVS is very important as it will provide a better view of the sellar base and make the management of the surgical instruments easier in the wider safe surgical field thus created.

Sürücü index and others.

BACKGROUND: In this study, we have aimed to evaluate the correlation between echocardiographic parameters that test systolic and diastolic function together. METHOD: The study population was divided into two groups according to Vp. Group-1 (n = 103) represented the control group (Vp > 50 cm/s) and group-2 (n = 86) represented patients with systolic and diastolic dysfunctions together (Vp ≤ 50 cm/s). The echocardiographic parameters that evaluate systolic and diastolic function together, such as the Tei and the Sürücü indices, were compared between the groups. RESULTS: In group-2, the Tei index was higher (p = 0.001) and the Sürücü index was lower (p < 0.001). We also showed that the Tei and Sürücü indices were significantly and negatively correlated. That is, as the Sürücü index decreases, the Tei index increases (p = 0.001). CONCLUSION: Vp is an index more affected by diastolic parameters but rarely by systolic parameters because it is measured at diastolic period. The Tei index, on the other hand, is affected by preload variables and needs two different heart cycles for calculation. The Modified Tei index, however, has limited diagnostic value because of high inter-observer variability. In this study, the usability of the Sürücü index is shown in comparison with other indices used for this purpose. Considering that it is less affected by preload variables, can be calculated over a single heart cycle, and has the ability to test variables of both systolic and diastolic periods unlike Vp. We postulate that the Sürücü index is more usable and reliable.

Evaluation of left ventricular circumferential contraction functions in obese patients.

BACKGROUND: We aim to evaluate left ventricular (LV) function abnormalities, especially circumferential contraction functions, in obese patients. METHOD: Cases without coronary artery disease (CAD) were divided into two groups according to their body mass indexes (BMI). RESULTS: Female predominance (P = 0.002), systolic blood pressure (BP) (P = 0.001), diastolic BP (P = 0.001), waist circumference (P < 0.001), left atrium (P < 0.001), LV end-diastolic diameter (P = 0.046), LV mass index (P = 0.001), and LV stroke volume (P = 0.016) were prominent in obese patients (BMI > or = 27). In obese patients, transmitral late velocity (P = 0.005) was prominent, and pulmonary vein antegrade diastolic velocity (PV-D) (P = 0.002) and mitral annular early diastolic pulsed-wave tissue Doppler imaging (pw-TDI) velocity (annular Ea) (P = 0.032) were lower. Transmitral late velocity was positively correlate with stroke volume (P = 0.029) and systolic BP (P < 0.001). Negatively correlation between PV-D and diastolic BP (P = 0.046) was found. And also, annular Ea velocity was negatively correlate with systolic BP (P = 0.017) and diastolic BP (P = 0.031). These findings may reflect LV longitudinal contraction abnormalities (LVLCA) and underlying mechanism that is responsible for LVLCA, may be volume and afterload alterations. However, LV circumferential contraction functions that evaluate by using pw-TDI, were not different among the groups. CONCLUSION: In obese patients without CAD, it was clearly said that while LVLCA were evident, LV circumferential contraction abnormalities were not. This differentiation may be explained by subepicardial myocardial fiber that is responsible for LV circumferential contractions is supplied by coronary arteries, subendocardial myocardial fiber that is responsible for LV longitudinal contractions, is supplied by systemic circulation via LV cavity penetration.

The association between left ventricular diastolic dysfunction and increased aortic stiffness can be explained by possible neurohumoral mechanisms.

OBJECTIVE: In our study, we tried to find an answer to the question "How could the association between left ventricular diastolic dysfunction (LVDDF) and increased aortic stiffness (IAS) be explained?" METHODS: Cases without coronary artery disease (CAD) were divided into three groups according to their left ventricular (LV) inflow patterns and their LV basal-lateral annulus pulsed-wave tissue Doppler imaging (pw-TDI). Group 1 (n = 38) represented the normal LV inflow pattern while Group 2 (n = 54) represented impaired LV relaxation and Group 3 (n = 18) represented pseudonormalization. Aortic diameters were measured by using M-mode at a level that is 3 cm above the aortic valve. Aortic strain (AS) and aortic distensibility (AD) were calculated by using aortic diameters and pulse pressure. RESULTS: In Group 3, AS was lower compared to Groups 1 and 2 (respectively P < 0.001, P = 0.040). AS was also lower in Group 2 compared to Group 1 (P = 0.012). AD was higher in Group 1 compared to Groups 2 and 3 (respectively P = 0.01, P < 0.001). Early diastolic velocity of aortic pw-TDI was higher in normal LV inflow compared to Groups 2 and 3 (respectively P = 0.022, P = 0.050). Unfortunately, none of echocardiographic parameters that evaluate LV and aortic functions together (stroke volume, pulse pressure/stroke volume, pulse pressure/stroke volume index) were different among the groups. CONCLUSION: The results of our study clearly showed the association between LVDDF and IAS in cases without CAD. Additionally, it was concluded that this togetherness could be explained not by hemodynamic factors but by possible neurohumeral mechanisms.

