Selçuk Pala

Objectives: The aim of this pilot study was to compare intracoronary bolus‐only with standard intravenous bolus plus maintenance infusion of tirofiban with respect to improvement in myocardial reperfusion after primary percutaneous coronary intervention (p‐PCI). Background: Changes in clinical practice may obviate the need for a maintenance infusion of small molecule glycoprotein IIb/IIIa inhibitors in current practice. Methods: Forty‐nine patients undergoing p‐PCI were randomized to either intracoronary bolus‐only (n = 25) or intravenous bolus plus infusion (n = 24) of tirofiban. The primary end point was coronary hemodynamic indices of microvascular perfusion measured 4–5 days after p‐PCI. The secondary end points were ST segment resolution at 90 min, the corrected TIMI frame count and myocardial blush grade. At 6 months, echocardiography and technetium‐99m single‐photon‐emission computed tomography were performed. Results: Microvascular perfusion did not differ significantly between the two treatment groups: index of microvascular resistance (27 ± 13 vs. 35 ± 15 U, P = 0.08) and coronary flow reserve (2.2 ± 0.7 vs. 1.9 ± 0.6, P = 0.25). The corrected TIMI frame counts assessed in the first (P = 0.13) and the second (P = 0.09) catheterization or the myocardial blush grades evaluated immediately (P = 0.23) and 4–5 days after MI (P = 1.00) were not significantly different between the two groups. At 6 months, there was no difference between the two groups in infarct size, left ventricular volumes, or ejection fraction. Conclusions: The standard intravenous bolus plus maintenance infusion of tirofiban in p‐PCI is not superior to intracoronary bolus‐only administration with respect to microvascular perfusion. Further, adequately powered randomized trials are warranted to evaluate the clinical outcomes associated with this strategy.

Isovolumic acceleration assessed by tissue Doppler imaging has been proposed as a preload-independent indicator of left ventricular contractility. We investigated the utility of isovolumic acceleration in the prediction of preclinical right and left ventricular systolic dysfunction in hypertensive and obese subjects. Seventy-eight obese subjects (BMI >30 kg/m2; 57 women, 21 men; mean age 51±8 years) were prospectively enrolled. Fifty patients (64.1%) had hypertension and 33 patients (42.3%) had diabetes mellitus. All the subjects were assessed by conventional and tissue Doppler echocardiography. Myocardial velocities of the left ventricular septal and lateral mitral annulus and lateral tricuspid annulus were determined. Isovolumic contraction wave was defined as the preceding wave of the systolic wave that began before the peak of the R wave on the electrocardiogram. Myocardial isovolumic acceleration was measured by dividing the peak velocity by the time passed from the onset of the wave (zero-crossing) during isovolumic contraction to the peak velocity of the wave. Waist circumference was in positive correlation with left ventricular end-systolic (r=0.22, p=0.047) and end-diastolic (r=0.384, p=0.001) diameters, and in negative correlation with the peak systolic velocity of the tricuspid annulus (r=-0.311, p=0.006). Although hypertensive and normotensive (n=28) obese subjects had similar myocardial velocities, lateral tricuspid annular isovolumic acceleration (p=0.027), septal isovolumic acceleration (p=0.026), and septal isovolumic contraction myocardial velocity (p=0.018) were significantly lower in hypertensive patients. Isovolumic acceleration and isovolumic contraction myocardial velocity analysis may be useful in the diagnosis of subclinical left and right ventricular dysfunction in hypertensive obese patients.

Left main coronary artery aneurysm (LMCAA) is an uncommon coronary abnormality seen in 0.1% of patients during routine diagnostic coronary angiographies. The most common etiology is atherosclerosis in acquired cases. However, it can also be a congenital malformation. We present the case of a 26 year-old female with a large LMCAA. She was diagnosed with tetralogy of Fallot initially.

Percutaneous closure of secundum atrial septal defects (ASD) may be complicated by immediate embolization. We report on a 35-year-old woman who underwent percutaneous device closure for a secundum ASD. The diameter of the defect was measured as 4 mm by two-dimensional transesophageal echocardiography and a 7-mm Figulla ASD occluder device was implanted without prior balloon sizing of the defect. Immediate embolization was noted into the aortic arch. Attempts to pull the devices into the sheath with a loop snare failed even after replacing the delivery sheath with a bigger one. Finally, a bioptome was used to grab and place the screw mechanisms in the sheath and percutaneous retrieval of the embolized ASD occluder was achieved. Balloon sizing was performed after removal, yielding a stretched diameter of 12 mm and a 15-mm device was deployed with success.

Elevated gamma-glutamyltransferase (GGT) level is independently correlated with conditions associated with increased atherosclerosis, such as obesity, elevated serum cholesterol, high blood pressure and myocardial infarction. It is demonstrated that serum GGT activity is an independent risk factor for myocardial infarction and cardiac death in patients with coronary artery disease. Diabetes is also a well-known cardiovascular risk factor and an equivalent of coronary artery disease. Although the relationship between GGT and coronary artery disease has been reported, there are limited data exploring the changes of GGT in acute coronary syndromes, especially in patients with diabetes. So, this study aimed to determine changes in GGT level in diabetic and non-diabetic acute coronary syndromes. This trial was carried out at Kosuyolu Cardiovascular Training and Research Hospital and Van Yuksek Ihtisas Hospital, Turkey. A total of 219 patients (177 men and 42 women) presenting with acute coronary syndrome) and 51 control subjects between September 2007 and September 2008 were included in the study. Serum γ-glutamyltransferase and serum lipoprotein levels were determined. The resuls indicated that serum GGT levels were higher in acute coronary syndrome patients compared with control. In subgroup analyses, there was no difference between diabetic and non-diabetic subgroups. There was also weak correlation between GGT and blood glucose levels. There was no correlation between GGT and serum lipoprotein levels. In conclusion, serum GGT levels were higher in acute coronary syndrome patients. In subgroup analyses, There was no difference between diabetic and non diabetic subgroup.

The Tei index, obtained from tissue Doppler echocardiography (TDE-Tei index), has emerged as a new parameter that incorporates both systolic and diastolic time intervals to express global ventricular performance. The study aim was to evaluate whether the TDE-Tei index also correlates with left ventricular (LV) systolic and diastolic function and plasma brain natriuretic peptide (BNP) levels and echocardiographic parameters in patients with symptoms of mitral regurgitation (MR). Thirty-three patients (17 males, 16 females; mean age 57 +/- 17 years) with isolated organic MR underwent transthoracic echocardiography and tissue Doppler echocardiography, and were also assessed for symptoms. Plasma BNP levels were also monitored. The patients were allocated to two groups, based on a TDE-Tei index cut-off level of 0.51. Correlations were identified between the TDE-Tei index and LV ejection fraction (LVEF) (r = -0.54), plasma BNP level (r = 0.5), MR index (r = 0.48), MR jet area (r = 0.38), MR effective regurgitant orifice area (r = 0.37), LV end-systolic diameter (r = 0.43), E/Ea (r = 0.41) and NYHA functional class (r = 0.38). However, no correlations were identified with the left atrial area, MR vena contracta width, MR regurgitant volume, MR regurgitant fraction, systolic pulmonary artery pressure, LV end-diastolic dimensions and LV diastolic dysfunction. The mean values of the TDE-Tei index were 0.40 +/- 11, 0.44 +/- 11 and 0.53 +/- 16 in MR patients in NYHA classes I, II and III, respectively. In patients with isolated organic MR, the TDE Tei index was found to correlate well with LVEF and plasma BNP levels, and thus may be considered as a new echocardiographic parameter for the assessment of global ventricular function during patient follow up.