Objectives: Atrial high-rate episodes (AHRE) can occur in patients who have permanent pacemakers (PPM). AHRE is classified as subclinical atrial fibrillation (AF). Also, AHRE is related to clinical AF. Epicardial fat tissue (EFT) thickness is linked to AF. The purpose of this study was to examine the relation between AHRE and EFT thickness in PPM patients. Methods: Forty patients with dual-chamber PPM were enrolled. Transthoracic echocardiography was used to measure the thickness of the EFT. Patients were examined in 2 groups according to whether there was AHRE in the records: group 1 (AHRE) and group 2 (AHRE-free). A high atrial rate of more than 175 beats per minute for more than 5 minutes was defined as AHRE. The findings of the standard 2-dimensional echocardiography and the Doppler echocardiography were all recorded. A statistical relationship between EFT thickness and the development of AF was investigated. Results: Group 1 had ten patients, while Group 2 included thirty individuals. When the demographic features of the two groups were compared, they were similar. Both groups had similar 2-D echocardiographic and Doppler results. The difference in EFT thickness between groups 1 (2.0 ± 1.1 mm) and 2 (2.9 ± 1.8 mm) was not statistically significant (p = 0.138). Conclusions: In patients with PPM, AHRE may develop after implantation and may be detected asymptomatically in periodic follow-up. In this population, we did not observe a significant association between EFT thickness and the development of AF.

Aim: Arterial stiffness is related with both atrial fibrillation (AF) and stroke. The CHA2DS2-VASc score is used to assess stroke risk in patients with AF. In this study, it was aimed to examine the relationship between arterial stiffness and CHA2DS2-VASc score in AF-related stroke patients. Material and Methods: Thirty stroke patients with paroxysmal AF participated in this research. Calculations of the patients' pre-stroke CHA2DS2-VASc scores were made. The SphygmoCor device was used to assess the Carotid-Femoral Pulse Wave Velocity (cfPWV), which served as a surrogate for arterial stiffness. It was determined whether or not there was a statistical connection between the CHA2DS2-VASc score and arterial stiffness. Results: The patients were seperated into groups based on their CHA2DS2-VASc scores prior to the stroke (group 1: score=0-1, group 2: score=≥2). The two groups' characteristics were comparable, except for age, BMI and systolic blood pressure. Patients with high CHA2DS2-VASc scores (group 2) demonstrated significantly greater cfPWV values than those with low scores (group 1). The CHA2DS2-VASc score and the cfPWV revealed a favourable association in the correlation study. Conclusion: The CHA2DS2-VASc score and cfPWV were substantially and linearly associated. Calculation of CHA2DS2-VASc and monitoring of arterial stiffness in stroke-prone individuals may be stimulus for taking preventive measures from stroke in these patients.

Aim: No-reflow, that is the absence of sufficient myocardial perfusion after stent implantation, is associated with increased mortality in patients with ST-elevation myocardial infarction (STEMI). There is no definitive treatment, although there are some preventive approaches. Therefore, it is important to predict the patients at risk of no-reflow. Fragmented QRS (fQRS) is the presence of different RSR' patterns without a bundle branch on electrocardiography. Both fQRS and no-reflow share similar pathophysiological mechanisms. Thus, we thought that the presence of fQRS on admission to hospital may reflect an increased risk for no-reflow. The aim of the study was to assess the possible relationship between fQRS on admission and the development of no-reflow. Materials and Methods: The study included patients with first anterior STEMI who underwent primary percutaneous intervention. fQRS was evaluated at the time of admission to the hospital. No-reflow was diagnosed by thrombolysis in myocardial infarction flow grade (< 3) after stent implantation. A multivariable model was created to determine factors independently associated with no-reflow Results: The study included 259 patients, including 56 (20.3%) with no-reflow and 203 (73.6%) without no-reflow. fQRS was more frequent in patients with no-reflow than in those without (71.4% vs 42.4%, p<0.001). In the multivariable model, fQRS (OR:3.731, 95% CI: 1.912-7.279, p>0.001) and male gender (OR:2.351, 95% CI:1.025-5.391, p=0.043) were independently associated with the development of no-reflow. Discussion: The presence of fQRS on admission is independently associated with no-reflow in these patients. It can be used as a simple and non-invasive tool to predict the patients at risk for no-reflow.

