Effects of mitral annular calcification on the outcomes of transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) has become the standard of care treatment in patients with severe aortic stenosis who carry intermediate or high risk for surgical aortic valve replacement. Mitral annular calcification (MAC) is frequently seen in patients with aortic stenosis and it is associated with increased cardiovascular morbidity and mortality. It is reported that MAC is an independent predictor of all cause mortality after TAVI.

Aim

The aim of this study is to both evaluate the relationship between mitral annular calcification and TAVI related complications and mortality; and to define the predictors of both all cause mortality and permanent pacemaker implantation after TAVI.

Methods

All of the patients who underwent TAVI procedure due to severe aortic stenosis between 01.01.2020 and 01.06.2020 in our University Hospital were screened and patients fullfilling including criterias were enrolled. Patients' baseline demographic datas, laboratory, echocardiography and TAVI procedure related parameters were recorded. Outcomes are identified as follows; association between mitral annular calcification and TAVI related complications, establishment of the predictors of all cause mortality and permanent pacemaker implantation, definition of the in-hospital and all cause mortality rates.

Results

A total of 245 patients including 98 males (40%) and 147 females (60%) were enrolled in the study. The mean age of the population was 76,3±8,3 years. The mean left ventricular ejection fraction was % 54,8±11,4; aortic valve area was 0,74±0,14 cm2 and mean aortic transvalvular gradient was 47,0±14,3 mmHg. MAC was detected in 148 (% 60,4) patients (Table 1). In-hospital mortality was occurred in 14 (5,7%) cases. Permanent pacemaker implantation was performed in %17,8 (n=42) patients and all cause mortality was developed in 89 (36,3%) cases during the median 23,1 (11,6–44,3) months follow-up. Pericardial effusion (26,4% vs 12,4%; p=0,013) and contrast induced nephropathy (21,6% vs 7,2%; p=0,005) were developed more frequently in patients with MAC than without MAC (Table-2). Only the presence of MAC extending to left ventricular outflow tract was detected to be independent predictor of permanent pacemaker implantation requirement (HR: 3,32; p=0,002). All cause mortality predictors were established as; use of renin-angiotensin-aldosterone system blockers (HR: p=0,012), level of hemoglobin (HR: 0,79; p=0,006), severe mitral annular calcification (HR: 1,94; p=0,024) and atrial fibrillation development after TAVI (HR: 2,39; p=0,002). There was not any correlation between aortic valve area and MAC vloume (r=0,03; p=0,689), MAC Hounsfield Unit (r=−0,007; p=0,934) and MAC Agatston score (r=−0,08; p=0,290).

Discussion

MAC is associated with all cause mortality after TAVI and MAC extending to left ventricular outflow tract is an independent predictor of permanent pacemaker implantation requirement.

Funding Acknowledgement

Type of funding sources: None.

P14893D strain echocardiography in assessing left ventricular diastolic dysfunction

Background

Diastolic dysfunction is an important factor in the development of heart failure with preserved ejection fraction (HFpEF). As the ejection fraction is preserved in HFpEF, the diagnosis of this disease with non-invasive methods is difficult.

Purpose

In this study, the relationship of BNP, NT-proBNP, Ghrelin, and echocardiographic 3D strain findings with diastolic dysfunction was investigated in patients undergoing left heart catheterization.

Methods

Our study is a cross-sectional study and included 78 patients in whom echocardiography was performed, and who underwent left heart catheterization based on relevant indications. The patient data recorded for evaluation included the findings from left heart catheterization, follow-up 3D echocardiography; and the levels of blood NT-proBNP, and Ghrelin.

Results

The rate of diastolic dysfunction was 42.3%. Longitudinal 2D and 3D mean strain as absolute values were observed to decrease more in patients with diastolic dysfunction. The median levels of BNP, NT-proBNP, and Ghrelin levels were higher in patients with diastolic dysfunction. The independent predictors of diastolic dysfunction were determined to be the left atrial volume index (LAVI) (OR=1.17; p=0.018), longitudinal 3D strain values (OR=1.88; p<0.001), NT-proBNP (OR=1.11; p=0.001), and Ghrelin (OR=1.40; p=0.001), respectively.

Relationship Between LV EDP and LV Longitudinal Strain LV EDP 2D Strain 3D Strain r p r p r p BNP, pg/ml 0.429 <0.001* 0.115 0.316 0.178 0.118 NT-proBNP, pg/ml 0.484 <0.001* 0.155 0.177 0.186 0.104 Ghrelin, pg/ml 0.478 <0.001* 0.086 0.455 0.157 0.169 SolV DB – – 0.481 <0.001* 0.591 <0.001* dP/dT −0.389 <0.001* −0.283 0.012* −0.307 0.006* Negative dP/dT −0.747 <0.001* −0.337 0.003* −0.458 <0.001* 2D. % 0.481 <0.001* – – 0.852 <0.001* 3D. % 0.591 <0.001* 0.852 <0.001* – – If p value is less than 0.05 shows statistical significance.

Measurement of longitudinal strain

Conclusion

In conclusion, our study found out that the reduced 3D strain absolute values and increased levels of NT-proBNP and Ghrelin biomarkers predicted diastolic dysfunction. If further large-scale studies prove the efficiency of these practical, they may not only allow for making a diagnosis of HFpEF more readily but may also eliminate the confusion in diagnostic algorithms.

