Angio-Seal Used as a Bailout for Incomplete Hemostasis After Dual Perclose ProGlide Deployment in Transcatheter Aortic Valve Implantation

BACKGROUND

The failure rate of vascular closure devices remains a significant cause of major vascular complications in contemporary transcatheter aortic valve implantation practice.

METHODS

This research aimed to evaluate use of the Angio-Seal device in a bailout context in the setting of incomplete hemostasis following use of dual Perclose ProGlide devices in patients undergoing transfemoral transcatheter aortic valve implantation. A total of 185 patients undergoing transfemoral transcatheter aortic valve implantation with either dual Per-close ProGlide (n = 139) or a combination of dual Perclose ProGlide and Angio-Seal (n = 46) were retrospectively analyzed. The baseline, procedural characteristics, and all outcomes (defined according to Valve Academic Research Consortium-2 criteria) were compared.

RESULTS

No significant differences were seen between the dual Perclose ProGlide vs dual Perclose ProGlide+Angio-Seal groups with regard to the in-hospital Valve Academic Research Consortium-2 primary end points of major vascular complications (n = 13 [9.4%] vs n = 2 [4.3%]; P = .36), minor vascular complications (n = 13 [9.4%] vs n = 8 [14.7%]; P = .14), major bleeding (n = 16 [11.5%] vs n = 2 [4.3%]; P = .25), and minor bleeding (n = 9 [6.5%] vs n = 5 [10.9%]; P = .34), with higher rates of hematoma in the dual Perclose ProGlide+Angio-Seal group (n = 4 [2.9%] vs n = 5 [10.9%]; P = .044).

CONCLUSION

Finding from the current study suggest that adjunctive Angio-Seal deployment may be feasible and safe, especially in patients with incomplete hemostasis following dual Perclose ProGlide use, and can be an optimal "bailout" procedure.

Neuroprotective effects of amantadine for experimental acute carbon monoxide poisoning

OBJECTIVE

Amantadine is known to have a neuroprotective effect in many neurological diseases. This study aims at investigating the neuroprotective effect of amantadine in rats exposed to carbon monoxide (CO) poisoning.

MATERIALS AND METHODS

Rats were maintained under standard experimental laboratory conditions and randomized into 4 different groups of 7 each namely control, amantadine only, CO exposure, and amantadine + CO exposure. For immunohistochemical analysis, tissues taken from the prefrontal and hippocampal regions were taken into formalin and kept for at least one day. Afterward, the tissue was followed and blocked for paraffin blocking. N-Methyl D-Aspartate (NMDA) levels in homogenates were studied by the Enzyme-Linked Immunosorbent Assay (ELISA) method. Superoxide dismutase (SOD) and catalase (CAT) activities in the supernatants were studied with commercial kits. Nitric oxide (NO) and Asymmetric Dimethyl Arginine (ADMA) levels were studied by the ELISA method. Enzyme activity values were calculated by dividing the protein values in the supernatants and normalizing them.

RESULTS

CAT, SOD, NMDA, ADMA, and NO levels were statistically significantly different between the groups (p < 0.05). According to post-hoc pairwise comparison test results, the values of the control and amantadine groups for CAT, SOD, NMDA, ADMA, and NO parameters were significantly higher than that of CO group. Similarly, values in the control and amantadine groups were considerably higher than values for the amantadine + CO group. NMDA values were significantly lower in group amantadine + CO than in CO group (p: 0.049).

CONCLUSIONS

Apoptosis and endothelial damage after CO poisoning is a complex process, and amantadine administration has a limited contribution in preventing this process.

The clinical significance and prognostic value of early second peak of hs-troponin t in patients successfully treated with primary pci

Background

It was previously demonstrated that in patients with ST segment elevation myocardial infarction (STEMI) high-sensitive troponin-T (Hs-cTnT) makes two peaks. However, the clinical significance of the second peak (early vs late) in patients undergoing successful primary percutaneous intervention (pPCI) is not known. We investigated the role of early second peak on clinical outcomes.

Methods

Patients who underwent successful pPCI were included. Baseline characteristics, angiographic variables and kinetics of Hs-cTnT levels following pPCI were recorded. Second peak of Hs-cTnT was defined as re-elevation of troponin levels above plateau levels. The second peak of Hs-cTnT is defined as early second peak, if re-elevation is detected earlier than 72 hours after the diagnosis and late second peak, when re-elevation is detected later than 72 hours.