Abstract Background  Parkes Weber syndrome (PWS) is a congenital disease characterized by vascular malformations, such as arteriovenous fistulas (AVFs). It frequently presents with overgrowth of a lower limb and high-output heart failure. The main treatment is to close vascular malformations. Surgical excision or endovascular coil insertion was performed in a few patients with AVFs. However, vascular covered stent implantation has not been used for treating PWS. Case summary  A 15-year-old male patient with PWS presented to our hospital because of dyspnoea and massive left upper limb swelling. After initial examination and left upper limb angiography, his symptoms and findings were attributed to the presence of high-flow large AVFs despite the presence of many coils previously inserted. We decided to implant a covered stent along the AVFs between the subclavian and axillary arteries. After stent implantation, the patient’s complaints and findings improved during the early term but they relapsed at the 6th month after percutaneous intervention. Discussion  Here, we report for the first time the use of covered stent implantation and its short and 6 months results in a patient with PWS. Although initial improvements were noted, the clinical outcome at 6 months after stent implantation was poor. This was probably associated with the presence of widespread subtle AVFs or collateral connections among the existing AVFs. Based on our result, we propose that closure of large AVFs is not useful and more definitive interventions, such as limb amputation may be required earlier.

Left ventricular outflow tract (LVOT) pseudoaneurysm is an uncommon but life-threatening pathology. It is generally observed after cardiovascular surgery or infective endocarditis. Its course ranges from an asymptomatic situation to severe complications including rupture, thromboembolism, fistula formation, and compression to the surrounding tissue (1-4). LVOT pseudoaneurysm usually presents with non-specific symptoms including chest pain, dyspnea, and cough. Until now, few cases with stable angina pectoris caused by LVOT compression on the left coronary arteries have been reported. However, in this case report, we present a patient with non-ST-elevation acute coronary syndrome caused by LVOT pseudoaneurysm.

Abdulkadir Kırış1, Hüseyin Bektaş1, Zeydin Acar1,2, Gülhanım Kırış3 1 Department of Cardiology, Medicalpark Karadeniz Hospital 2 Avrasya University Faculty of Health Sciences 3 Department of Cardiology, Ahi Evren Cardiovascular and Thoracic Surgery Training and Research Hospital, Trabzon, Turkey Angiographic predictor of thrombus formation Angiographic predictors of left ventricular thrombus after anterior myocardial infarction

Arterial stiffness (AS) has a detrimental effect on cardiovascular system particularly on left ventricle (LV). The aim of the study was to evaluate the impact of AS on LV functions in patients with rheumatoid arthritis (RA). Forty patients with RA and 25 age-sex matched control subjects (mean age 48.5 ± 6.3 vs. 45.1 ± 6.9 years, respectively, p = 0.06) were enrolled in study. AS was assessed by carotid-femoral pulse wave velocity (CF-PWV) and heart rate corrected augmentation index (AIx@75) measured by applanation tonometry (SphygmoCor). LV function was evaluated using tissue Doppler-derived myocardial performance index (MPI) from lateral mitral annulus. CF-PWV (28.3 ± 10.3 vs. 21.8 ± 9.3 m/s, p = 0.03), AIx@75 (10.2 ± 2.3 vs. 9.2 ± 1, %, p = 0.01) and MPI (0.46 ± 0.12 vs. 0.36 ± 0.1, p < 0.001) were significantly higher in patients with RA than in controls. LV MPI was found to be significantly positive correlated with CF-PWV, AIx@75, and ESR (r = 0.360, p = 0.005; r = 0.334, p = 0.009; r = 0.293, p = 0.023, respectively). Arterial stiffness parameters including CF-PWV and AIx@75 are associated with subclinical left ventricular dysfunction in patients with RA.

Objective: Left ventricular (LV) systolic synchrony is defined as simultaneous activation of corresponding cardiac segments. Impaired synchrony has some adverse cardiovascular effects, such as LV dysfunction and impaired prognosis. Epicardial fat tissue (EFT) is visceral fat around the heart. Increased EFT thickness is associated with some disorders, such as LV dysfunction and hypertrophy, which play a role in the impairment of LV synchrony. However, the relationship between EFT and LV systolic synchrony has never been assessed. Thus, we aimed to evaluate the possible relationship between EFT and LV synchrony in this study. Methods: The study population consisted of 55 consecutive patients (mean age 46.4±13.4 years, 32 female) without bundle branch block (BBB). EFT and LV systolic synchrony were evaluated by transthoracic echocardiography using 2D and tissue Doppler imaging. Maximal difference (Ts-6) and standard deviation (Ts-SD-6) of time to peak systolic (Ts) myocardial tissue velocity obtained from 6 LV basal segments were used to assess LV synchrony. Multiple regression analysis was used to detect the independently related factors to LV synchrony. Results: The mean values of EFT thickness, Ts-6, and Ts-SD-6 were found to be 2.7±1.6 mm (ranging from 1-7 mm), 20.1±14.2 msec, and 7.7±5.6, respectively. EFT thickness also was independently associated with Ts-6 (β =0.332, p=0.01) and Ts-SD-6 (β =0.286, p=0.04). Conclusion: EFT thickness is associated with LV systolic synchrony in patients without BBB.