Acknowledgement/Funding

None

Possible prenatal impact of sertraline on human placental glutathione S-transferase-π

Sertraline (SER), a tricyclic antidepressant, is considered to belong to the group of selective amine reuptake inhibitors. Its ability to cross the blood–brain barrier and transplacental transport has been reported previously. It is widely distributed in the brain and is bound to human glutathione S-transferase-π (GST-π). If SER is taken during pregnancy, it gets accumulated in the embryo and fetus, and some studies have suggested it may cause congenital malformations, thus the study of the interaction of GST-π with antidepressants is crucial. In this study, the interaction of human placental GST-π with SER in the presence of the natural ligand, reduced glutathione (GSH) and a xenobiotic ligand, 1-chloro-2,4-dinitrobenzene (CDNB) was investigated. The Vm values obtained at variable [CDNB] and variable [GSH] were 61.3 ± 2.3 and 46.4 ± 1.7 U/mg protein, respectively. The kcat and kcat/ Km values for GSH and CDNB were 3.63 × 106 s−1, 2.59 × 1010 M−1 s−1 and 4.79 × 106 s−1, 1.29 × 1010 M−1 s−1, respectively. The half maximal inhibitory concentration value for SER was 4.60 mM. At constant [CDNB] and variable [GSH] the inhibition type was linear mixed-type, with Ks, α, and Ki values of 0.14 ± 0.02, 2.90 ± 1.64, and 2.18 ± 0.80 mM, respectively. On the other hand, at fixed [GSH] and at variable [CDNB], the inhibition type was competitive, with Ki value of 0.96 ± 0.10 mM. Thus, these findings weaken the importance of the protective role of GST against toxic electrophiles in vivo in adults, but due to its immature enterohepatic system SER may accumulate in the fetus and cause congenital malformations.

Optical Indices of Tin-Doped Indium Oxide and Tungsten Oxide Electrochromic Coatings

Thin films of tin-doped indium oxide are widely used for transparent conductors. One application of ln203:Sn (ITO) is transparent contacts for electrochromic electrodes. Optical design of electrochromic devices requires knowledge of the optical constants for each layer from the near ultraviolet and visible to the mid infrared. Determination of the optical constants of the electrochromic layer cannot be made in isolation; a complete device or at least a half-cell including a layer of ITO is required to change the optical state of the electrochromic material. Measurements on ITO were made using variable-angle spectral ellipsometry, and spectral transmittance and reflectance. A series of structural models were fit to this data. The problem is complicated because of inhomogeneity in the films, variability in the manufacturing process, and sensitivity to environmental conditions. The spectral dependency was modeled by a single Lorentz oscillator and a Drude free-electron component. This data was then used as the basis for a model to extract the optical constants for a tungsten oxide electrochromic film.

Effect of balloon inflation-induced acute ischemia on QT dispersion during percutaneous transluminal coronary angioplasty

BACKGROUND

QT dispersion (QTd = QTmax-QTmin) measured as interlead variability of QT interval reflects the spatial inhomogeneity of ventricular repolarization times, and increased QTd may provide a substrate for malignant ventricular arrhythmias. Ischemia is associated with regional abnormalities of conduction and repolarization.

HYPOTHESIS

This study aimed to investigate the effect of acute ischemia on QTd during successful percutaneous transluminal coronary angioplasty (PTCA).

METHODS

Forty-three patients (10 women, 33 men, mean age 56 years) were enrolled in the study. Electrocardiogram (ECG) recordings were taken before PTCA and during balloon inflation period. QT maximum (QTmax), QT minimum (QTmin), and QTd (QTmax-QTmin) values were calculated from the surface ECG.

RESULTS

There was no difference among QTmax values (p = 0.6). Mean QTmin during balloon inflation was lower than before PTCA (368 +/- 45 vs. 380 +/- 41 ms, p = 0.002). The difference between QTd values before and during balloon inflation was statistically important (65 +/- 9 vs. 76 +/- 10 ms, p = 0.001). This difference is caused by a decrease in QTmin during balloon inflation.

CONCLUSION

Acute reversible myocardial ischemia induced by balloon inflation causes an increase in QTd value, and this increment is the result of a decrease in QTmin interval. Therefore, QTd may be a marker of reversible myocardial ischemia.

Circadian variations of QTc dispersion: is it a clue to morning increase of sudden cardiac death?

BACKGROUND

Several studies related to cardiac events including sudden death have shown a peak incidence in the early morning hours. It has also been known that acute ischemia is a potent stimulus to increased dispersion of repolarization and development of malignant arrhythmias.

HYPOTHESIS

The purpose of the present study was to investigate diurnal variations of corrected QT dispersion (QTcD) in patients with coronary artery disease (CAD) (Group 1) compared with controls with normal coronary angiograms (Group 2).

METHODS

We investigated a total of 110 patients who had been referred for coronary angiography, of whom 62 (42 men, 20 women; age 55 +/- 7 years) had double- or triple-vessel disease, and of whom 48 (31 men, 17 women; age 54 +/- 9 years) had normal coronary angiograms. QTcD measurements were calculated from a 12-lead resting electrocardiogram (ECG) during sinus rhythm. These ECGs were obtained for each patient in the morning, at noon, in the evening, and at night on the day after performance of coronary angiography. QTcD was significantly greater in patients with abnormal coronary angiograms (Group 1) than in patients with angiographically documented normal coronary arteries (Group 2). This difference appeared to be more prominent in the morning hours (p < 0.001) than at other times. QTcD in the evening and night hours was not statistically different (p > 0.05) between both groups. We also compared intragroup QTcD values: QTcD values were significantly increased in the morning hours and were more prominent in Group 1 than in Group 2.

