in Patients with

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Tiirk Kardiyol Dem Arş 2002:30: 78-81

Summaries of Articles

Clinicallnvestigations

Protective Effect of Severe Mitral Regurgitation Against Left Atrial T hrombus Formation a nd Syste mic

Embolisın

in Patients with

Rheuınatic

Atria l Fibrillation

N. Ö:demir, C. Kaymaz, O. Karakaya, M. Akçay, M. Şişmano,q/u, O. İncedere, C. Çevik, C. İzgi, C.

Ku·ma, M. Yiice, M. Özkan

Koşuyolu Heaı·ı

Hospital, Istanbul , Tu rkey

Arrial

fibrillaıion

(AF) anel /or mitral stcnosis (MS) have been clocumentecl to be associated w ith increa- secl ine idence of left atrial (LA) thro mbus (T) formution anel systemic

enıbolism

(SE), and se vere mitral regurgitation (MR) has bcen

docunıented

to lower these risks . However , indication s of a nticoa- gu larion in

patienıs

with A F

conconıittant

with seve-

re MR

renıained

to be

deterınined.

The purpose of

our stud y is to investigate the ine idence of LAT w it- h in th e main LA cavity and/o r LA appendage in pa- tients with AF w ho underwent va! ve replacement be- cause of r heumatic MS and/o r MR , a nd to asess the

iınpact

of severe MR on ineidence of L AT and SE in patie nts with c hronic AF. Th e study popul ation

conıprised

979 Pts (F 636 , M 343, mean age 40± 1 4.5 yrs) ope rared fo r pure or predom

inant MS

(n=5 17), purc MR (n= 388) , and combineel severe MS and severe MR (n= 74) in our instituti on betwe- e n 1993 and 2001. Preoperative cardiac

rhythın

w as AF in 530 patients (54.

ı%),

anel s in us

rhythnı

(S R) in the

remainder.

History of SE before s urgery was

docuınented

in

2ı

:8% of the paticnts w ith MS, but in none of

theın

with pure MR or MS

conconıittant

with severe MR (MS+MR) . C hronic anticoag ulation w as noteel in 146 patie nts w ith history of SE and/or Tl-IR w ithin the L A doc umented by echocardiog- raphy. Age, gencler, and preop LA eliarneter were not di fferent between patients with pure MS , MR, and MS+M R (p>0.05). Intraoperative assessment disclo- sed T HR w ithin the LA and/or LA appendage in

ı

08 patients. In MS group ineidence of LAT was higher in pat ients with AF as compareel to patients with SR

78 (3 I .3 % vs 4.8%, p<O.OO 1 ). In subg roup of MS w ith A F (n=3 1 0),

thronıbus

was found to be lo cated in the LAA in 5 1(1 6.4%), in the LA in 14(4.5%), and both in the LA and LA appendage in 3 1 ( 1 0.3%) pa- tie nts. In s ubgrou p of MS with SR (n=207), all of the LAT ( n=

1

0) w as Iocatcd in the LA appenclage.

However, none of the patie nts with severe MR had LAT. In MS +MR group , LAT was dctected in one patie nt with AF in the LA appe ndage. Ineidence of the L AT was lower in MR g roup irrcs pectivc of rh ythm as compareel to patients with MS

wiıh

AF (p<O.OO 1 ), and MS w ith SR (p<0.05). Parieni s w ith MS

concoınittant

with severe MR had a lower inci- de nce of LAT than patients with MS wi th AF (p<O.OO 1) and MS w ith SR (p<0.05).

Conclus ion: Results from elinica l his tory anel intrao- perative assessment of ou r study provide furthcr sup- port for the protecti ve effect of severe MR against SE and LAT

forınation

in non-anticoag ulatcd pati - ents with chronic AF. The indications of anticoag u-

lation

in pati ents with chroni c AF re lated to severe MR

seeın

to need recons icleration.

Key worcls: Mitral regurg itation, atri al fib rill ation, le ft atrial

thronıbi, eınbolism

The Effec t of Fenofibrate Therapy on Lipid Profile, CRP and Fibrinogen Levels in Type II Diabetic Patients with Combineel Hy1>erlipidemia

M. Kaytkçtoğlu, L.H. Can, F. Özerkan, H. Kültürsay,

S.

Payzin,

i.