Background: Myocardial fibrosis is a well-known side effect of radiotherapy. Fragmented QRS (fQRS) has been shown to be a marker of myocardial fibrosis. We postulated that radiotherapy induces development of fQRS in breast cancer patients. Patients and Methods: Breast cancer patients receiving locoregional radiotherapy were enrolled. Patients who had fQRS on electrocardiography (ECG) before radiotherapy were excluded. All patients were revaluated for the development of fQRS at 1-year follow-up. An age-matched healthy group served as controls. Results: A total of 52 breast cancer patients receiving locoregional radiotherapy were included (median age 49 years, interquartile range (IQR) 13). Of these, 19 (37%) had developed fQRS at 1-year follow-up. Compared with the control group, prevalence of fQRS was significantly higher in the irradiated group (37 vs. 12%; p < 0.002). Median total cardiac radiation dose was significantly higher in patients who had developed fQRS (5 Gy, IQR 5.2 vs. 1.7 Gy, IQR 4.4; p = 0.003). Cardiac radiation dose, entered either as a continuous variable (odds ratio (OR) 1.35, 95% confidence interval (CI) 104-1.74) or as a dichotomized variable (≥ 2.2 Gy, OR 6.48, 95% CI 1.47-28.61), was independently associated with the development of fQRS at 1-year follow-up. Conclusion: Radiotherapy for breast cancer induces development of fQRS on ECG. Cardiac radiation dose is independently associated with the development of fQRS.

Objective: We aimed to investigate whether fragmented QRS (fQRS) is associated with subclinical left ventricular (LV) dysfunction in patients with obstructive sleep apnea (OSA). Subjects and Methods: A total of 141 patients with OSA who had normal LV ejection fraction (LVEF) were included in the study. The fQRS was defined as the presence of an additional R wave, notching of R or S wave or the presence of fragmentation in 2 contiguous electrocardiography (ECG) leads. Subclinical LV dysfunction was defined as the presence of a tissue Doppler-derived Tei index of ≥0.5 in the absence of impaired LVEF (<50%) as assessed by transthoracic echocardiography. Results: Of the 141 patients, 71 (50.4%) had subclinical LV dysfunction. Overall, the prevalence of the fQRS was 61% (86/141). Patients with fQRS had significantly higher Tei indices than those without fQRS [median 0.66, interquartile range (IQR) 0.39 vs. median 0.40, IQR 0.15, p < 0.001]. The presence of fQRS on ECG predicted subclinical LV dysfunction in univariate logistic regression analysis [odds ratio (OR) 6.69, 95% confidence interval (CI) 3.10-14.43]. The association remained significant after adjusting for all potential confounders (OR 4.59, 95% CI 1.94-10.87). Conclusion: fQRS on ECG was an independent predictor of subclinical LV dysfunction in patients with OSA. This simple tool might help to identify OSA patients who could be at risk for developing overt cardiac dysfunction.

Background: Ventricular premature beats (VPBs) are one of the most common rhythm abnormalities. Structural heart diseases such as myocardial hypertrophy and left ventricular dysfunction are associated with VPBs. However, the exact mechanism of VPBs in patients without structural heart disease has not been revealed yet. Epicardial fat tissue (EFT) is a visceral fat around the heart. Increased EFT thickness is associated with myocardial structural and ultrastructural myocardial abnormalities, which may play a role in the development of VPBs. Aims: To evaluate the possible relationship between EFT thickness and frequent VPBs. Methods and results: The study population consisted of 50 patients with VPBs and 50 control subjects. Frequent VPBs were defined as the presence of more than 10 beats per hour assessed by 24-h Holter electrocardiography monitoring. EFT thickness was measured by transthoracic echocardiography. Multivariable logistic regression analysis was used to assess factors related with frequent VPBs. Baseline demographic and biochemical features including age, gender, and rates of hypertension and diabetes mellitus were similar in both groups. EFT thickness was significantly higher in patients with frequent VPBs than in controls (3.3 ± 1.3 mm vs. 2.2 ± 0.8 mm, p < 0.001). In multivariable logistic regression analysis, EFT thickness was independently associated with VPB frequency (B = 1.030, OR = 2.802, p < 0.001). Conclusions: Patients with frequent VPBs had increased EFT thickness compared to control subjects. EFT thickness was independently associated with frequent VPBs.