Subtle systolic dysfunction may be associated with the tendency to develop diastolic heart failure in patients with preserved left ventricular ejection fraction.

BACKGROUND: We looked for an answer to the question of whether diastolic heart failure (DHF) is a reality or all heart failures are systolic. METHOD: 300 cases (hypertensive, aged, obese, etc.), not being diagnosed DHF, with preserved left ventricular (LV) ejection fraction (EF) but having the tendency to develop DHF in future were examined. One hundred and eighty cases without exclusion criteria were selected. Cases were assigned to three groups according to noninvasively obtained pulmonary capillary wedge pressure (PCWP). RESULTS: In cases with higher PCWP (>10 mmHg), transmitral A velocity was increased (P < 0.001) and among the pulsed wave tissue Doppler imaging (pw-TDI) parameters Ea velocity was decreased (P < 0.001) and Ea-dt was prolonged (P < 0.005). In cases with lower PCWP (<8 mmHg), transmitral E velocity was higher (P< 0.001). Furthermore, a more meaningful relationship was found between PCWP and systolic pw-TDI parameters. In all the groups, it was observed that Sa velocity was progressively decreased and Q-Sa interval was progressively prolonged as PCWP increased (for all the groups P < 0.046). CONCLUSION: The question whether DHF is a reality or all heart failures are systolic may be answered as follows. Subtle systolic dysfunction may be associated with the tendency to develop DHF in patients with preserved LV ejection fraction. As in systolic heart failure (EF < 45%), in patients with preserved systolic function (EF > or = 45%), systolic and diastolic functions may impair together. The pw-TDI method may be more sensitive than standard echocardiography parameters in detection of systolic dysfunction in cases with preserved EF.

Clinical significance of positive isovolumetric relaxation velocity of pulsed-wave tissue Doppler imaging.

OBJECTIVE: Among the pulsed-wave tissue Doppler imaging (pw-TDI) parameters, there are two different pw-TDI velocities (IVRa and IVRb) after systolic velocity, but before Ea velocity. In our study, we investigated the clinical importance of these two velocities in left ventricular diastolic dysfunction (LVDDF) evaluation. METHODS: One hundred and eighty cases without exclusion criteria were included in the study. Cases with a transmitral E to A flow (E/A) ratio below 1 were assigned to group 2. In cases with an E/A ratio between 1 and 2, the pw-TDI parameters were taken into consideration. Cases with an Ea/Aa ratio above 1 were assigned to group 1 and cases with an Ea/Aa ratio 1 or below than 1 were assigned to group 3. Group 1 (n: 68) represented normal diastolic left ventricular (LV) inflow while group 2 (n = 87) represented impaired relaxation and group 3 (n = 25) represented pseudonormal LV inflow. RESULTS: In our study, we found that IVRa velocity was lower in group 1 compared to group 2 and group 3 (P < 0.001 and P = 0.038, respectively). Similarly, this velocity was significantly different in group 3 and group 2 such as it was higher in group 2 compared to group 3 (P = 0.022). There was no difference in IVRb velocity and IVRa/IVRb ratio among the groups. A negative correlation was found between IVRa velocity and Ea velocity (r = 44%, P < 0.001). Positive correlation was found between IVRa velocity and isovolumetric relaxation time (r = 18%, P = 0.014) and also between IVRa velocity and Aa velocity (r = 19%; P = 0.010). CONCLUSION: Based on the results of our study, we concluded that IVRa velocity is an important pw-TDI parameter in the evaluation of LVDDF, especially in differentiating pseudonormal LVDDF type from normal LV inflow.

Evaluation of subendocardial and subepicardial left ventricular functions using tissue Doppler imaging after complete revascularization.

