Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 2002
Thromboembolism is still one of the most important complications of prosthetic heart valves. Embo... more Thromboembolism is still one of the most important complications of prosthetic heart valves. Embolism to a major coronary branch is rare, but acute proximal occlusions can be fatal, even when the coronary arteries are otherwise normal and intervention is rapid. We report a fatal complication of an exercise test in a patient who had a St. Jude bileaflet mitral valve. After an exercise test, a 42-year-old woman with a mechanical prosthetic valve had a severe hemodynamic collapse with acute ST segment changes. Coronary angiography showed a totally occluded left main coronary artery with TIMI grade 0 to 1 flow. Rapid injection of contrast material and the passage of a floppy guidewire through the thrombus restored a TIMI grade 3 flow. Angiography showed no coronary atherosclerostic involvement. Despite successful coronary reperfusion, intra-aortic balloon counterpulsation, and intensive medication, the patient died. This case demonstrates that exercise testing should be applied with gre...
BACKGROUNDThrombus formation around the intracardiac end of the catheter, thromboembolism, and in... more BACKGROUNDThrombus formation around the intracardiac end of the catheter, thromboembolism, and infection are the most important and life-threatening complications of ventriculoatrial shunts. In this article we report a patient with a large right atrial mass that was diagnosed by 2-D echocardiogram and removed via standard median sternotomy and cardiopulmonary bypass.CASE DESCRIPTIONA 63-year-old man who had a right ventriculoatrial shunt was
Spontaneous pseudonormalization (PN) is a unique 12-lead electrocardiography (ECG) finding which ... more Spontaneous pseudonormalization (PN) is a unique 12-lead electrocardiography (ECG) finding which has been reported to be associated with severe, transmural myocardial ischemia. To date, a paucity of data exists about the incidence and clinical characteristics of patients with PN. Therefore the aim of this study was to investigate the incidence and the electrocardiographic, echocardiographic, and angiographic characteristics of patients with PN. Clinical, laboratory, electrocardiographic, echocardiographic, and angiographic characteristics of 12 consecutive patients with PN on 12-lead ECG (Group 1) were compared with patients (Group 2, n=28) presenting with acute coronary syndrome (ACS) associated with ST-T wave changes without PN. All patients presented with chest pain. The incidence of PN among patients presenting with ACS was 1%. Pseudonormalization was present in precordial leads in 11 and in inferior leads in 1 patient. Nine out of 12 (75%) patients in Group 1, 16 out of 28 (57%) patients in Group 2 had elevation of cardiac enzymes compatible with acute myocardial infarction. Severely narrowed or totally occluded ischemia and/or infarction-related coronary arteries were present in all patients in Group 1, in 20 (71%) patients in Group 2. Three patients in Group I and one patient in Group 2 had coronary artery thrombus formation. Group 1 patients had worse coronary collateral grading in comparison to Group 2 patients. Pseudonormalization is a rare entity and it is typically associated with severely narrowed or totally occluded coronary arteries along with thrombus formation, and poor coronary collateral development.
The International Journal of Cardiovascular Imaging, 2006
A left ventricular aneurysm (LVA) is most commonly the result of myocardial infarction, usually i... more A left ventricular aneurysm (LVA) is most commonly the result of myocardial infarction, usually involving the anterior wall. A left ventricular pseudoaneurysm (LVPSA) or false aneurysm forms when cardiac rupture is contained by adherent pericardium or scar tissue. The accurate diagnosis, although difficult to establish, is an important one to make because these aneurysms are prone to rupture. In this article, we report a challenging case of a cardiac aneurysm a year after a coronary bypass operation which could not be definitively diagnosed despite of imaging with different techniques including echocardiography, coronary angiography, left ventriculography and magnetic resonance imaging (MRI). The patient underwent a second cardiac surgery, the aneurysm was resected, the mitral valve was replaced and the defect in the ventricular wall was repaired. Because of the combined diagnostic capabilities like detailed and functional pathoanatomy and aneurysmal wall characterization, MRI seems to have multiple advantages in differential diagnosis.
