Is it Possible to Implant HeartMate 3 Less Invasively? New Pump, New Approach.

HeartMate 3 (HM3) left ventricular assist device (LVAD) is a compact, intrapericardial, centrifugal flow pump with a fully magnetically levitated rotor and a wide range of operation (2-10 L/min) to accommodate a broad range of clinical needs. We analyzed our experience with Heartware VAD (HVAD) and HM3 implantation through minimally invasive left thoracotomy (MILT) and upper minimal J sternotomy. Between March 2015 and October 2016, 31 patients who underwent LVAD implantation through MILT were included in this study. Twenty-three patients had HVAD (Group A) implantation, whereas 8 patients had HM3 (Group B). To compare outcomes of these pumps, measures were; mortality, cardiopulmonary bypass (CPB) time, duration of mechanical ventilatory support, blood loss and transfusion, intensive care unit (ICU) stay, right ventricular failure (RVF) and requirement of support with temporary devices, stroke, pump thrombosis, gastrointestinal bleeding and driveline infection rates. Interagency Registry for Mechanically Assisted Circulatory Support profiles, Pennsylvania and Michigan Risk Scores, right ventricular stroke work index and central venous pressure/pulmonary capillary wedge pressure ratio did not differ between these two groups. There was no difference in the length of ICU stay (P = 0.056), post-operative blood product administration (P = 0.701), total time on mechanical ventilation (P = 0.386), RVF (P = 1) or duration of CPB (P = 0.836). In-hospital cerebrovascular event rate was 13% in Group A and 0% in Group B, respectively. The HM3 assist system can be successfully implanted with minimally invasive techniques. This technique has proved to be safe and reproducible, with good clinical outcomes. Further, large collaborative studies are needed to identify the advantages of this approach.

Parameters influencing the physical activity of patients with a history of coronary revascularization.

INTRODUCTION AND OBJECTIVE: Coronary artery disease is the leading cause of mortality worldwide. Regular physical activity is part of a comprehensive management strategy for these patients. We investigated the parameters that influence physical activity in patients with a history of coronary revascularization. METHODS: We included outpatients with a history of coronary revascularization at least six months prior to enrollment. Data on physical activity, demographics, and clinical characteristics were collected via a questionnaire. RESULTS: A total of 202 consecutive outpatients (age 61.3±11.2 years, 73% male) were enrolled. One hundred and four (51%) patients had previous percutaneous coronary intervention, 67 (33%) had coronary bypass graft surgery, and 31 (15%) had both procedures. Only 46 patients (23%) engaged in regular physical activity. Patients were classified into two subgroups according to their physical activity. There were no significant differences between subgroups in terms of age, comorbid conditions or revascularization type. Multivariate regression analysis revealed that low education level (OR=3.26, 95% CI: 1.31-8.11, p=0.01), and lack of regular follow-up (OR=2.95, 95% CI: 1.01-8.61, p=0.04) were independent predictors of non-adherence to regular physical activity among study subjects. CONCLUSIONS: Regular exercise rates were lower in outpatients with previous coronary revascularization. Education level and regular follow-up visits were associated with adherence to physical activity in these patients.

Relationship between functional capacity and socioeconomic status in a cohort of Turkish heart failure patients.

OBJECTIVE: New York Heart Association (NYHA) classification predicts prognosis for heart failure (HF) patients. Socioeconomic status (SES) has the potential to affect treatment strategy and disease course. The present objective was to investigate whether SES of Turkish HF patients affected NYHA classification. METHODS: Turkish research team-HF (TREAT-HF) is a questionnaire study with 52 questions, the purpose of which is to aid in the assessment of various qualities of HF patients. The 2013 TREAT-HF cohort included 503 patients from 11 centers in Turkey. Patients were divided into 2 groups according to NYHA functional classification: I-II, a better functional classification, or III-IV, a poorer functional classification. In addition, patients were analyzed according to gender. RESULTS: Evaluated were NYHA functional classifications of 459 (326 males and 133 females) patients with a mean age of 59.7±14.07 years and a mean ejection fraction (EF) of 31.7±9.22%. Total monthly family income level of ≥1000 TL, younger age, higher EF, and male gender were independently associated with better NYHA functional classification. In addition to EF, regular weight control was found to be independently associated with better NYHA classification for females, while younger age and income of ≥1000 TL were independently associated with better NYHA classification for males. CONCLUSION: The present results demonstrated that SES was associated with NYHA functional classification in a cohort of Turkish HF patients.

Long-term outcome in patients with prosthetic valve endocarditis: results from a single center in Turkey.