Results

We included 250 patients divided into two groups; patients with early second peak as group 1 (n=118) and rest of the patients as group 2 (n=132). Baseline characteristics and comorbidities were similar. Peak level of Hs-cTnT, Hs-CRP and pro-BNP levels were significantly lower in group 1 patients. Left ventricular ejection fraction was higher in group 1 patients (47.48±7.7 vs 43.80±9.3, p-value: 0.001). There was no significant difference with respect to new-onset heart failure (24% vs %28, p: 0.503) between groups however cardiac mortality was significantly lower in group 1 patients (%2 vs %11, p: 0.007).

Conclusion

The early second peak of Hs-cTnT in patients with STEMI is associated with successful reperfusion and predictors of better clinical outcome. Moreover, early second peak of Hs-cTnT is associated with decreased cardiac mortality and has a potential to be used as a marker of good prognosis.

Funding Acknowledgement

Type of funding source: None

Comparison of the HEART and HEARTS3 scores to predict major adverse cardiac events in chest pain patients at the emergency department

Introduction:

The aim of this study was to determine the risk assessment of acute coronary syndrome and prediction of major adverse cardiac events by HEART (History, ECG, Age, Risk factors, Troponin) and HEARTS3 (HEART + 3S = Sex, Serial 2-h ECG, and Serial 2-h delta Troponin) scoring systems in patients admitted to the emergency department with chest pain.

Methods:

This is a single-center prospective cohort study. This study was conducted in patients admitted to the emergency department with chest pain, without ST-elevation myocardial infarction, who were 18 years or older, and agreed to participate in the study. The primary endpoint is the occurrence of major adverse cardiovascular events within 30 days. The receiver operating characteristic curve was used to assess the power of HEART and HEARTS3 scores to predict major adverse cardiovascular events.

Results:

The mean age of 239 patients was 47.91 ± 13.93 years and 72.4% (173) were male. Major adverse cardiovascular events developed in 20.1% (48) of the patients. The mean HEART and HEARTS3 scores of the patients with major adverse cardiovascular events (5.67 ± 1.46 and 9.38 ± 3.91, respectively) were both statistically and significantly higher than the scores of the patients without major adverse cardiovascular events (2.33 ± 1.44 and 2.22 ± 1.39; p = 0.001). The area under the curve values of HEART and HEARTS3 scores were found to be 0.943 (95% confidence interval: 0.905–0.968) and 0.990 (0.968–0.999), respectively.

Conclusion:

In our study, the power of HEARTS3 score to predict major adverse cardiovascular events was better in the risk assessment of acute coronary syndrome in patients admitted to the emergency department with chest pain compared to the HEART score. We think that patients with a low HEARTS3 score can be safely discharged from emergency department without further cardiac examination.

Morphometric characterization and estimating body weight of two Algerian camel breeds using morphometric measurements

This study was carried out in order to identify the body measurements of two different Dromedary camel breeds raised in Algeria. The animal material of the study consisted of a total of 115 animals belong to Steppe (n = 55) and Sahraoui (n = 60) camel breeds. Eye and coat colors along with body measurements such as head length, neck length, neck girth, tail length, distance between eyes, distance between ears, body length, withers height, chest girth, and live weight were determined. Least squares means for head length, neck length, neck girth, tail length, distance between eyes, distance between ears, body length, withers height, chest girth, and live weight are found 48.2, 116.9, 65.7, 55.6, 24.1, 22.5, 152.2, 184.5, 141.2 cm, and 217.2 kg for Steppe and 48.1, 101.2, 56.2, 51.2, 23.4, 18.3, 135.6, 167.3, 176.8 cm, and 298.9 kg for Sahraoui camel breeds, respectively. The distribution of brown and black eye colors for the Steppe camel breed is as 58.2% and 41.8%, respectively, while all of the Sahraoui camels studied had a brown eye color. The proportional distribution in terms of body color included are coffee, dark coffee, and red colors for 1.8%, 83.6%, and 14.6% in the Steppe camel and 98.3%, 1.7%, and 0.0% for the Sahraoui camel, respectively. As a result, this study concluded that the withers height and chest girth could estimate the body weight in the two breeds of camels with different ages.