Statins may provide additional benefits in patients with cardiac failure due to their pleiotropic... more Statins may provide additional benefits in patients with cardiac failure due to their pleiotropic effects besides their cholesterol-lowering actions. In this study, we aimed to evaluate the impact of 12-week fluvastatin therapy on the inflammatory cytokines and the ventricular performance markers in patients with heart failure. Fourty chronic heart failure patients, twenty with idiopathic dilated cardiomyopathy (DCM group) and 20 with ischemic cardiomyopathy (ICM group), for whom statin treatment was indicated according to Adult Treatment Panel III were included to this open label and prospective study. After a 12-week treatment with fluvastatin 80 mg/day; clinical functional capacity, echocardiographic indices of cardiac performance and inflammatory markers were evaluated. After the treatment, functional capacity (in DCM group: 2.05+/-0.4 versus 1.65+/-0.6, p=0.005; in ICM group: 2.25+/-0.5 versus 1.8+/-0.6, p=0.003), left ventricular ejection fraction, LVEF (from 30+/-5% to 33+/-5%, p=0.001 in DCM and 29+/-4% to 31+/-5%, p=0.001 in ICM group) and tissue Doppler mitral annular systolic velocity, Sm (5.8+/-1 cm/s to 7+/-1 cm/s, p=0.001 in DCM and 5.4+/-0.8 cm/s to 7+/-1 cm/s, p=0.001 in ICM group) improved. Tumor necrosis factor-alpha and interleukin-6 levels decreased, but no significant changes in high sensitive C-reactive protein and brain natriuretic peptide levels were detected with the fluvastatin treatment in both groups. Fluvastatin improved cardiac functions and the clinical symptoms in HF patients with either idiopathic dilated or ischemic etiology. This positive effect of fluvastatin which might be secondary to inflammatory modulation was more marked in patients with ischemic etiology. Statins in HF deserves special attention by means of further large-scale trials.
Left ventricular hypertrophy (LVH) increases the risk of ventricular arrhythmias and sudden death... more Left ventricular hypertrophy (LVH) increases the risk of ventricular arrhythmias and sudden death and has a significant effect on total cardiovascular mortality. QT dispersion (QTd) is a measure of inhomogeneous repolarization and is used as an indicator of arrhythmogenicity. In this study we detected QTd in patients with different etiologies of left ventricular hypertrophy and the effect of LVH in QTd on endurance athletes. The study group consisted of 147 white male subjects with 3 different etiologies of LVH and 30 healthy male individuals. The underlying etiologies of LVH were essential hypertension, valvular aortic stenosis and long-term training (athletic heart). QTd was measured by surface electrocardiogram and Bazett's formula was used to correct QTd for heart rate (QTcd). Left ventricular mass was determined by transthoracic echocardiography and left ventricular mass index was calculated in relation to body surface area. The QTcd was significantly higher in patients with pathological LVH (due to hypertension and aortic stenosis) than in the athletes' group (physiological LVH) and healthy subjects (P<0.05). The magnitude of QTcd was similar between athletes and the control group (P=0.6). The difference of QTcd between the groups with pathological LVH was not statistically significant (P=0.1). In conclusion; the increasing of QT dispersion is associated with only pathological conditions of LVH. The left ventricular hypertrophy has not a negative effect in QT dispersion on endurance athletes. The measurement of QT dispersion may be a non-invasive useful method for screening additional pathological conditions in endurance athletes.