CONCLUSIONS

Our data suggest that QTcD has a circadian variation with an increase in the morning hours, especially in patients with coronary artery disease. This finding was thought to be an explanation for the role played by sympathetic nervous system in the occurrence of acute cardiac events and sudden death during these hours.

QT dispersion plus ST-segment depression: a new predictor of restenosis after successful percutaneous transluminal coronary angioplasty

BACKGROUND

ST-segment depression during exercise testing is frequently observed in the absence of restenosis after percutaneous transluminal coronary angioplasty (PTCA).

HYPOTHESIS

With the goal of improving the prediction of restenosis after PTCA, we evaluated the usefulness of ST-segment depression plus QT dispersion (QTd = QTmax - QTmin) during treadmill stress test.

METHODS AND RESULTS

Fifty-six patients (37 men, 19 women, mean age 51 +/- 14 years) were evaluated with treadmill exercise testing and coronary angiography 7 +/- 5 months after PTCA. Treadmill test was positive in 30 patients and negative in 26 patients. At coronary angiography, restenosis was present in 16 patients with positive exercise electrocardiogram (ECG) and in 6 patients with negative exercise ECG. Fourteen patients with a positive stress test did not have restenosis. There was no difference in QTd values between groups at baseline (p > 0.05). Exercise QTd was 63 +/- 9 ms in patients with positive exercise test, 54 +/- 18 ms in patients with negative exercise test (p = 0.003), 71 +/- 13 ms in patients with restenosis, and 53 +/- 17 ms in patients without restenosis (p = 0.001). ST-segment depression during the stress test determined restenosis with a sensitivity of 80% and a specificity of 58%. Sensitivity and specificity of QTd of > or = 60 ms for prediction of restenosis were 83 and 61%, respectively. When QTd of > or = 60 ms was added to ST-segment depression as a condition for positive test, the sensitivity and specificity increased to 91 and 78%, respectively. QT dispersion plus ST-segment depression had higher sensitivity and specificity than either QTd or ST-segment depression alone (p < 0.05).

CONCLUSION

The addition of QTd to ST-segment depression during exercise test improves the diagnostic value and can be used as a noninvasive tool in the diagnosis of restenosis after PTCA.

Lack of association between angiotensin-converting enzyme gene polymorphism and type I aortic dissection

The relationship between angiotensin-converting enzyme (ACE) gene polymorphism and type I aortic dissection was examined in 205 unrelated hypertensives. A total of 94 patients underwent emergency repair due to type I aortic dissection, confirmed by computed tomography, and the remaining 111 were controls. Polymerase chain reaction was used to confirm that ACE gene polymorphism was due to insertion (I) or deletion (D) of a 287 base pair (bp) DNA sequence within intron 16. The genotype distribution and allele frequency of ACE I/D polymorphism between patients and controls were not statistically significant. When the frequency of at least one D allele carrier (DD or ID genotype) was compared with the II homozygous genotype, there was also no significant difference between the study groups. The findings revealed no association between ACE I/D polymorphism and aortic dissection. We conclude that I/D mutation of the ACE gene does not seem to be a risk factor for aortic dissection.

The effect of tocopheryl phosphates on atherosclerosis progression in rabbits fed with a high cholesterol diet

The effect of tocopheryl phosphate on atherosclerosis progression has been studied in rabbits, fed with a 2% cholesterol diet and compared with an equivalent amount of alpha-tocopheryl acetate. The results show that the atherosclerotic-preventing effect of the phosphate derivative was more pronounced than that of the acetate derivative. alpha-Tocopheryl phosphate was also more potent in diminishing the expression of CD36 than the acetate derivative.

Sand fly species of Sanliurfa province in Turkey

The species composition and seasonal abundance of sand flies (Diptera: Phlebotominae) were studied in the years 2000-2002 in the Sanliurfa region, which is the largest focus of cutaneous leishmaniasis in south-eastern Turkey. Sixteen species were identified among 29 771 specimens collected at 17 different sites by light traps, sticky papers and aspirators. The most common species were Phlebotomus papatasi (Scopoli) (45.4%), P. perfiliewi Parrot (21.9%), and P. sergenti Parrot (19.4%). The other species found were P. major Adler & Theodor (3%), P. neglectus Leger & Pesson (2.2%), P. brevis Theodor & Mesghali (2%), P. alexandri Sinton (1.9%), P. galilaeus Theodor (1.6%), P. halepensis Theodor (0.84%), Sergentomyia adleri Theodor (0.78%), S. dentata Sinton (0.49%), S. minuta Rondani (0.42%), S. theodori Parrot (0.16%), P. kazeruni Theodor & Mesghali (0.001%) and P. mascitti Grassi (0.001%) and one unidentified Phlebotomus species. Among these species P. galilaeus, S. minuta and S. dentata are the first records for this area. All species showed seasonal fluctuations, with the period of highest abundance between May and October.