OBJECTIVE: Prosthetic valve endocarditis (PVE) is associated with increased mortality and morbidity. Information regarding the long-term outcome of PVE is scarce in Turkey. The aim of this study was to evaluate long-term mortality rates of PVE and identify predictors of mortality in these patients. METHODS: From January 2008 through August 2013, 44 patients (25 male, 19 female; mean age 49.3±12.1 years) who received a definitive diagnosis of PVE enrolled in the study.Median follow-up period was 23 months. Survival status was assessed for each patient by reviewing charts and making contact by phone. Cox regression analysis was used to evaluate outcome predictors. RESULTS: The mitral valve was the most commonly affected valve and Staphylococcus aureus the most prevalent microorganism. Fourteen patients (32%) underwent surgery, 7 of whom underwent early surgery. Overall mortality and in-hospital mortality rates were 39% (n=17) and 25% (n=11), respectively. In multivariate analysis, NYHA classification >2 (hazard ratio [HR] 3.7; 95% confidence interval [CI], 1.16-11.8; p=0.03), early-onset PVE (HR 4.23; 95% CI, 1.1-16.42; p=0.04), vegetation size ≥10 mm (HR 3.94; 95% CI, 1.1-14.75; p=0.04), and heart failure (HR 4.18; 95% CI, 1.36-12.8; p=0.01) were found to be independent predictors of mortality. CONCLUSION: Our findings suggest that PVE is associated with increased long-term mortality rates. Poor functional status, early-onset PVE, heart failure, and vegetation size are independent predictors of survival in patients with PVE.

Assessment of atrial electromechanical interval and P wave dispersion in patients with polycystic ovary syndrome.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is associated with increased cardiovascular risk, including ischemic stroke. Prolonged atrial electromechanical interval (EMI) is related to increased atrial fibrillation (AF) risk. The aim of the study is to evaluate atrial EMI and electrocardiographic P-wave indices related to increased AF risk in patients with PCOS. METHODS: Forty PCOS patients diagnosed on the basis of the Rotterdam criteria and 20 age-matched controls were prospectively included. patients with atrioventricular or intraventricular conduction abnormalities, dysrhythmia or taking antiarrhythmic drugs, atherosclerotic heart disease, cardiomyopathies, valvular lesions, pericardial disease, a history of pulmonary emboli or pulmonary hypertension, and abnormal thyroid function were excluded. Intra and interatrial EMI were measured by tissue Doppler imaging and P-wave dispersion (Pd) was calculated on 12-lead electrocardiography (ECG). The Isovolumetric relaxation time was the interval between the aortic valve closure artifact at the end of the LV outflow envelope and the mitral valve opening artifact at the beginning of the mitral E wave. RESULTS: Patients with PCOS had significantly higher interatrial [38 (24-65) ms vs. 16 (9-19) ms p<0.001], left-sided intra-atrial (14.8±6.1 vs. 7±1.7 ms, p<0.001), and right-sided intra-atrial (22.3±8.1 vs. 8.6±3.6 ms, p<0.001) EMI compared with the control group. Pd was significantly greater in the PCOS group compared with control group [45 (27-60) ms vs. 30 (26-38) ms, p<0.001]. Echocardiographic parameters of atrial EMI were significantly correlated with body mass index, Pd, and isovolumetric relaxation time in patients with PCOS. CONCLUSION: PCOS is associated with prolonged inter- and intra-atrial conduction times, which are related to increased AF risk.

Severe Tricuspid Regurgitation Diagnosed 13 Years after a Car Accident: A Case Report.

Blunt chest traumas mostly occur due to car accidents and can cause many cardiac complications such as septal rupture, free-wall rupture, coronary artery dissection or thrombosis, heart failure, arrhythmias, and chordae and papillary muscle rupture. One of the most serious complication is tricuspid regurgitation (TR), which can be simply diagnosed by physical examination and confirmed by echocardiography. We describe a 48-year-old female patient, diagnosed with severe TR 13 years after a blunt chest trauma due to a car accident. TR was diagnosed with transthoracic echocardiography and three dimensional transthoracic echocardiography had defined the exact pathology of the tricuspid valve. The patient underwent successful surgery with bioprosthetic valve implantation and was discharged at 6th postoperative day without any complication. The patient had no problem according to the follow-up one month and six months after operation.

The usefulness of serum troponin levels to predict 1-year survival rates in infective endocarditis.