Outcomes of the novolimus-eluting bioresorbable vascular scaffold in real world clinical practice

BACKGROUND

Most of the current data regarding the use of bioresorbable scaffolds (BRS) come from everolimus-eluting stent platforms. Adverse events with the everolimus-eluting BRSs which are the most comprehensively characterized BRS, hampered the clinical use of other BRS. There is paucity of published data regarding long term use of novolimus-eluting BRS.

METHODS

This study sought to evaluate the performance of novolimus-eluting BRS device at midterm follow-up in real world clinical practice. One hundred and forty-four patients (mean age 57.5±9.7 years, 78.5% male) treated with 206 scaffolds between October 2015 and December 2017 were enrolled. A device-oriented composite endpoint (DOCE) comprising cardiac death, target vessel myocardial infarction (TV-MI), clinically driven target lesion revascularization (TLR) and rate of scaffold thrombosis were investigated.

RESULTS

During a mean follow-up of 33±9 months, DOCE occurred in 9 patients (6.3%) of which cardiac death occurred in 2 patients (1.4%), and clinically driven TLR in 7 patients (4.9%), TV-MI in one patient. Target vessel revascularization (TVR) was observed in nine patients. None of the patients experienced scaffold thrombosis.

CONCLUSIONS

The use of novolimus-eluting BRS in this real-world population achieved good clinical outcomes.

Outcomes of the novolimus-eluting bioresorbable vascular scaffold in real world clinical practice

BACKGROUND

Most of the current data regarding the use of bioresorbable scaffolds (BRS) come from everolimus-eluting stent platforms. Adverse events with the everolimus-eluting BRSs which are the most comprehensively characterized BRS, hampered the clinical use of other BRS. There is paucity of published data regarding long term use of novolimus-eluting BRS.

METHODS

This study sought to evaluate the performance of novolimus-eluting BRS device at midterm follow-up in real world clinical practice. One hundred and forty-four patients (mean age 57.5±9.7 years, 78.5% male) treated with 206 scaffolds between October 2015 and December 2017 were enrolled. A device-oriented composite endpoint (DOCE) comprising cardiac death, target vessel myocardial infarction (TV-MI), clinically driven target lesion revascularization (TLR) and rate of scaffold thrombosis were investigated.

RESULTS

During a mean follow-up of 33±9 months, DOCE occurred in 9 patients (6.3%) of which cardiac death occurred in 2 patients (1.4%), and clinically driven TLR in 7 patients (4.9%), TV-MI in one patient. Target vessel revascularization (TVR) was observed in nine patients. None of the patients experienced scaffold thrombosis.

CONCLUSIONS

The use of novolimus-eluting BRS in this real-world population achieved good clinical outcomes.

The effects of childhood trauma on psychotic symptoms in bipolar disorder

Introduction

Although history of childhood trauma is present in nearly 50% of bipolar patients, the effects of childhood trauma on the course of bipolar disorder are rarely investigated. Thus, we aimed to investigate the effects of childhood trauma on psychotic symptoms seen in patients with bipolar disorder.

Methods

One-hundred DSM-IV-TR diagnosed bipolar patients who were either manic or depressive were recruited from inpatient units of Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery. Patients were initially evaluated by Young Mania Rating Scale (YMRS), Montgomery-Asperg Depression Rating Scale (MADRS), Scales for Assessment of Positive Symptoms. Patients were also evaluated by Childhood Trauma Questionnaire (CTQ) and Dissociative Experiences Scale in euthymia which was defined by scores of < 7 in YMRS, < 4 in MADRAS

Results

There were no differences between the patients with and without a history of psychotic episode in terms of age at onset, duration of illness and episode characteristics. Patients with a history of psychotic episode were hospitalized more. CTQ physical abuse scores were higher in male comparing to female. CTQ sexual abuse scores were higher in female comparing to male. CTQ emotional abuse, physical neglect, physical abuse and total scores were higher in patients who had at least one psychotic episode in lifetime than in patients without a history of psychotic episode.

Conclusion

The history of childhood trauma should be investigated and therapeutic interventions for childhood trauma should be added to the standard treatment plan of bipolar patients.