Erectile dysfunction (ED) commonly coexists with coronary artery disease (CAD) and/or risk factor... more Erectile dysfunction (ED) commonly coexists with coronary artery disease (CAD) and/or risk factors for atherosclerosis. Because the silent or documented atherosclerosis or vascular risk factors are very frequent, the possibility of endothelial dysfunction in ED patients is expected to be increased. Our aim was to evaluate the endothelial functions in patients with vasculogenic ED with vascular risk factors and compare them with age-matched non-ED patients or healthy controls. We studied 36 patients with presumed vasculogenic ED, 39 age-matched patients with similar risk factors without ED and 25 age-matched healthy controls without ED, known cardiovascular disease or risk factors. Erectile function was evaluated by the International Index of Erectile Dysfunction (IIEF) scores. Brachial artery flow-mediated dilatation (FMD) and nitroglycerine-mediated dilatation (NMD) were measured. Baseline demographics were similar except the IIEF score and duration of diabetes in patients with ED. Brachial artery FMD and NMD were significantly reduced in patients with ED (3.2+/-3. vs. 6+/-4, p<0.0001 for FMD, 12.2+/-6 vs. 15.4+/-6 p=0.032 for NMD). In patients with similar risk factors but without ED, FMD was significantly lower but NMD were not different compared with healthy controls (6+/-4 vs. 10.2+/-3, p<0.0001 for FMD and 15.4+/-8 vs. 16.4+/-6, p=0.81). IIEF scores were weakly correlated with FMD (r=0.25, p=0.028) in patients with ED. There were significant correlations between FMD and NMD in patients with ED (r=0.46, p=0.05) and with risk factors (r=0.72, p<0.0001) but not in healthy controls (r=0.54, p=0.792). Vasculogenic ED patients have more markedly impaired endothelial and smooth muscle functions compared with patients with similar risk factors but no ED.
A 44-year-old female undergoing radiofrequency ablation in the right ventricular outflow tract fo... more A 44-year-old female undergoing radiofrequency ablation in the right ventricular outflow tract for symptomatic, frequent premature ventricular contractions developed stress cardiomyopathy (Tako-Tsubo). Stress cardiomyopathy was probably due to hyperadrenergic state induced by the procedure itself, dobutamine infusion, sympathetic nerve stimulation at the ablation site, and parasympathetic withdrawal with atropine administration.
The study was designed to evaluate the severity of mitral regurgitation by cardiac magnetic reson... more The study was designed to evaluate the severity of mitral regurgitation by cardiac magnetic resonance imaging (MRI). We proposed a new measurement of signal void by MRI and tried to define threshold values for the severity of regurgitation with different sequences. Twenty-one patients with mitral regurgitation were evaluated by echocardiography and MRI. We measured the length, width, and the area of jet flow void from long-axis and four-chamber views. The regurgitant area was measured with TrueFISP, FLASH sequences, and phase images by tracing the signal-void area in left atrium parallel to mitral annulus. This new parameter for grading of the severity of mitral regurgitation by cine MRI was called regurgitant area from short axis (RAFSA). All methods (EROA, vena contracta) were correlated for determining the regurgitation severity (P < 0.01). There was a correlation between EROA by echocardiography and RAFSA by MRI with the TrueFISP, FLASH sequences, and phase images (P < 0.01). Stepwise regression analysis revealed that EROA was significantly correlated with RAFSA by phase images (P < 0.001). After regression analysis, threshold values of RAFSA by phase imaging were calculated and found to be 0.27 cm(2) and 0.92 cm(2) between mild, moderate, and severe mitral regurgitations (100% sensitivity, 67% specificity, and 100% sensitivity, 78% specificity, respectively) (P < 0.01, P < 0.05). MRI is an alternative method for evaluating mitral regurgitation. Our study suggests a new parameter, RAFSA by cine MRI, to grade the severity of mitral regurgitation and provides threshold values in order to define mild, moderate, and severe regurgitations.
ST-segment deviation in lead augmented vector right (aVR) is useful for evaluating patients with ... more ST-segment deviation in lead augmented vector right (aVR) is useful for evaluating patients with acute coronary syndrome (ACS). The ST-segment elevation in this aVR in the patient with clinically suspected acute coronary syndrome suggests a strong possibility of left main coronary artery (LMCA) obstruction due to fixed stenosis. In this article, we report the first case, to our knowledge, of ST-segment elevation in lead aVR due to diffuse LMCA spasm.