BACKGROUND AND AIM: Infective endocarditis (IE) is associated with increased mortality and morbidity. In this study, we aimed to evaluate the role of troponin levels in predicting long-term survival in patients with IE. METHODS: A retrospective analysis of the medical database of Yuksek Ihtisas Education and Research Hospital was performed to reach the patients that received the diagnosis of definite IE according to Duke criteria. Out of 84 definite IE cases, 48 patients (mean age 45.6 ± 17.3, 39.6% female) that had troponin T levels measured upon hospital admission were included. The survival status of the study subjects was assessed during a follow-up period of 1 year. RESULTS: A total of 20 (41.7%) patients died during the follow-up. Baseline median troponin T levels were significantly higher in fatal cases (0.08 [0.02-0.24] ng/ml vs. 0.02 [0.01-0.04] ng/ml p = 0.003). The optimal troponin T level to detect mortality was 0.05 ng/ml according to receiver operating characteristic curve (area under the curve 0.75, 95% Confidence Interval (CI) [0.61-0.9], p = 0.003) with 70% sensitivity and 79% specificity. Patient with elevated troponin levels were older, were more likely to be male and tended to have enterococcal infection. These patients had also higher creatinine levels and increased systolic pulmonary pressures. In the multivariate Cox regression analysis, renal failure (hazards ratio (HR) 8.23, CI 95% 2.53-26.9, p < 0.0001), heart failure (HR 4.48, CI 95% 1.73-11.61, p = 0.002) and troponin T ≥ 0.05 ng/ml (HR 3.11, CI 95% 1.13-8.56, p = 0.03) were associated with increased mortality rates. CONCLUSIONS: IE has poor outcome and baseline troponin T levels may predict long-term survival rates in these patients.

Asymptomatic Tricuspid Stenosis Following a Complex Lead Extraction Procedure.

The number of transvenous extraction procedures for leads of intracardiac rhythm devices increased recently and the most common reason for lead extraction is device infection. In some cases, combined use of two different techniques is necessary. Long-term results of this approach are not clear. In this case report, we present a patient with biventricular implantable cardioverter defibrillator who underwent percutaneous hardware removal due to recurrent pacemaker pocket infections. Mechanical dilator sheath removal and Needle's Eye Snare were used in the same patient. Although asymptomatic, tricuspid stenosis was detected three years after the operation.

Aortic valve sclerosis is associated with lower serum adiponectin levels.

AIMS: The sclerotic lesions of the aortic valve share common features with atherosclerosis. An anti-inflammatory protein, adiponectin, seems to have a protective effect on the cardiovascular system. The goal of our study is to determine adiponectin levels in patients with aortic sclerosis and to compare these values with the control group with similar age and cardiovascular risk profile. METHODS: Sixty-eight patients with aortic sclerosis and 40 controls were included. Serum adiponectin levels were measured by solid-phase enzyme-linked immunosorbent assay. RESULTS: There were no significant differences regarding age, sex and other cardiovascular risk factors between groups. Also, mean body mass index values were similar. The rate of mitral annular calcification and left ventricular hypertrophy were significantly higher in patients with aortic sclerosis. Among laboratory variables, high-sensitive C-reactive protein (hsCRP) levels were significantly higher in patients with aortic sclerosis than in those without (4.0 ±â€Š2.9 vs. 2.9 ±â€Š2.3 mg/dl, P = 0.04). Adiponectin levels were found to be significantly lower in aortic sclerosis group than in controls (9.7 ±â€Š4.4 vs. 11.7 ±â€Š4.9 µg/ml, P = 0.034). In the whole group, adiponectin levels were significantly correlated with BMI (r = -0.22, P = 0.02), white blood cell count (r = -0.2, P = 0.03), hsCRP (r = -0.25, P = 0.008), total cholesterol (r = -0.18, P = 0.05), high-density lipoprotein (HDL) cholesterol (r = 0.31, P = 0.001) and triglyceride (r = -0.36, P < 0.001). CONCLUSION: In patients with aortic sclerosis, serum adiponectin levels were significantly lower compared with those with normal aortic valves. Our findings suggested that adiponectin might play a role in the progression of degenerative aortic valve disease.

Red cell distribution width predicts mortality in infective endocarditis.

BACKGROUND: Infective endocarditis (IE) is associated with significant morbidity and mortality. Red cell distribution width (RDW) is a recently recognized biomarker of adverse outcome in a number of acute and chronic conditions. AIM: To investigate the relationship between RDW and 1-year survival in patients with IE. METHODS: Clinical records from two tertiary centres were used to analyze data from patients with definite IE. Clinical, echocardiographic and biochemical variables were evaluated along with RDW. One-year survival status after index hospitalization was identified for each patient. RESULTS: One hundred consecutive patients (mean age 47.8±16.7 years; 61% men) with definite IE were enrolled. According to receiver operating characteristic curve analysis, the optimal RDW cut-off value for predicting mortality was 15.3% (area under the curve 0.70; P=0.001). Forty-one patients (41%) died within 1 year; of these, 88% had RDW results>15.3%. Univariate Cox proportional-hazards analysis showed that RDW>15.3%, heart failure, renal failure, cardiac abscess, severe valvular regurgitation and presence of dehiscence were associated with increased mortality. Multivariable Cox proportional-hazards analysis revealed that renal failure (hazard ratio [HR] 3.21, 95% confidence interval [CI] 1.35-7.59; P=0.008), heart failure (HR 2.77, 95% CI 1.1-6.97; P=0.03) and RDW>15.3% (HR 3.07, 95% CI 1.06-8.86; P=0.03) were independent predictors of mortality in patients with IE. CONCLUSION: According to our results, mortality is high in patients with IE. RDW is a promising biomarker for predicting 1-year survival rates in these patients.