OBJECTIVE: We aim to evaluate subepicardial and subendocardial left ventricular (LV) functions in patient single coronary artery lesion at early stage after percutaneous coronary intervention (PCI). Additionally, a comparison of LV functions between patients and control cases was aimed. METHOD: Patients with culprit left anterior descending (LAD) lesion (n = 25) and subjects with normal coronary angiography (n = 25) were evaluated. Patients underwent PCI and at least one coronary stent was placed. After PCI, the pulsed-wave tissue Doppler imaging (pw-TDI) parameters taken from subepicardial and subepicardial layers were compared among the patients. RESULTS: Left atrium (P = 0.050), LV end-diastolic (P = 0.049), and end-systolic (P = 0.006) diameters were larger compared to the control group. LV inflow velocities were not different between the patient and the control group. But, the myocardial performance index was different (P = 0.049). The systolic and diastolic pw-TDI parameters were apparently different between the patient and the control group. While the systolic pw-TDI parameters did not change, the diastolic pw-TDI parameters taken from both subepicardial (circumferential contraction) and subendocardial layers (longitudinal contraction) improved after PCI. After PCI, it was shown that while Ea velocity (P = 0.012) taken from the subendocardial layer increased, IVRa velocity (P < 0.001) taken from the subepicardial layer decreased. CONCLUSION: In our study, it could be said that LV, left atrium, and aortic valve diameter increase in patients with coronary artery disease. The systolic and diastolic functions were impaired at subendocardial and subepicardial layers. These dysfunctions can be easily presented with pw-TDI. Although systolic dysfunction persists, diastolic dysfunction improves at early stage after PCI.

A new parameter of pulsed-wave tissue Doppler imaging: IVRa.

OBJECTIVE: We investigated how velocity of isovolumetric relaxation period on pulsed-wave tissue Doppler trace (IVRa and IVRb) is affected by the left ventricular (LV) geometry changes. METHODS: Two hundred cases without exclusion criteria were included in the study. Normal LV mass index (LVMI) and normal relative wall thickness (RWT) was assigned to group 1 (n = 72). Concentric remodeling (normal LVMI and increased RWT) was defined to group 2 (n = 25). Eccentric LV hypertrophy (LVH) (increased LVMI and normal RWT) was defined to group 3 (n = 62). And finally, concentric LVH (increased LVMI and increased RWT) was defined to group 4 (n = 41). RESULTS: Patients with LVH (groups 3 and 4) were older than group 1 (P = 0.017 and 0.001). It was observed in the assessment of M-mode ECHO parameters that the aortic valve diameter, aortic valve opening, LV end-systolic diameter (LVESD), LV end-diastolic diameter (LVEDD), and left atrium (LA) were higher in cases with eccentric LVH. It was shown that Ea velocity and Sa velocity time integral (Sa-VTI) were decreased with LV geometry change. However, IVRa velocity and E/Ea were increased as LV geometry change. A positive correlation between IVRa velocity and LVMI (correlation ratio = 34%, P = 0.000) was found. Similarly, a positive correlation between IVRa velocity and RWT (correlation ratio = 17%, P = 0.025) was found. CONCLUSION: IVRa velocity exhibits a positive correlation with LV geometry changes indicating that IVRa velocity is affected by LV geometry like the other parameters influenced by LV geometry.

Evaluation of the effects of obesity on heart functions using standard echocardiography and pulsed wave tissue Doppler imaging.

OBJECTIVES: This study aimed to investigate abnormalities in right and left ventricular function in older obese patients with no left ventricular (LV) hypertrophy. DESIGN: Subjects with normal coronary angiography were included in this study. They were divided into two groups according to their body mass index (BMI): Group I = BMI > or = 27, and group II BMI = < 27. Standard echocardiography and pulsed wave tissue Doppler imaging (PW-TDI) parameters were performed in all subjects. RESULTS: The obese patients had tachycardia (P = 0.017) and hypertension (P = 0.020). In the obese patients, there was evidence of altered LV geometry; an increase in the posterior wall thickness (P = 0.001), and larger aortic valve diameter (P = 0.007). CONCLUSIONS: In obese patients of older ages, there is evidence of left and right ventricular dysfunction.

Coronary artery ectasia in a patient with Behcet's disease.

Behcet's disease is a multisystemic disease of unknown etiology. Disease manifestations consist of recurrent oral and genital ulceration, skin lesions, and relapsing ocular inflammation. Arterial involvement is an uncommon complication of Behcet's disease, and it most frequently affects the abdominal aorta followed by femoral artery, and the pulmonary artery. Coronary lesions in Behcet's disease have been little reported in the literature. A-36-year-old female with 6-year history of Behcet's disease was hospitalized with ectasia of the left main coronary artery. This unusual vascular complication Behcet's disease is presented.