Soydan

Ege University Medical

Faculıy, İzmir

Structural and func tional c ha nges in lipoproteins

associated w ith diabetes s ubstantiall y contribute to

the increased risk of cardiovascular di sease. The ai m

of this study was to in vesti gate the e ffica cy of a

fibrate d erivate fe nofibrate, in ty pe

II

cliabetic

patients with combined

hyperlipidenıia

who

freq uently have e levated leve ls of fibrinogen and C-

reactive protein (CRP).

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Tiirk Kardiyol Dem Arş 2002; 30: 78-81

Methods: Fo rty -seven patients who we re fo llowed for com bi ne el hy pe rli pidem ia re fractory to clie t regulation of a t least 3

ınonths

and we re free of coronary arte ry di sease we re e nro llecl in this study.

Fifteen of the patie nts had diabetes

ınellitus

type II.

All patie nts rece ivecl fe nofibrate therapy (250

ıng

once a day PO) for 6

ınonths. Senıın lipid profi

les, C RP anel f ibrinogen lcvels, w ho le blood coun ts, urine and blood

cheınistry

analyse s we re trac ked du- rin g thcrapy. Ar the e nd of 6 months , e fficacy and s icle effects were ev alua ted. D iabetic and non- cliabetic patients were comp areel acco rding to th eir respo nse to fenofibrate therapy.

Res ults : At the end of 6

montlıs, ılıere

were favo urable results in res pec t

to lipid pro

files, and CRP and fibrinoge n leve ls in al l patie nts. There we- re statistically s

ign

ificant recluctions in the serum leve ls of total-c ho

lesterol

( -%9), trig lyce rides (-

%58), and LDL ( -% 17) in both groups . The

!eve!

s of HDL anel apo A l we re sig ni fi cantly e levated.

The cha nges obser ved

in lipop

ro te in le ve ls wer e qu ite s imilar in diabetic and non-diabctic group.

Base line f ibrinogen levels we re s ligrh ly

lıigher

in diabetics (378±82 mg/d! vs 350±76

ıng/d!,

p>0,05).

Afte r treatme nt fib

ri

noge n le ve ls d ec rea secl significa ntly in both d iabeti c ( 1 6%) and nondiabe tic patie nts ( 1 2%) . At baseline the CR P levels were also slightly highe r in diabetics (0,855 ( 0,68 1 mg/d ! vs 0,578( 0,5 84 m g/d!; p=0,05). In both groups CRP leve ls decre ased s ignificantly (54 % in cl iabe tics and 35% in non-diabetics). The re we re no s ignifi cant adverse eve nts durin g the study.

Conc lus ion: F enofibrate is an effic ie nt and s afe anrihype

rlipidemic agent in

the treatment o f both di- abe tic a nd non-diabctic patie nts with combineel

hyperlipideınia.

Fenofibrate may alsa be a poss

ible

antiatherosc lcro tic age nt due to both C RP and fibri nogen lowering effec ts.

Key w ords: Comb ineel

hyperlipideınia,

C reactive prote

in, Diabetes melli

tus, Fibrinogen, Fenofibrate

New F indings of the T urkish Hear t Stud y:

G uidin g Tr eatmen t Sug gestions for Leve ls of Plasma Lipids a nd Low HDL

R.W. Mali/ey, G.M. Pepin, T.P. Bersot, K.E.

Pa/aoğ/u,

K.Ö zer

Gladstone Institute of Cardiovaseular Disease, San Franciseo and American Hospital of Vehbi Koç Foundation, Istanbul

T urks have unique

li

pid and lipoprotein profiles c haracterized espec ially by low

plasına

levels of hi gh dens ity lipoprote in choleste

rol

( HDL-C). The low levels of HDL -C are associatecl wi th low levels of the protecti ve subc lasses of H DL,

HDLı

and LpAI , and

witlı

a 25-30%

elevaıion

of

lıepatic

lipase activity that wou ld be predicted to lower HDL levels . The widespread occurrence of low HDL-C in T urkey and in Turks li ving in Ger many and the United States s uggests that it

is at least parıly

of genetic orig in. Turkish child ren

exlıibit

a mar keel 10- 20 mg/d i drop in HDL-C levels assoc iated

witlı

pube rty, suggestin g that an ethnic difference in ho rmonal balance contributes to the profounclly low HDL -C leve

ls

in adult T urks. Compariso n of population data generateel in th e early 1990s in the origina l Turkish He art Study

wiıh

the present update s tudy of Tu rki sh men and women

!i

v ing in Is tanbu l inclicates that the li pid profile anel other r is k factors for coronary heart disease (CH D) have no t

iınproved

in this decade, cons is tent with the d ata f ro m the Turk is h Soc ie ty o f Cardi o logy. Despite