Objectives: Atrial fibrillation (AF) is one of the most common causes of preventable ischemic stroke and is related to increased cardiovascular morbidity and mortality. There is a lack of data in Turkey on the use of new oral anticoagulants (NOACs), and time in therapeutic INR range (TTR) in vitamin K antagonist users and AF management modality. In this multi-center trial, we aimed to analyze, follow and evaluate the epidemiological data in non-valvular AF patients. Study design: Four thousand one hundred consecutive adult patients from 42 centers with at least one AF attack identified on electrocardiography will be included in the study. Patients with rheumatic mitral valve stenosis and prosthetic valve disease will be excluded from the study. At the end of one year, the patients will be evaluated in terms of major cardiac end points (death, transient ischemic attack, stroke, systemic thromboembolism, major bleeding and hospitalization). Results: First results are expected in June 2015. Data about major cardiovascular end-points will be available in January 2016. Conclusion: The rates and kind of oral anticoagulant use, TTR in vitamin K antagonist users and main management modality applied in non-valvular AF patients will be determined by AFTER-2 study. In addition, the rate of major adverse events (MACEs) and the independent predictors of these MACEs will be detected (AFTER-2 Study ClinicalTrials.gov number, NCT02354456.).

OBJECTIVE:More cardiovascular events are seen in nephrotic syndrome (NS) patients than in the normal population. Fragmented QRS (fQRS) includes various RSR' patterns with different morphologies of the QRS complexes with or without the Q wave on a resting 12-lead ECG. A relationship between the presence of fQRS and myocardial function impairment has been shown in several studies. The purpose of this study was to evaluate the presence of fQRS in this patient group and the relationship with myocardial functions.METHODS:Thirty-four NS patients were included in the cross-sectional study. Demographic data were recorded, and electrocardiograms (ECGs) were analyzed for the presence of fQRS following investigation of biochemical parameters and 24-h protein excretion. In addition to classic echocardiographic parameters, the myocardial performance (Tei index) was calculated as an indicator of cardiac function. For comparison of group's data Student's t-test and Mann-Whitney U test were used. Multiple linear regression analysis was performed for parameters affecting presence of fQRS.RESULTS:We identified fQRS in half of our patients group. Patients with fQRS had significantly greater proteinuria level and Tei index than those without (p<0.05 and p<0.001, respectively). Tei index was also affected presence of fQRS (p<0.05, β=0.45, R2=0.32) and positively correlated with proteinuria levels (p<0.05 r=0.366).CONCLUSION:We demonstrated, for the first time in the literature, that the determination of fQRS in patients with NS in surface ECG, an easily accessible technique, can be used as a parameter in the prediction of myocardial functions.

Objective: Our aim was to investigate the possible relationship between myeloperoxidase (MPO) and myocardial damage markers such as heart-type fatty acid-binding protein (H-FABP) and troponin T (TnT) in patients with chronic heart failure (HF). Materials and Methods: Forty-two consecutive patients (age range: 27-80 years) with chronic HF were enrolled in the study. Serum H-FABP, TnT and MPO levels were measured. Routine biochemical and clinical parameters were recorded. Echocardiographic examinations were performed on all patients. A linear regression analysis was performed to determine the correlates of serum H-FABP. Results: The MPO, H-FABP and TnT levels were 255 ± 227, 60.6 ± 48.5 and 0.07 ± 0.15 ng/ml, respectively. In multiple linear regression analysis, age (β = -0.36, p = 0.006), creatinine level (β = 0.3, p = 0.024) and serum MPO level (β = 0.41, p = 0.009) were significant determinants of H-FABP levels. Bivariate predictors were not significantly associated with TnT levels in linear regression analyses. Conclusions: The MPO was significantly associated with serum H-FABP levels but not with TnT.

The aim of this study was to evaluate atrial electromechanical delay (EMD), P wave dispersion (Pwd), and left atrial (LA) mechanical functions in patients with active acromegaly. Twenty-three patients with active acromegaly and 27 age- and sex-matched controls were included in this study. All atrial electromechanical interval parameters (PA lateral, PA septum, PA tricuspid, interatrial EMD, intra-LA EMD, and intra-right atrial EMD) were measured from mitral lateral annulus, mitral septal annulus, and right ventricular tricuspid annulus by tissue Doppler imaging. LA volumes were measured by the disk method in the apical four-chamber view and were indexed to the body surface area. Mechanical function parameters of LA were calculated. Pwd was performed by 12-lead electrocardiograms. Atrial electromechanical intervals (PA lateral, PA septum, PA tricuspid, interatrial EMD, intra-LA EMD, and intra-right atrial EMD) and Pwd were similar between patients with acromegaly and control subjects (all p > 0.05). LA volumes (maximum, minimum, and presystolic) and LA mechanical functions were not significantly different between the groups (all p > 0.05). Additionally, serum levels of growth hormone and insulin-like growth factor-1 were not correlated with atrial electromechanical parameters and LA mechanical functions. Atrial electrical conduction times were not prolonged and LA mechanical functions were not impaired in patients with active acromegaly compared with controls. And the prevalence of supraventricular arrhythmia risk may not increase in this population.