The role of free oxygen radicals in the aetiopathogenesis of rosacea

A possible link between superoxide dismutase activity and malondialdehyde level with the clinical manifestations of rosacea was investigated. We found differences in superoxide dismutase activities between mild rosacea (stages I and II) and severe involvement (stage III) groups, as well as between disease and control groups that were statistically significant (P < 0.05). In the mild involvement group (stages I and II), the superoxide dismutase activity was higher than in the control group (P < 0.05), while the malondialdehyde levels did not differ from the control. In the severe involvement group (stage III), the superoxide dismutase activity was lower than in the control group (P < 0.05), and this was coupled to a raised level of malondialdehyde (P < 0.05). These findings clearly show that in the mild involvement phase of rosacea patients, superoxide dismutase activity was stimulated to protect the skin against reactive oxygen species so that the malondialdehyde levels were maintained. In contrast, in more severe disease, due to a decrease in the capacity of the antioxidant defence system, the malondialdehyde levels were increased. These findings support the 'antioxidant system defect hypothesis' in rosacea patients.

In vivo half life of nanoencapsulated L-asparaginase

In the present study, antileukemic enzyme L-asparaginase (ASNase) was encapsulated into poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBV) nanocapsules in order to decrease the immunogenicity and toxicity of the enzyme and to increase its in vivo half life in mice. Nanocapsules were prepared by water-in-oil-in-water approach and each phase was changed systematically. By changing the pH of the w(2) phase to the isolelectric point of L-ASNase, the encapsulation efficiency was increased from 23.7% to 28.0%. Also, modification of ASNase with PEG(2) increased the encapsulation efficiency from 23.7% to 27.9% and protected the enzyme against denaturation. Combination of the various optima enabled a substantial increase in the activity (0.074-0.429 U/mg nanocapsule). The enzyme activity in the blood due to unmodified PHBV nanocapsules dropped to 38% of its initial value 4 h after injection. When the same sample was tested for the enzyme content in the circulation by using the radio-labeled enzyme a much lower enzyme (30% of initial) could be detected after a shorter time (3 h). The PHBV nanocapsules with heparin conjugated on their surface had a longer presence in the circulation than unmodified PHBV nanocapsules. After 6 h, around 50% of the enzyme was still present in the blood. Radioactivity measurements using the same sample showed a sharp decrease in enzyme amount in the circulation in the early stages. However, radioactivity was still detectable at the eighth hour. No adverse effects and symptoms of anaphylaxis were observed upon injection of encapsulated ASNase-PHBV nanocapsules to mice i.v. through the tail vein.

Poly(hydroxybutyrate-co-hydroxyvalerate) nanocapsules as enzyme carriers for cancer therapy: an in vitro study

In the present paper, poly(3-hydroxybutyrate-co-3-hydroxyvalerate) nanocapsules were prepared by a double emulsion-solvent evaporation procedure (w/o/ w) for the encapsulation of model enzymes (L-asparaginase, catalase, glucose oxidase) and bovine serum albumin. To increase the encapsulation efficiency and activity of the encapsulated enzyme, numerous modifications were made in the compositions of the phases of double emulsion. For the preparation of low molecular weight PHBV, the polymer was treated with sodium borohydride. A 14-fold decrease in molecular weight (from 297000 to 21000) was observed upon 4 h of incubation. Although the amount of encapsulated protein was not increased, the enzyme activity increased upon use of low molecular weight PHBV, indicating that these nanocapsules have a higher permeability to solutes (reactants and products). The adjustment of the second water phase to the isoelectric point of the proteins significantly increased the encapsulation yields of catalase, L-asparaginase and BSA. Likewise, polyethylene glycol coupling significantly increased the entrapment efficiency as well as the activity of catalase and L-asparaginase. A combination of the various optimum preparation conditions further increased the encapsulated catalase activity (about six-fold) in comparison to the initial basic conditions (with no modification and no isoelectric point adjustment).

Intracellular superoxide dismutase, catalase, and glutathione peroxidase activities and membrane lipid peroxide levels in Fusarium acuminatum upon environmental changes in a defined medium

The variations of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GSH-Px) activities and lipid peroxide (LPO) levels in Fusarium acuminatum, an aerobic filamentous fungus, were investigated depending on the carbon and nitrogen sources during the incubation period. Fungus was cultivated in growing medium containing either maltose or saccharose in 5-25 g/L concentration range as a carbon source and either glycine or peptone in 5-35 g/L concentration range as a nitrogen source at 28 degrees C and 100 rpm. The observed highest SOD, CAT, and GSH-Px activities were 31.2+/-0.655, 62.5+/-5.23, and 1.52+/-0.0122 IU/mg in the presence of 20 g/L maltose and 73.96+/-1.48, 74.46+/-2.94, 3.48+/-0.083 IU/mg in the 15 g/L glycine-containing medium at 16 days, respectively. At the same time, the minimum LPO level was observed at 20 g/L maltose and 15 g/L glycine compared with the other carbon and nitrogen sources. The results showed a negative correlation between antioxidant enzyme activities and membrane LPO levels in F. acuminatum cells.

Modification of human erythrocyte pyruvate kinase by an active site-directed reagent: bromopyruvate

Human erythrocyte pyruvate kinase was modified with bromopyruvate and the kinetic behavior of the modified enzyme was investigated. When the enzyme was modified with bromopyruvate in the absence of adenosine-5'-diphosphate, phosphoenolpyruvate or fructose-1,6-diphosphate the inactivation followed a pseudo first-order kinetics. The inactivation rate constant, ks, was 1.84 +/- 0.15 min(-1). Kd of the bromopyruvate-enzyme complex was 0.14 +/- 0.03 mM. The presence of adenosine-5'-diphosphate, phosphoenolpyruvate or fructose-1,6-diphosphate in the modification medium or the presence of fructose-1,6-diphosphate in the assay medium resulted in deviation of the inactivation kinetics from pseudo first-order. Phosphoenolpyruvate was better than adenosine-5'-diphosphate for protection against bromopyruvate modification whereas fructose-1,6-diphosphate was ineffective. The modified enzyme showed negative cooperativity in the presence of fructose-1,6-diphosphate whereas in the absence of it no activity was detected.