Impact of continuous positive airway pressure therapy on atrial electromechanical delay and P-wave dispersion in patients with obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) has been shown to be associated with atrial fibrillation (AF). Prolongation of inter- and intraatrial conduction times during sinus rhythm has also been shown to be related to AF generation. Nasal continuous positive airway pressure (CPAP) is an effective treatment modality of OSA. METHODS: Twenty-four OSA patients diagnosed through polysomnography and 18 controls were included in the study. The basal inter- and intraatrial electromechanic delays prior to onset of the therapy were measured using tissue Doppler imaging. P-wave dispersion (Pd) was calculated on the basis of 12-lead electrocardiography. Same measurements were performed in OSA patients 6 months after the initiation of the therapy. RESULTS: Interatrial (39.2 ± 8 vs. 21.1 ± 2.8 ms, P < 0.001), left intraatrial (20.5 ± 7.2 vs. 11.1 ± 2 ms, P = 0.003), and right intraatrial electromechanical delays (20.7 ± 11 vs. 10 ± 2.6 ms, P < 0.001) prior to CPAP therapy were found to be significantly greater in OSA group as compared with the controls. Pd was also greater in the OSA group as compared with the controls (44 ± 7 vs. 28.5 ± 4 ms, P < 0.001). However, significant improvement has been noted after 6 months of CPAP therapy in interatrial (P < 0.0001), left intraatrial (P = 0.002), and right intraatrial electromechanical delays (P < 0.0001) as well as in Pd (P < 0.0001) as compared to baseline values in patients with OSA. CONCLUSION: Our findings suggested that CPAP therapy provides more homogenous conduction through atria in patients with OSA. This effect may translate into decreased risk for AF associated with OSA.

Management of cardiac device infections according to current data.

The use of implantable devices in management of cardiac diseases is increasing as a result of improvements in technology of permanent pacemaker and implantable cardioverter defibrillators. Device related infections are also rising accordingly and have become an important clinical problem. Accurate diagnosis and optimal management of these infections is challenging, necessitating complete removal of the device and prolonged antibiotic therapy. In this regard, a multidisciplinary approach is required with the essential support of microbiology and imaging modalities. This paper highlights the current literature on the pathogenesis, risk factors, diagnosis and management of device related infections.

Factors influencing the use of ambulance among patients with acute coronary syndrome: results of two centers in Turkey.

OBJECTIVE: In this study, we aimed to identify the factors influencing the use of ambulance among patients admitted to two Turkish hospitals with acute coronary syndrome (ACS). METHODS: Overall, 330 with a mean age of 55±13 years, hospitalized patients with ACS at 2 different hospitals were included in this prospective cohort study. The factors influencing the use of ambulance hospital were investigated through a questionnaire. The comparisons were made between two groups regarding use of ambulance. The predictors of the use of ambulance were determined using multiple logistic regression analysis. RESULTS: Despite the high rate of knowing the emergency service number of "112", of the 330 patents, only 96 (29%) used ambulance. Ambulance users had shorter arrival duration with median of 60 min vs 120 min (p=0.03). Presenting with ST elevation myocardial infarction (OR=3.127, 95% CI: 1.555-6.2877, p<0.001), severity of chest pain (OR=2.665, 95% CI: 1.938-3.665, p<0.001), presence of accompanying symptoms such as dyspnea (OR= 5.510, 95% CI: 2.614-11.614, p<0.001), dizziness (OR=4.172, 95% CI: 1.901-9.154, p<0.001) and vomiting (OR=3.756, 95% CI: 1.521-9.272, p=0.004), knowledge of cardiac risk factors (OR=10.512, 95% CI: 4.497-24.572, p<0.001) or chest pain related to heart attack and the importance of quickly seeking for medical care by calling ambulance (OR= 4.184, 95% CI: 2.528-6.926, p<0.001) are the factors associated with ambulance use. CONCLUSION: Using ambulance was in a very low rate among our study patients with ACS. Severity of symptoms, type of ACS and knowledge are seemed to be related with increased ambulance use. Informative health educational programs can be organized to achieve a behavioral change in using of ambulance.