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 2002
Thromboembolism is still one of the most important complications of prosthetic heart valves. Embo... more Thromboembolism is still one of the most important complications of prosthetic heart valves. Embolism to a major coronary branch is rare, but acute proximal occlusions can be fatal, even when the coronary arteries are otherwise normal and intervention is rapid. We report a fatal complication of an exercise test in a patient who had a St. Jude bileaflet mitral valve. After an exercise test, a 42-year-old woman with a mechanical prosthetic valve had a severe hemodynamic collapse with acute ST segment changes. Coronary angiography showed a totally occluded left main coronary artery with TIMI grade 0 to 1 flow. Rapid injection of contrast material and the passage of a floppy guidewire through the thrombus restored a TIMI grade 3 flow. Angiography showed no coronary atherosclerostic involvement. Despite successful coronary reperfusion, intra-aortic balloon counterpulsation, and intensive medication, the patient died. This case demonstrates that exercise testing should be applied with gre...
BACKGROUNDThrombus formation around the intracardiac end of the catheter, thromboembolism, and in... more BACKGROUNDThrombus formation around the intracardiac end of the catheter, thromboembolism, and infection are the most important and life-threatening complications of ventriculoatrial shunts. In this article we report a patient with a large right atrial mass that was diagnosed by 2-D echocardiogram and removed via standard median sternotomy and cardiopulmonary bypass.CASE DESCRIPTIONA 63-year-old man who had a right ventriculoatrial shunt was
Spontaneous pseudonormalization (PN) is a unique 12-lead electrocardiography (ECG) finding which ... more Spontaneous pseudonormalization (PN) is a unique 12-lead electrocardiography (ECG) finding which has been reported to be associated with severe, transmural myocardial ischemia. To date, a paucity of data exists about the incidence and clinical characteristics of patients with PN. Therefore the aim of this study was to investigate the incidence and the electrocardiographic, echocardiographic, and angiographic characteristics of patients with PN. Clinical, laboratory, electrocardiographic, echocardiographic, and angiographic characteristics of 12 consecutive patients with PN on 12-lead ECG (Group 1) were compared with patients (Group 2, n=28) presenting with acute coronary syndrome (ACS) associated with ST-T wave changes without PN. All patients presented with chest pain. The incidence of PN among patients presenting with ACS was 1%. Pseudonormalization was present in precordial leads in 11 and in inferior leads in 1 patient. Nine out of 12 (75%) patients in Group 1, 16 out of 28 (57%) patients in Group 2 had elevation of cardiac enzymes compatible with acute myocardial infarction. Severely narrowed or totally occluded ischemia and/or infarction-related coronary arteries were present in all patients in Group 1, in 20 (71%) patients in Group 2. Three patients in Group I and one patient in Group 2 had coronary artery thrombus formation. Group 1 patients had worse coronary collateral grading in comparison to Group 2 patients. Pseudonormalization is a rare entity and it is typically associated with severely narrowed or totally occluded coronary arteries along with thrombus formation, and poor coronary collateral development.
The International Journal of Cardiovascular Imaging, 2006
A left ventricular aneurysm (LVA) is most commonly the result of myocardial infarction, usually i... more A left ventricular aneurysm (LVA) is most commonly the result of myocardial infarction, usually involving the anterior wall. A left ventricular pseudoaneurysm (LVPSA) or false aneurysm forms when cardiac rupture is contained by adherent pericardium or scar tissue. The accurate diagnosis, although difficult to establish, is an important one to make because these aneurysms are prone to rupture. In this article, we report a challenging case of a cardiac aneurysm a year after a coronary bypass operation which could not be definitively diagnosed despite of imaging with different techniques including echocardiography, coronary angiography, left ventriculography and magnetic resonance imaging (MRI). The patient underwent a second cardiac surgery, the aneurysm was resected, the mitral valve was replaced and the defect in the ventricular wall was repaired. Because of the combined diagnostic capabilities like detailed and functional pathoanatomy and aneurysmal wall characterization, MRI seems to have multiple advantages in differential diagnosis.