Effect of balloon-induced acute ischaemia on P wave dispersion during percutaneous transluminal coronary angioplasty

AIMS

P wave dispersion is a recent ECG marker that reflects discontinuous and inhomogeneous conduction of sinus impulses, which has been studied in a limited number of cardiac conditions. The aim of our study was to investigate the effects of angioplasty induced-ischaemia on atrial conduction abnormalities as estimated by P maximum and P dispersion.

METHODS AND RESULTS

The study consisted of 67 consecutive patients (41 men, mean age 58 +/- 11 years) with 1-vessel coronary artery disease who underwent elective single vessel coronary angioplasty (left anterior descending (LAD) coronary artery in 28 patients, the right coronary artery (RCA) in 22 patients and the left circumflex coronary artery (LCx) in 17 patients. All patients underwent 12-lead surface ECG before the first inflation (baseline) and then 60 s after intra-coronary balloon inflation. The maximum P wave duration, the minimum P wave duration, and P wave dispersion (Pd=Pmax - Pmin) were calculated from 12-lead surface ECGs. Baseline P wave duration measurements were not significantly different among the patients with LAD, RCA and LCx coronary artery disease (P>0.05). P dispersion and P maximum were significantly higher during balloon occlusion compared with the baseline condition in all three types of coronary dilatation procedures. However, P minimum was not found to differ between baseline and during balloon occlusion (P>0.05).

CONCLUSION

The prolongation of P wave dispersion may be a useful and simple additional marker for myocardial ischaemia.

The in-vitro and in-vivo characterization of PLGA:L-PLA microspheres containing dexamethasone sodium phosphate

Dexamethasone sodium phosphate (DSP) is a widely used corticosteroid in the treatment of brain oedema associated with brain tumours. DSP has many side effects that limit its usage at an effective concentration. The objective of this study was to minimize these side effects by encapsulating DSP using biodegradable synthetic polymers, to extend the release time from microspheres and to evaluate the effectiveness in the treatment of brain oedema. Microspheres containing 5% DSP were formulated by the solvent evaporation method by using a 1:1 mixture of two synthetic polymers, poly(lactic-co-glycolic acid) and L-polylactic acid (PLGA and L-PLA). The surface morphologies and particle size distribution of the microspheres were investigated. The in-vitro release studies were performed in pH 7.4 phosphate buffer solution. For determining the effectiveness of microspheres in the treatment of brain oedema, Sprague-Dawley rats weighing 200-250g were used as an animal model. Brain oedema was generated by the cold lesion method, and the effectiveness of the microspheres in treatment of oedema was investigated by the wet-dry weight method, lipid peroxidation ratios and histological evaluations. The average particle size of the microspheres was 13.04 +/- 2.05 microm, and the in-vitro release time of the microspheres was 8 h for 100/release. The degree of oedema was significantly different from the control group for the wet-dry weight method and lipid peroxidation ratio (p < 0.05). Similarly, histological evaluation of the tissues shoved that degree of oedema was significantly decreased with respect to the control group. All these results showed that implantation of microspheres was significantly more effective with respect to the systemic administration of DSP.

[Evaluation of dynamic left ventricular outflow tract obstruction by dobutamine stress echocardiography]

OBJECTIVE

This study was planned to evaluate the dynamic left ventricular outflow tract (LVOT) obstruction by using dobutamine stress echocardiography (DSE) in patients with asymmetric septal hypertrophy and/or septal bulging, who have no signs of LVOT gradient detected by conventional echocardiography, with symptoms mimicking hypertrophic obstructive cardiomyopathy (HOCM).

METHODS

In sixty-one consecutive patients referred to our echocardiography laboratory with HOCM pre-diagnosis, exercise dyspnea and limitation of exercise capacity were evaluated. DSE was performed in 31 patients who fulfilled the inclusion criteria. Patients were divided into two groups according to the degree of dynamic gradient increase above baseline values during stress-test (Group 1 < 30 mmHg, Group 2 > 30 mmHg). Left ventricular diameters, septum and posterior wall thicknesses, ejection fraction, LVOT and aortic root diameters, presence of septal bulging and systolic anterior motion (SAM) and degree of septal angulation were sought.

RESULTS

There were no significant differences between groups by means of LV diameters, septum and posterior wall thicknesses, EF, LVOT and aortic root diameters, presence of septal bulging (p > 0.05); whereas there were significant differences in SAM and degree of septal angulation (p < 0.05 and p < 0.0001, respectively). Systolic anterior motion (r = 0.61, p < 0.0001) and degree of septal angulation (r = -0.71, p < 0.001) correlated significantly with the dynamic gradient increase.

CONCLUSION

Presence of SAM and degree of septal angulation obtained by DSE are reliable parameters to determine dynamic LVOT obstruction in patients who have asymmetric septal hypertrophy and septal bulging with no gradient on LVOT by conventional echocardiography.