ıheir

relati vely

low plasma

c holesterol levels, Tu rks have

extreınely low HDL

-C (<40 mg/d! in >70% of men a nd - 50% of wom en) re sulring

in ve

ry

higlı

to tal

cholesıerol/HDL-C

ratio s tha t pre d ic t ine rc aseel C HD in o th e r popu lations. The new Nat iona

l

Cholester ol Eclucation Pr ogram guide

lines continue

to focus on Jow clens ity lipoprotein cho leste rol lev els a nd virtuall y ignore

Iow

H DL -C

leve

ls, w hich

uncloubıedly

are a powerful risk factor in Turks. We

woul cl s uggest that g uidelines for Turkey consider

low clensity li poprotein cholesterol levels a nel the

total chole ste ro

l/

HDL-C ratio as th resholds fo r

initiating lifesryle changes or dru g treatment for

patients with C HD ri sk.

(3)

Tiirk Kareliyol Dem Arş 2UU2; jU: llHSI

Pharınacological Therapy of Atrial Fibrillation.

An update

K. Adalet

Istanbul Medical Faculty, Istanbul, Turkey

A trial fib

rillation (AF)

is a comma n arrhythmia as- sociated w ith s ign ifi cant morb id ity and

nıortality.

T he ai m of therapies is to red u ce the freque ncy , duralia n and severity of AF, improve qu ality of life, prevent of a tachyca rdia-induceel c ardio myopathy,

reduce

ris k of e mboli, anel if poss ible, prolong life.

Life-threate ning and he modi na mically intolera ble AF req uires immeelia te e lec trical cardi overs ion (CV). For the better-tolerated episodes, if

eluratioıı

of episoel e is less th an 48 hours, ph armacolo gica l ca nve rs ion or elec tri cal CV

nıay

be perfo rmed w ithou t anticoagulati on, othe rwi se fo r e pisodes la nger than 48 ho urs, a nticoagulant the rapy with wa

rfari

n to a target INR of 2-3 for 3 to 4 weeks before elec tive CV is advised. Earlie r C V

ınay

be ta ke n in to acco un t if tra nses op ha ge al echoca rd iog raphy d oes

no

t revea

l

ev iel ence of em bolic ris k. W hen

seleeling

an an tiarrhythm ic d ru g,

underlying

s tru ctur al he art d

isease

and concomitant other di seases s hould be ca refully evaluate d. B eta bloeke r is pre ferred

in

ischaemic

heart

di s ea se, digox in

in left

ventric ula r (L V) dysf unc tio n , be ta bloeke r o r

verapaınil

in

hyp

e rtro phic ca rdi omyopa th y ,

verapaınil

or dil tiazem in patients (pts) with hypertensio n and in pts without organic heart disease for ventricular ra te contro l. Sotalol, dofetilide or amiodarone sho uld be pre fe

rre

d in coronary

he

a rt d isease, sotalol, dofetilide or amiodarone in dil ated cardiomyopathy, am

iodarone or dofetilide in

co ngestive heart fa ilure, pro p afe n o ne or fl eca in id e

ın

pts wit h hype rtens ion/mild LV hypertrophy or in pts witho

ut

str uc tu ral hea rt disease for s uppression of AF.

Frequent or into

le

rable pa roxysmal and persiste nt A F epi sodes should prove a s trate gy d irecteel at sinus

rhythın

maintenance. In contrast, infreque nt or well-tole rateel

paroxysnıal

AF can be observed witho

ut antiarrhythnıic

inte

rven

tion, sa me of the m

80 may neeel o nly rate contro l.

In pts with infrequent

and brie f e pisoeles of AF, the long- term warl' a rin may not be necessary, bu t

in

hi gh-ris k pts with

paroxysmal/persisıent/chronic

A F dose-adj usteel warfarin is even be tter than low elose warfarin plus aspirin for prevention of emboli. The methods of non-pharmacologica l treatment for rate c ontro l or

res

tore s in us rh yth m may be necessary in pts re fractory to elrug

ıherapy.