Successful transcatheter mitral valve replacement in a patient with bioprosthetic valvular degeneration and severe regurgitation

The implantation of aortic transcatheter heart valves has been successfully performed throughout the world in hundreds of patients with severe dysfunction of a degenerated mitral bioprosthesis or those at high surgical risk for re-operation. The transseptal approach may be more technically challenging, but is a less invasive procedure and may have a lower mortality rate compared with a transapical approach, and also offers a quick patient recovery. This report is a description of a rare case in Turkey: a successful transseptal mitral valve replacement in a case of a failed bioprosthetic valve. This case illustrates the feasibility and safety of percutaneous valve-in-valve implantation to treat a degenerated bioprosthesis.

[Does hospital volume correlate with surgical process time? : Retrospective analysis of the five most common procedures for visceral surgery, trauma and orthopedic surgery and gynecology/obstetrics from the benchmarking program of the Berufsverband Deutscher Anästhesisten (BDA), Berufsverband Deutscher Chirurgen (BDC) and Verband für OP-Management (VOPM)]

BACKGROUND

Minimum volume thresholds for specific surgical procedures in German hospitals were established in 2004 but remain controversial. For the first time, this study investigated the relationship between hospital performance volume and surgical procedure duration in a multicenter approach. The question here was whether a concentration on frequently performed procedures leads to a reduction in surgical process times.

METHODS

In a retrospective analysis, the 5 most common procedures from visceral, trauma/orthopedic and gynecological/obstetrics surgery were examined in hospitals participating in a benchmarking program. For each procedure performed between 2013 and 2015, hospitals were divided into 4 groups depending on the hospital volume provided. The average surgical duration of incision to suture time was calculated between the group with "very low" hospital volume and the other three groups ("low", "high" and "very high").

RESULTS

OR cases from 75 hospitals were analyzed. The number of included cases per procedure ranged from 31,940 to 2705. The average number of operations performed in a specific procedure was 3-4 times higher in high-volume hospitals compared to very low-volume hospitals. A linear relationship between hospital volume and surgical process time only appeared to be clearly seen in laparoscopic cholecystectomy, appendectomy and arthroscopic meniscus surgery: a higher case load led to a reduction in incision to suture time. For the other procedures, the surgical process times were inconsistent between the hospital groups.

CONCLUSION

The case volume only appeared to have a direct but limited influence on incision to suture times in laparoscopic and arthroscopic procedures. Overall, the hospital performance volume appeared to be of subordinate importance in terms of OR-economics.

Effect of cardiac resynchronization therapy on mitral valve geometry: a novel aspect as "reversed mitral remodeling"

Amelioration of the valvular geometry is a possible mechanism for mitral regurgitation (MR) improvement in patients receiving cardiac resynchronization therapy (CRT). We aimed to establish the precise definition, incidence, and predictors of reversed mitral remodeling (RMR), as well as the association with MR improvement and short-term CRT outcome. Ninety-five CRT recipients were retrospectively evaluated for the end-point of "MR response" defined as the absolute reduction in regurgitant volume (RegV) at 6 months. To identify RMR, changes in mitral deformation indices were tested for correlation with MR response and further analyzed for functional and echocardiographic CRT outcomes. Overall, MR response was observed in 50 patients (53%). Among the echocardiographic indices, the change in tenting area (TA) had the highest correlation with the change in RegV (r = 0.653, p < 0.001). The mean TA significantly decreased in MR responders (4.15 ± 1.05 to 3.67 ± 1.01 cm² at 6 months, p < 0.001) and increased in non-responders (3.68 ± 1.04 to 3.98 ± 0.97 cm², p = 0.014). The absolute TA reduction was used to identify patients with RMR (47%) which was found to be associated with higher rates of functional improvement (p = 0.03) and volumetric CRT response (p = 0.036) compared to those without RMR. Non-ischemic etiology and the presence of LBBB independently predicted RMR at multivariate analysis. In conclusion, reduction in TA is a reliable index of RMR, which relates to MR response, and functional and echocardiographic improvement with CRT. LBBB and non-ischemic etiology are independent predictors of RMR.