[The evaluation of the severity of mitral regurgitation using color Doppler echocardiographic methods]

OBJECTIVE

This study was planned to assess the vena contracta (VC), flow convergence area (PISA) and jet area (JA) methods in evaluating the severity of mitral regurgitation (MR) and to test the accuracy of a proposed algorithm using these methods.

METHODS

Eighty-seven patients with chronic MR were enrolled in the study. VC of < 0.3 cm, maximal MR flow rate calculated by PISA (Qmax) of < 72 cm3/sn and JA of < 4 cm2 were classified as mild MR. VC of > 0.5 cm, Qmax of > 240 cm3/sn and JA of > 8 cm2 were classified as severe MR. Whereas the values between these ranges were called to be moderate MR. The algorithm was planned as follows: In the first step, VC width was measured. If a patient has VC = 0.3-0.5 cm, it was used Qmax in the eccentric jets and JA in the central jets in the second step. The severity of MR were considered as severe, moderate and mild for > 50%, 21-49% and 20% of the regurgitant fraction calculated by the reference method (the quantitative Doppler method depending on aortic and mitral stroke volumes), respectively.

RESULTS

The sensitivity of VC was low in differentiating between moderate and severe MR (63%). In eccentric jets, the regurgitant volume calculated by PISA was higher than that of reference method (70 +/- 49 vs. 59 +/- 29 cm3) and the JA was found to be less than that of central jets despite similar regurgitant fraction (6.8 +/- 3.2 vs. 8.5 +/- 3.3 cm2). The algorithm agreed well with the reference method and it was better than those of each tree methods (Cappa coefficients 0.89 vs. 0.65, 0.63 and 0.45 for VC, Qmax and JA; respectively). The accuracies of the algorithm in discriminating between mild and moderate MR or severe and non-severe MR were high (98% and 95%, respectively).

CONCLUSIONS

The severity of MR can be determined accurately and simply by using VC, PISA and JA methods together.

[Value of tissue Doppler imaging in the determination of the right ventricular systolic function]

OBJECTIVE

Since there is a difficulty in the assessment of right ventricular systolic function by 2D echocardiography, a noninvasive, practical and, cost effective method is desirable. Tissue Doppler technique enables to visualize systolic and diastolic velocities of the tissue through sample volume replacement. In this study, we aimed to evaluate the relationship between tricuspid annular tissue Doppler velocities and right ventricular systolic functions.

METHODS

For this purpose, tricuspid annular systolic (S), early diastolic (E) and, late diastolic (A) velocities were obtained from 38 patients (23 with dilated cardiomyopathy, 15 with mitral stenosis, all of them in sinus rhythm) and 15 healthy control subjects by placing the pulsed wave sample volume at the junction of right ventricular free wall and tricuspid annulus. The time velocity integral (TVI) of S, peak velocity of S and isovolumic contraction time (IVCT) were compared with right ventricular ejection fraction (RVEF) determined by 2D echocardiographic hemi-elliptic shell model, peak velocity of tricuspid regurgitation and dP/dt calculated from the spectral trace of this regurgitation.

RESULTS

A significant correlation was determined between RVEF and peak S velocity, S TVI and IVCT (r: 0.76, p < 0.001, r: 0.82, p < 0.0001 and r: -0.85, p < 0.0001 respectively). The peak S velocity < 12 cm/sec, S TVI < 2 cm and IVCT > 75 msec yielded 76%, 84%, 92% sensitivity and 84%, 84%, 80% specificity for predicting the patients with right ventricular ejection fraction < 40%, respectively. A significant and powerful correlation was determined between the peak S velocities and dP/dt in 19 patients whose tricuspid regurgitation could be clearly recorded (r: 0.88, p < 0.0001).

CONCLUSIONS

The analysis of tricuspid annular velocities obtained by tissue Doppler technique is a practical method of the assessment of right ventricular systolic functions.

Echocardiographic evaluation of left and right ventricular diastolic function in patients with chronic obstructive pulmonary disease

The aim of this study was to investigate the effects of chronic obstructive pulmonary disease (COPD) on left ventricular and right ventricular diastolic and systolic functions. Forty-eight patients with severe COPD were studied. Patients were divided into 2 subgroups according to pulmonary artery pressures: 25 patients with pulmonary hypertension (group 1) and 23 patients with normal pulmonary artery pressure (group 2). As a control group, 59 normal subjects were studied (group 3). Patients in group 1 had higher tricuspid peak A velocity, lower tricuspid E velocity, longer isovolumetric relaxation time, higher mitral A wave, lower mitral E wave, and slower color propagation velocity than groups 2 and 3. There was no significant difference between left ventricular diastolic filling parameters between groups 2 and 3. Patients with COPD and pulmonary hypertension have left and right ventricular diastolic dysfunction. However, patients with COPD and normal pulmonary artery pressure have normal left and right ventricular diastolic function.