Effects of coronary collateral vessels in left ventricular segmental motions and myocardial viability using color kinesis dobutamine stress echocardiography.

OBJECTIVE: To detect the functional importance of coronary collaterals, which develop after acute myocardial infarctions (AMI). METHODS: Forty patients with acute AMI whose coronary angiography demonstrated a total occlusion of the left anterior descendant (LAD) artery were included in the study, between January 2003 and June 2004. All of the study patients underwent coronary angiography and left ventriculography using standard Judkins techniques (Phillips Integris-3000). Left ventricular (LV) free walls were divided into 5 segments, and all of these segments motions were evaluated then LV free wall motion score index (WMSI) was calculated. The study patients were divided into 2 groups: good (Rentrop 3; group I; n = 14) and poor coronary collateral circulation (Rentrop 0-2; group II; n = 26) according to the Rentrop grading. Then, color kinesis dobutamine stress echocardiography (CK-DSE) was performed to all patients with standard techniques 6 weeks after AMI. RESULTS: There were no significant differences for age, gender, risk factors for the coronary artery disease and use of the fibrinolytic therapy between the groups. There were no significant statistical differences for angiographic WMSI, left ventricular ejection fraction (LVEF), end-diastolic volume, end-systolic volume and end-diastolic pressures between the 2 groups. No difference was detected between Group I and II for initial EF, WMSI and peak dose WMSI in CK-DSE procedure. Viability was determined in all of the 14 patients in group I (100%) and 12 of 26 patients in group II (46%) (p = 0.03). CONCLUSION: In early periods of an AMI genesis of the coronary collateral circulation does not affect left ventricular global and regional systolic functions, but increase viability quite significantly. According to our findings early revascularization could be carried out in patients with good coronary collateral circulation without doing any test for viability.

Seventy-four defibrillations for sotalol-induced torsades de pointes.

We report a patient with sotalol-induced torsades de pointes episodes that did not respond to magnesium and amiodarone. Electrical defibrillation totaling 15,120 joules had to be applied. However, torsades de pointes episodes could be brought under control only after the induction of general anesthesia with pentothal.

Branching pattern of the left coronary artery and an important branch. The median artery.

OBJECTIVE: This study was performed to assess the variations in the branching pattern and diameters of the terminal branches of the left coronary artery and discuss various names given to the third branch. METHODS: Hearts of 21 autopsies and 19 cadavers were fixed with 10% formalin and their coronary arteries were examined by dissecting the epicardium. The dissections were performed at the Anatomy Departments of Faculties of Medicine, Ankara and Hacettepe Universities, Ankara, and Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey, between April 2001 and June 2003. RESULTS: There were 2 branches in 19 hearts, 3 branches in 19 hearts, 4 branches in one heart and 5 branches in another. Diameter and length of these vessels are noted. CONCLUSION: Upon examination of the diameters and important variations of the branches of the left coronary artery, the importance of the median artery has been noted. Various names given to this artery in the literature should be replaced with the name "median artery".

Specific tissue Doppler predictors of preserved systolic and diastolic left ventricular function after an acute anterior myocardial infarction.

The degree of left ventricular (LV) dysfunction determines the outcome of patients suffering an acute anterior myocardial infarction (AAMI). Many recent studies have utilized tissue Doppler echocardiography (TDE) parameters in the assessment of LV function. We sought to investigate whether some variables easily obtained from TDE profiles of mitral annulus corners would predict a relatively preserved LV global function traditionally assessed with ejection fraction (EF) and deceleration time (DT), within the acute phase of AAMI. Included were 50 consecutive patients with a first AAMI. Standard echocardiography and TDE of mitral annulus were performed within 36 hours of admission. Pulsed wave sample volumes were set at the septal, lateral, anterior, and inferior corners of the mitral annulus. Preserved LV function was defined as an EF > 40% together with a DT > or = 140 ms and < 220 ms. An inferior annular systolic velocity of > 7.5 cm/s predicts preserved global left ventricular function with a sensitivity of 81% and specificity of 71%. An anterior mitral annular early diastolic velocity of > 8cm/s had a sensitivity of 69% and specificity of 85%. When these two velocities both exceed the limits above, such a combined index yielded a sensitivity of 69%, specificity of 94%, and an overall diagnostic accuracy of 86% for the estimation of preserved LV global function. The parameters derived from TDE profiles of inferior and anterior mitral annulus comers provide valuable information to predict preserved global left ventricular function during the early period of AAMI.