Predicting Ventricular Arrhythmias in Cardiac Resynchronization Therapy: The Impact of Persistent Electrical Dyssynchrony

BACKGROUND

Although response to cardiac resynchronization therapy (CRT) has been conventionally assessed with left ventricular volume reduction, ventricular arrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]) are of critical importance associated with unfavorable outcomes even in the "superresponders" to therapy. We evaluated the predictors of VT/VF and the association of residual dyssynchrony during follow-up.

METHODS

Ninety-five patients receiving CRT were followed-up for 9 ± 3 months. Post-CRT dyssynchrony was defined as a prolonged QRS duration (QRSd) for persistent electrical dyssynchrony (ED), and a Yu index ≥ 33 ms for persistent mechanical dyssynchrony. The first VT/VF episode, including nonsustained VT detected on device interrogation and/or appropriate antitachycardia pacing or shock for VT/VF, were the end points of the study.

RESULTS

Forty-five patients who reached the study end points had significantly lower mean ΔQRS (baseline QRSd - post-CRT QRSd) values than those without VT/VF (-20.8 ± 28.9 ms vs -6.6 ± 30.7 ms, P = 0.022). Both the baseline and post-CRT QRSds, along with the Yu index values, were not different in two groups. Patients with VT/VF were statistically more likely to have persistent ED (38% vs 9%, P = 0.021). Kaplan-Meier curves showed that a negative ΔQRS was associated with a higher incidence of VT/VF during follow-up (P = 0.016). A multivariate Cox model revealed that QRS prolongation was an independent predictor of VT/VF after CRT (P = 0.029).

CONCLUSIONS

A negative ΔQRS, also called persistent ED, is associated with VT/VF. Narrowest possible QRSd might be a reliable goal of both implantation and optimization of devices to reduce arrhythmic events after CRT.

Percutaneous Retrieval of an Embolized Catheter Tip With the Balloon Dilatation Technique

Introduction:

Increasing numbers of complex percutaneous coronary interventions have been accompanied by various intra-procedural complications. The fracture and embolization of devices or their fragments are potentially life-threatening situations, depending on the site of embolization. Different non-surgical methods to handle embolic complications have been proposed for different clinical situations.

Case Presentation:

We present a case of a distally embolized catheter fragment that was percutaneously retrieved. The catheter fragment was tightly held by the inflated balloon, moved together with the system, and successfully retrieved out of the circulation via the femoral sheath. Considerable distal embolization of the foreign body and retrieval with the balloon dilatation technique are the unique features of this case.

Conclusions:

The present case appears to offer a safe and relatively simple method of balloon dilatation inside the lumen of the embolized fragment when the foreign body is too distal to retrieve with conventional snare systems.

Adjusting the QRS Duration by Body Mass Index for Prediction of Response to Cardiac Resynchronization Therapy: Does One QRS Size Fit All?

BACKGROUND

QRS duration (QRSd) is known to be affected by body weight and length. We tested the hypothesis that adjusting the QRSd by body mass index (BMI) may provide individualization for patient selection and improve prediction of cardiac resynchronization therapy (CRT) response.

METHODS

A total of 125 CRT recipients was analyzed to assess functional (≥1 grade reduction in NYHA class) and echocardiographic (≥15% reduction in LVESV) response to CRT at 6 months of implantation. Baseline QRSd was adjusted by BMI to create a QRS index (QRSd/BMI) and tested for prediction of CRT response in comparison to QRSd.

RESULTS

Overall, 81 patients (65%) responded to CRT volumetrically. The mean QRS index was higher in CRT responders compared to nonresponders (6.2 ± 1.1 vs 5.2 ± 0.8 ms.m(2) /kg, P < 0.001). There was a positive linear correlation between the QRS index and the change in LVESV (r = 0.487, P < 0.001). Patients with a high QRS index (≥5.5 ms.m(2) /kg, derived from the ROC analysis, AUC = 0.787) compared to those with a prolonged QRSd (≥150 ms, AUC = 0.729) had a greater functional (72% vs 28%, P < 0.001) and echocardiographic (80% vs 44%, P < 0.001) improvement at 6 months. QRS index predicted CRT response at regression analysis.

CONCLUSIONS

Indexing the QRSd by BMI improves patient selection for CRT by eliminating the influence of body weight and length on QRSd. QRS index is a novel indicator that provides promising results for prediction of CRT response.