Percutaneous balloon pericardiotomy for patients with malignant pericardial effusion including three malignant pleural mesotheliomas

Ten patients were enrolled in this study to evaluate the therapeutic value of percutaneous balloon pericardiotomy in patients with symptomatic pericardial effusion secondary to malignant diseases. Four patients had breast cancer; 2 had lung cancer; 1 had non-Hodgkin's lymphoma; and 3 had malignant pleural mesothelioma, which is commonly seen in Central Anatolian region of Turkey. All patients underwent percutaneous balloon pericardiotomy with monofoil balloons (Mansfield, NuMed). No complication was seen during these procedures. In 3 patients, the balloon could not be expanded completely and was entered from a more lateral position by a second puncture. There was no recurrence of pericardial effusion in 6 of 7 patients without mesothelioma. After percutaneous balloon pericardiotomy, surgical subxiphoid windowing was performed due to drainage greater than 100 mL/day in a patient with lung cancer and in 1 patient with mesothelioma. In the other 2 patients with mesothelioma, recurrence of pericardial effusion was seen and then subxiphoid surgical windowing was performed due to development of cardiac tamponade in 1 of them. All the patients died 68.6 +/- 36 days later due to the primary malignancies. The survival time of patients with mesothelioma was shorter than that of the others (p < 0.05). These results suggest that percutaneous balloon pericardiotomy may be used in the treatment of patients with malignant pericardial effusion as an alternative to surgical pericardial window creation. But in patients with malignant pleural mesothelioma, the success rate of this procedure was lower than that of the others.

Acute anterior myocardial infarction following a mild nonpenetrating chest trauma--a case report

Myocardial infarction in patients under age 45 years is a relatively unusual phenomenon; blunt chest trauma is one of the nonatherosclerotic mechanisms leading to acute myocardial infarction in young adults. The authors report a rare case of anterior myocardial infarction in a 22-year-old man following a mild nonpenetrating chest trauma whose left chest was elbowed during a soccer game.

Hydatid cyst of the heart as a rare cause of embolization: report of 5 cases and review of published reports

Cardiac hydatid cyst is seen infrequently, even in regions where hydatid cysts are endemic. We report 5 cases of cardiac hydatid cysts, which were diagnosed after an embolic event.

Kinetic properties of human placental glucose-6-phosphate dehydrogenase

The kinetic properties of placental glucose-6-phosphate dehydrogenase were studied, since this enzyme is expected to be an important component of the placental protection system. In this capacity it is also very important for the health of the fetus. The placental enzyme obeyed "Rapid Equilibrium Ordered Bi Bi" sequential kinetics with K(m) values of 40+/-8 microM for glucose-6-phosphate and 20+/-10 microM for NADP. Glucose-6-phosphate, 2-deoxyglucose-6-phosphate and galactose-6-phosphate were used with catalytic efficiencies (k(cat)/K(m)) of 7.4 x 10(6), 4.89 x 10(4) and 1.57 x 10(4) M(-1).s(-1), respectively. The K(m)app values for galactose-6-phosphate and for 2-deoxyglucose-6-phosphate were 10+/-2 and 0.87+/-0.06 mM. With galactose-6-phosphate as substrate, the same K(m) value for NADP as glucose-6-phosphate was obtained and it was independent of galactose-6-phosphate concentration. On the other hand, when 2-deoxyglucose-6-phosphate used as substrate, the K(m) for NADP decreased from 30+/-6 to 10+/-2 microM as the substrate concentration was increased from 0.3 to 1.5 mM. Deamino-NADP, but not NAD, was a coenzyme for placental glucose-6-phosphate dehydrogenase. The catalytic efficiencies of NADP and deamino-NADP (glucose-6-phosphate as substrate) were 1.48 x 10(7) and 4.80 x 10(6) M(-1)s(-1), respectively. With both coenzymes, a hyperbolic saturation and an inhibition above 300 microM coenzyme concentration, was observed. Human placental glucose-6-phosphate dehydrogenase was inhibited competitively by 2,3-diphosphoglycerate (K(i)=15+/-3 mM) and NADPH (K(i)=17.1+/-3.2 microM). The small dissociation constant for the G6PD:NADPH complex pointed to tight enzyme:NADPH binding and the important role of NADPH in the regulation of the pentose phosphate pathway.

Increased plasma levels of soluble selectins in patients with unstable angina

BACKGROUND

Inflammation plays an important role in the pathogenesis of unstable angina. Adhesion molecules, such as selectins, mediate the interactions between leukocytes, platelets and endothelial cells during inflammation and thrombogenesis.

HYPOTHESIS

The purpose of this study was to determine whether soluble E-selectin, P-selectin and L-selectin levels are increased in patients with unstable angina (UA).

METHODS

Soluble E-, P- and L-selectin levels were measured by enzyme-linked immunoassay in the peripheral blood of 23 patients with UA, 26 patients with stable angina (SA) and 15 control patients with angiographically normal coronary arteries.

RESULTS

Soluble E-selectin levels were significantly higher in patients with UA (45+/-11 ng/ml) than in controls (30+/-8 ng/ml, P<0.001), or patients with SA (34+/-8 ng/ml, P=0.001). Similarly, plasma levels of P- and L-selectin were significantly higher in patients with UA (427+/-144 and 772+/-160 ng/ml, respectively) than in patients with SA (278+/-79 and 643+/-94 ng/ml, respectively, P<0.005 vs. UA for both), or control patients (189+/-43 and 601+/-126 ng/ml, respectively, P=0.001 vs. UA for both).

CONCLUSIONS

Plasma levels of soluble selectins were increased in patients with UA compared with patients with SA or patients without angiographically visible coronary artery disease. Measurements of these adhesion molecules may be helpful as non-invasive markers of coronary plaque destabilization in UA.