Statins may provide additional benefits in patients with cardiac failure due to their pleiotropic... more Statins may provide additional benefits in patients with cardiac failure due to their pleiotropic effects besides their cholesterol-lowering actions. In this study, we aimed to evaluate the impact of 12-week fluvastatin therapy on the inflammatory cytokines and the ventricular performance markers in patients with heart failure. Fourty chronic heart failure patients, twenty with idiopathic dilated cardiomyopathy (DCM group) and 20 with ischemic cardiomyopathy (ICM group), for whom statin treatment was indicated according to Adult Treatment Panel III were included to this open label and prospective study. After a 12-week treatment with fluvastatin 80 mg/day; clinical functional capacity, echocardiographic indices of cardiac performance and inflammatory markers were evaluated. After the treatment, functional capacity (in DCM group: 2.05+/-0.4 versus 1.65+/-0.6, p=0.005; in ICM group: 2.25+/-0.5 versus 1.8+/-0.6, p=0.003), left ventricular ejection fraction, LVEF (from 30+/-5% to 33+/-5%, p=0.001 in DCM and 29+/-4% to 31+/-5%, p=0.001 in ICM group) and tissue Doppler mitral annular systolic velocity, Sm (5.8+/-1 cm/s to 7+/-1 cm/s, p=0.001 in DCM and 5.4+/-0.8 cm/s to 7+/-1 cm/s, p=0.001 in ICM group) improved. Tumor necrosis factor-alpha and interleukin-6 levels decreased, but no significant changes in high sensitive C-reactive protein and brain natriuretic peptide levels were detected with the fluvastatin treatment in both groups. Fluvastatin improved cardiac functions and the clinical symptoms in HF patients with either idiopathic dilated or ischemic etiology. This positive effect of fluvastatin which might be secondary to inflammatory modulation was more marked in patients with ischemic etiology. Statins in HF deserves special attention by means of further large-scale trials.
Left ventricular hypertrophy (LVH) increases the risk of ventricular arrhythmias and sudden death... more Left ventricular hypertrophy (LVH) increases the risk of ventricular arrhythmias and sudden death and has a significant effect on total cardiovascular mortality. QT dispersion (QTd) is a measure of inhomogeneous repolarization and is used as an indicator of arrhythmogenicity. In this study we detected QTd in patients with different etiologies of left ventricular hypertrophy and the effect of LVH in QTd on endurance athletes. The study group consisted of 147 white male subjects with 3 different etiologies of LVH and 30 healthy male individuals. The underlying etiologies of LVH were essential hypertension, valvular aortic stenosis and long-term training (athletic heart). QTd was measured by surface electrocardiogram and Bazett's formula was used to correct QTd for heart rate (QTcd). Left ventricular mass was determined by transthoracic echocardiography and left ventricular mass index was calculated in relation to body surface area. The QTcd was significantly higher in patients with pathological LVH (due to hypertension and aortic stenosis) than in the athletes' group (physiological LVH) and healthy subjects (P<0.05). The magnitude of QTcd was similar between athletes and the control group (P=0.6). The difference of QTcd between the groups with pathological LVH was not statistically significant (P=0.1). In conclusion; the increasing of QT dispersion is associated with only pathological conditions of LVH. The left ventricular hypertrophy has not a negative effect in QT dispersion on endurance athletes. The measurement of QT dispersion may be a non-invasive useful method for screening additional pathological conditions in endurance athletes.