Hemopericardium and Cardiac Tamponade in a Patient Treated with Dabigatran Etexilate

Dabigatran etexilate is one of the new oral anticoagulants approved to reduce the risk of stroke in patients with atrial fibrillation (AF). A variety of bleeding complications with dabigatran have been reported, but reports of hemopericardium are rare. We described a case of a 66 year-old female patient with non-valvular AF receiving dabigatran etexilate 150 mg twice daily for one year who suffered from hemopericardium. Her laboratory tests performed 1 year prior were normal and her admission tests revealed acute renal failure and elevated international normalized ratio (INR) level (4.79). Urgent pericardiocentesis was followed by improved renal functions and normalized INR. Dabigatran etexilate is a new oral anticoagulant that is increasingly used in daily practice. However, life-threatening complications warrant caution. Elevated INR may be related with overdose but the association of bleeding risk of dabigatran and INR requires further confirmation.

Impact of valve surgery on serum osteopontin levels in patients with mitral regurgitation

OBJECTIVE

Osteopontin (OPN), a sialoprotein present within atherosclerotic lesions, especially in calcified plaques, is linked to the progression of coronary artery disease and heart failure. We assessed the impact of valve surgery on serum OPN and left ventricular (LV) function in patients with mitral regurgitation (MR).

METHODS

Thirty-two patients with severe MR scheduled for surgery were included in the study. Echocardiography markers were assessed preoperatively and at 3 months following the surgery and matched with the serum OPN levels.

RESULTS

Valve surgery was associated with a reduction of the ejection fraction (EF) from 55.2 ± 6.3 to 48.8 ± 7.1% after surgery, p < 0.001. Following surgery, the OPN level was significantly higher than preoperatively (mean 245, range 36-2,284 ng/ml vs. 76, 6-486 ng/ml, p = 0.007). Preoperative OPN exhibited a slight negative correlation with the EF (r = -0.35, p = 0.04), and a moderate correlation with vena contracta (r = -0.38, p = 0.02). There were no other meaningful correlations between conventional echocardiographic parameters and OPN.

CONCLUSION

Following valve surgery due to severe MR, patients exhibited a decrease in EF and an increase in OPN levels. The assessment of preoperative OPN failed to strongly predict probable LV dysfunction.

Effect of interleukin 12 (IL-12) on embryonic development and yolk sac vascularisation

BACKGROUND

In the recent days there has been an increase in diseases known as "angiogenic diseases" characterized by pathologic vascularisation. In the rat, the development of embryonic vessel starts to occur at 9.5 days of gestation. In mammals, the vascular system starts developing in a very early embryonic stage. The majority of rat embryo circulation system gets complete approximately at 11 - 12 days. Therefore the in vitro study of 9.5 - 11.5-day old embryo culture could be a suitable model to study the effects of angiogenic and antiangiogenic substances on yolk sac vascularisation. In the present study, the effects of Interleukin-12 (IL-12) on the yolk sac vascularisation are investigated during the in vitro embryo culture, where the latter angiogenic factor was added to serum.

METHODS

After 48-hour culture period, effects of different doses of IL-12 (50 ng/ml, 100 ng/ml, and 200 ng/ml) were estimated morphologically.

RESULTS

According to morphologic scoring system, the total morphologic score, yolk sac diameter, crown rump length, and somite number were retarded in all experimental groups when compared to control. These developmental retardations were statically significant. There was also a poor development in the yolk sac vascularisation and the heart.

CONCLUSION

As a result, the IL-12 could cause developmental retardation of embryos owing to its antiangiogenic effect (Tab. 3, Fig. 2, Ref. 39).

Tako-tsubo cardiomyopathy following catheter ablation of atrial fibrillation

Tako-tsubo cardiomyopathy is characterized by reversible left ventricular dysfunction following emotional or surgical stress. Unlike the well-known complications of catheter ablation (CA) of atrial fibrillation (AF), Tako-tsubo cardiomyopathy has been rarely reported so far. We report a case of acute reversible left heart failure following successful CA of paroxysmal AF in a patient with a history of panic disorder.

Acute myocarditis or the kounis syndrome: Role of cardiac mri and speckle-tracking echocardiography in diagnosis

Introduction:

The Kounis syndrome and acute myocarditis are two distinct clinical entities, which could share nearly the same symptomatology as well as ECG (electrocardiography) and laboratory findings.