Verapamil SR and trandolapril combination therapy is safe and effective in hypertensive patients with metabolic disorders

Verapamil SR (180 mg) plus trandolapril (2 mg) is a potent antihypertensive combination but the efficacy and safety of this treatment has not been studied fully in hypertensive patients with metabolic disorders. We enrolled 298 patients with mild to moderate hypertension who had at least one of the following disorders: diabetes mellitus, hypercholesterolaemia or mild renal failure. The sitting systolic pressure and diastolic blood pressures were significantly decreased after 12 weeks of treatment. Blood pressure was inadequately controlled in only 24 patients (8.8%). Progressive decreases in blood glucose, total cholesterol, low-density lipoprotein and triglyceride levels were observed during the study. There was no significant change in blood urea nitrogen, creatinine and transaminase levels (p > 0.05). There was a significant decrease in microalbuminuria levels. There was no significant change in glycosylated haemoglobin levels in diabetic patients. Verapamil SR plus trandolapril is an effective drug combination in the treatment of hypertension. It may be used safely in patients with diabetes mellitus, hyperlipidaemia and mild renal failure.

Echocardiographic findings of pericardial involvement in patients with malignant pleural mesothelioma with a history of environmental exposure to asbestos and erionite

OBJECTIVE

The aim of the present study was to evaluate the pericardial involvement in patients with malignant mesothelioma caused by exposure to different minerals.

METHODOLOGY

Forty-two patients (mean age of 52 +/- 12 years) with malignant mesothelioma were examined with transthoracic echocardiography. Thirty-three (78.9%) patients had a history of environmental exposure to asbestos and nine (21.4%) had a history of environmental exposure to erionite.

RESULTS

In 19 (45.2%) patients with malignant pericardial mesothelioma, pericardial involvement was determined by echocardiography. The other 23 (54.8%) patients had no pericardial involvement. Pericardial effusion was detected in nine (64.3%) patients and pericardial effusion was small in six (14.3%) patients, moderate in one (2.4%) patient and large in two patients. Thickening of the pericardium was observed in eight (19%) patients. In another two (7.1%) patients pericardial calcification was observed. Among the 33 patients who had been exposed to asbestos, 15 (45.5%) had pericardial involvement, and among the nine patients with a history of exposure to erionite, four (44.4%) had pericardial involvement. There was no difference in terms of pericardial involvement in different stages of the tumour (P > 0.05).

CONCLUSIONS

Pericardial involvement is commonly seen in patients with malignant mesothelioma. Among patients exposed to asbestos or zeolite there was no difference in terms of pericardial involvement. Furthermore, pericardial involvement was not related with the stage of the tumour.

Circulating adhesion molecules in patients with stable coronary artery disease

To evaluate platelet and endothelial function in patients with stable coronary artery disease (CAD), we investigated levels of the plasma-soluble (s) adhesion molecules E-selectin (sE-selectin), P-selectin (sP-selectin), and intercellular adhesion molecule-1 (sICAM-1) in 74 patients (mean age, 53 +/- 8 years) with angiographically documented coronary artery disease. Levels were compared to 27 matched healthy control subjects. Patients were excluded if they had recent cardiovascular events or any illness that might influence platelet and endothelial cell function. Concentrations of sP-selectin were significantly higher in patients with stable CAD (276 +/- 61 ng/mL) compared with control subjects (188 +/- 32 ng/mL) (P = .0001), whereas sE-selectin and sICAM-1 levels were similar between the 2 groups. Pooling both groups showed that sICAM-1 correlated weakly with triglycerides (r = 0.240, P = .01) and sP-selectin correlated weakly with low-density lipoprotein cholesterol (r = 0.204, P = .04). Although plasma sICAM-1 concentrations were significantly increased in hypercholesterolemic patients compared with those of normocholesterolemic patients (P = .04), sP-selectin and sE-selectin levels were similar between the 2 groups. In conclusion, significantly increased sP-selectin levels, indicating platelet activation, were found in patients with stable CAD. No other sign of endothelial cell activation in these patients could be detected. Moreover, sP-selectin levels seem to reflect the activation of platelets rather than of endothelial cells.

P wave dispersion in hypertensive patients with paroxysmal atrial fibrillation

It is important to assess the risk of developing paroxysmal atrial fibrillation (PAF) in hypertensive patients since hypertension is a common disorder predisposing to PAF. We sought to determine if patients with hypertension at risk of PAF can be identified while in sinus rhythm by measurements of P wave dispersion. Twelve-lead surface electrocardiograms were recorded in 44 hypertensive patients with history of PAF (group I, mean age = 60) and in 50 hypertensive patients without history of AF (group II, mean age = 57). The maximum P wave duration, the minimum P wave duration, and P wave dispersion (Pd = Pmax - Pmin) were calculated from 12-lead surface ECGs. Left atrial dimension (LAD) and left ventricular ejection fraction (LVEF) were measured by echocardiography. P wave dispersion was significantly greater in group I than group II (50 +/- 12 vs 38 +/- 8 ms, P = 0.001). P minimum (75 +/- 13 vs 87 +/- 11 ms, P = 0.001) and LVEF (0.63 +/- 0.05 vs 0.67 +/- 0.04, P = 0.03) were significantly lower in group I than group II. However P maximum and LAD were not significantly different in group I than group II (P > 0.05). In univariate analysis, P minimum, P wave dispersion, and LVEF were significant predictors of PAF, whereas only P wave dispersion remained a significant independent predictor of PAF in a multivariate analysis. Measurement of P wave dispersion in sinus rhythm may be a useful noninvasive clinical tool to identify patients with hypertension at risk of developing atrial electrical instability and atrial fibrillation.