Erectile dysfunction (ED) commonly coexists with coronary artery disease (CAD) and/or risk factor... more Erectile dysfunction (ED) commonly coexists with coronary artery disease (CAD) and/or risk factors for atherosclerosis. Because the silent or documented atherosclerosis or vascular risk factors are very frequent, the possibility of endothelial dysfunction in ED patients is expected to be increased. Our aim was to evaluate the endothelial functions in patients with vasculogenic ED with vascular risk factors and compare them with age-matched non-ED patients or healthy controls. We studied 36 patients with presumed vasculogenic ED, 39 age-matched patients with similar risk factors without ED and 25 age-matched healthy controls without ED, known cardiovascular disease or risk factors. Erectile function was evaluated by the International Index of Erectile Dysfunction (IIEF) scores. Brachial artery flow-mediated dilatation (FMD) and nitroglycerine-mediated dilatation (NMD) were measured. Baseline demographics were similar except the IIEF score and duration of diabetes in patients with ED. Brachial artery FMD and NMD were significantly reduced in patients with ED (3.2+/-3. vs. 6+/-4, p<0.0001 for FMD, 12.2+/-6 vs. 15.4+/-6 p=0.032 for NMD). In patients with similar risk factors but without ED, FMD was significantly lower but NMD were not different compared with healthy controls (6+/-4 vs. 10.2+/-3, p<0.0001 for FMD and 15.4+/-8 vs. 16.4+/-6, p=0.81). IIEF scores were weakly correlated with FMD (r=0.25, p=0.028) in patients with ED. There were significant correlations between FMD and NMD in patients with ED (r=0.46, p=0.05) and with risk factors (r=0.72, p<0.0001) but not in healthy controls (r=0.54, p=0.792). Vasculogenic ED patients have more markedly impaired endothelial and smooth muscle functions compared with patients with similar risk factors but no ED.
A 44-year-old female undergoing radiofrequency ablation in the right ventricular outflow tract fo... more A 44-year-old female undergoing radiofrequency ablation in the right ventricular outflow tract for symptomatic, frequent premature ventricular contractions developed stress cardiomyopathy (Tako-Tsubo). Stress cardiomyopathy was probably due to hyperadrenergic state induced by the procedure itself, dobutamine infusion, sympathetic nerve stimulation at the ablation site, and parasympathetic withdrawal with atropine administration.
The study was designed to evaluate the severity of mitral regurgitation by cardiac magnetic reson... more The study was designed to evaluate the severity of mitral regurgitation by cardiac magnetic resonance imaging (MRI). We proposed a new measurement of signal void by MRI and tried to define threshold values for the severity of regurgitation with different sequences. Twenty-one patients with mitral regurgitation were evaluated by echocardiography and MRI. We measured the length, width, and the area of jet flow void from long-axis and four-chamber views. The regurgitant area was measured with TrueFISP, FLASH sequences, and phase images by tracing the signal-void area in left atrium parallel to mitral annulus. This new parameter for grading of the severity of mitral regurgitation by cine MRI was called regurgitant area from short axis (RAFSA). All methods (EROA, vena contracta) were correlated for determining the regurgitation severity (P < 0.01). There was a correlation between EROA by echocardiography and RAFSA by MRI with the TrueFISP, FLASH sequences, and phase images (P < 0.01). Stepwise regression analysis revealed that EROA was significantly correlated with RAFSA by phase images (P < 0.001). After regression analysis, threshold values of RAFSA by phase imaging were calculated and found to be 0.27 cm(2) and 0.92 cm(2) between mild, moderate, and severe mitral regurgitations (100% sensitivity, 67% specificity, and 100% sensitivity, 78% specificity, respectively) (P < 0.01, P < 0.05). MRI is an alternative method for evaluating mitral regurgitation. Our study suggests a new parameter, RAFSA by cine MRI, to grade the severity of mitral regurgitation and provides threshold values in order to define mild, moderate, and severe regurgitations.
ST-segment deviation in lead augmented vector right (aVR) is useful for evaluating patients with ... more ST-segment deviation in lead augmented vector right (aVR) is useful for evaluating patients with acute coronary syndrome (ACS). The ST-segment elevation in this aVR in the patient with clinically suspected acute coronary syndrome suggests a strong possibility of left main coronary artery (LMCA) obstruction due to fixed stenosis. In this article, we report the first case, to our knowledge, of ST-segment elevation in lead aVR due to diffuse LMCA spasm.
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Papers by Oguz Yavuzgil