Key wo rds :

Arrhythnıia,

atri a

l

fibri ll a ti on , pharmaco logic al therapy

Case Reports

Reperfusion With Throınbectomy after poiled primary balloon Angioplasty in Acute Myocardial Infaretion

A.K. Bilge, B. Umman, E. Yilmaz, Y. Nişanct Istanbul Medical Faculty, Istanbul, Turkey

Primaı·y

percutaneous coronary interventio ns were used in pati ents w ith acute

ınyocardial

in fa re tion especiall y with a ltereel

heınodynamic

parame ters for over 20 years. A

ltho

ugh convention al perc utaneous inte rventions are more e ffective a nel pe rform re perfus io n fas ter than th romboly tic the rapy, propagation or em boli satian of the thrombus to d istal coronary arteries may dec rease the s uccess. In this report, 7 8 years o ld woman wi th inf e ri or myocardial infa

rcti

on, right ventric ul ar infaretio n a nd cardiogenic shock was presented. She was

iınmediately

taken in cathete r laboratory at

the th

ird hour of the c

hest

pa

in

beca use of hemoely nam ic a lte ratio n. The coronary angiogra phy showeel that, the right coronary artery was totally occ luded in the midelle and there was no distal anteg rad flo w.

Ttıere

was also seriou s obstructions in

circuınflex

and left anterior deseenel ing arte ries. T he obstruction in the right co ronary artery was c rosse d with a g uide wire a nd in s pite of mu

ltiple

ba lloon in fl ations, ang ioplasty was unsuccessful beca use of

throınbus.

With X-sizer

throınbectomy

device, thrombus was

extracted and TIMI-III fl ow was restored.

Afıer

the

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Tiirk Kardiyol Dem Arş 2002:30: 78-81

thrombectomy, a residual obstruction remained and a dissection that did not

liınit

the flow appeared. For thi s reason s tent implantat ion was done. After this proced ure hemodynami c and elinical

paraıneters

were qu ic kly improved. One wee k later, the stenosis in the le ft ante rio r d eseeneling artery was treated with baloon ang ioplas ty and stent implanta tion. One week after th e second

intervention,

s he wa s d

ischarged with improved general condition.

Key words: Ac ute my ocardial infarction,

priınary

percutaneous co ronary interventio n, intracoronary

throınbecromy.

Ascending Aorta Dissection After Aortic Valve Replacement

A.

Belgi, U.

Doğan,

H. Ytlmaz,

^O.

Sancaktar

Akdeniz University Medical Faculty, Ankara, Turkey Ascending aorta d

issection following aortic valve

replacement (A VR), is a rare but potent ia

lly

fatal co mplication. The optimal s urgical management of patients with aortic valv e disease associated with ascending aortic d ilatation is a controversial issue.

While replacement of ascending aorta at th e time of presthe ti c valve implanta tion is mandatery when markeel dilatation of the aortic root is present, the surgica l strategy in case of mode rate dilatation

is

s tili unc lea r.

In

patients wit h ascending ao rtic di latation, A VR alone may not prevent progression of aortic root

enlargeınent.

Painless ascend

ing aorta

dissection a nd sign ificant furthe r enlargement of ascendi ng ao rta in eight mo nths after aort ic valve

replacement have

been observed in a pat ient who showeel mild to moderate ascending aortic di latation at the tim e of the

acıtic

valve replacement.

Key words: Aortic valve replacement , asseneling aortic dissection

Successful Manage ment with Coated Stent of Ostea l Perforation of Left Anterior Deseeneling Artery due to Laser Angioplasty

H. Yrlma z,

O.

Sancaktar,

İ.

Demir, F.E. Tüzüner

Akdeniz University Medical Faculty, Antalya, Turkey Coronary pe rforation is a rare comp lication of percuta neous coronary intervention. We report a case of osteal left anterior desee nel ing artcry pe rforation and cardi ac tamponade during excimer laser a ngioplasty on

priınaı·y

ang ioplasty of acu te

ınyocardial

infarction. Perforation was successfully covere d wi th PTFE-coate d s tent. Pericardial tamponade was decompressed with the

aiın

of a 6- French pig tail advanced into the

pericarcliuın