Case Presentation:

First case was a 39-year-old male presented with acute chest pain and inferolateral ST elevation on ECG. The second case was a 29-year-old male presented with chest pain and diffuses ST elevation. Diagnosis of acute myocarditis was achieved by demonstrating subepicardial contrast enhancement as well as atypical involvement in both of our clinical cases.

Conclusions:

We reported two cases in which specific imaging modalities (cardiac magnetic resonance imaging and speckle-tracking echocardiography) were used when the signs and symptoms were indistinguishable.

Adding lipoprotein(a) levels to the GRACE score to predict prognosis in patients with non-ST elevation acute coronary syndrome

BACKGROUND

High levels of lipoprotein(a) [Lp(a)] are known to be a cardiovascular risk factor associated with premature coronary artery disease. In predicting the long term prognosis in acute coronary syndromes (ACS), the relationship between Lp(a) and risk scoring systems remains unclear.

AIM

We investigated whether adding Lp(a) to the GRACE scoring system has an incremental value in predicting prognosis in ACS.

METHODS

115 patients (mean age 64 ± 11 years) with non-ST elevation acute coronary syndromes (NSTE-ACS) were enrolled in this prospective study. Patients were categorised into quartiles according to the Lp(a) levels. Statistically significant variables in the univariate analysis (haemoglobin, creatinine, age, left ventricular ejection fraction, previous myocardial infarction (MI) history, Killip class) were included in the multivariate analysis to determine the independent predictors of cardiovascular outcomes (mortality, rehospitalisation) with and without Lp(a) quartiles for one year follow-up.

RESULTS

Previous MI history and Lp(a) quartile were detected as independent predictors of combined cardiovascular events (OR: 2.969 [95% CI 1.413-6.240] and OR: 6.279 [95% Cl 1.363-28.927] respectively). Lp(a) quartile also remained as an independent predictor for prognosis when added to a model based on GRACE risk score (OR: 2.589 [95% CI 1.402-4.780]). Serum Lp(a) levels were moderately correlated with GRACE risk score (r = 0.371; p < 0.001).

CONCLUSIONS

Lipoprotein(a) has an additional prognostic value over GRACE risk score in predicting one-year adverse outcomes in NSTE-ACS. The combination of serum Lp(a) with GRACE risk score could provide enhanced risk stratification in patients with ACS.

Elevated uric acid and functional mitral regurgitation in dilated cardiomyopathy

BACKGROUND

Recent findings suggest that there is a close relationship between chronic heart failure and uric acid.

AIMS

The aim of the study was to assess whether increased uric acid levels in patients with dilated cardiomyopathy might correlate with the degree of functional mitral regurgitation (MR).

MATERIALS AND METHODS

Sixty two consecutive patients diagnosed with dilated cardiomyopathy were included in the study. The patients were classified according to severity of functional MR into two groups: mild-moderate functional MR (ERO < 0.2 cm2) and severe functional MR.

RESULTS

The patients with severe functional MR had significantly higher serum uric acid levels compared to patients without severe functional MR (6.34 ± 1.61 mg/dL vs 5.43 ± 1.17 mg/dL respectively, p = 0.012). Furthermore, tenting area, an important predictor of functional MR severity, was moderately correlated with the serum uric acid levels (r = 0.351, p = 0.005). It was also shown that the serum uric acid concentrations were inversely correlated with left ventricular (LV) ejection fraction, and positively correlated with LV volumes. There was also a significant relation between the serum uric acid and left atrial volumes and also brain natriuretic peptide (BNP) levels.

CONCLUSIONS

In conclusion, this study demonstrates that elevated serum uric acid levels in patients with dilated cardiomyopathy are correlated with the severity of functional MR and echocardiographic volume indices.

Treatment of saddle pulmonary embolism with streptokinase in an 83 year-old man - a case report

Saddle pulmonary embolism (PE) is an embolus at the level of the bifurcation of the pulmonary trunk that extends into both main pulmonary arteries. Because of the unstable, large clot burden in the pulmonary artery and the risk of sudden haemodynamic collapse and sudden death, identifying a saddle embolus is extremely important. In this report, we describe successful treatment with streptokinase of a saddle PE in an elderly patient.