Aorto-right ventricular fistula (ARVF) is a rare complication of transcatheter aortic valve replacement (TAVR) with limited evidence to guide its treatment. Five months following TAVR, an 82-year-old woman complained of edema and dyspnea. ARVF was confirmed by echocardiography, which revealed a shunt flow originating at the site of the prosthetic valve to the right ventricle. Unlike continuous shunt flow published in the literature, in this case the flow was observed distinctly during diastole. This situation was attributed to the prosthetic valve opening during systole, interrupting the shunt flow. After refusing invasive treatment, she was treated conservatively. As TAVR becomes more common, we will encounter this rare consequence more often. To determine the best management techniques for this rare condition, more research is required. Learning objective Aorto-right ventricular fistula (ARVF), a rare complication of transcatheter aortic valve replacement (TAVR), can manifest with varying localizations and hemodynamic characteristics. An ARVF with flow controlled by the aortic cusp is reported here for the first time. Patients post-TAVR should undergo long-term echocardiographic follow-up for ARVF as well.

BackgroundMicrovascular reperfusion strongly influences prognosis after ST-elevation myocardial infarction (STEMI). While invasive indices are established, practical non-invasive biomarkers remain limited. This study evaluated whether coagulation markers correlate with myocardial blush grade (MBG)-an angiographic surrogate of tissue-level reperfusion-and could serve as non-invasive indicators of microvascular reperfusion.MethodsIn this single-center case-based study, 48 consecutive STEMI patients undergoing coronary angiography were enrolled. MBG was assessed by an experienced interventional cardiologist blinded to laboratory data. Blood was sampled after reperfusion for tissue plasminogen activator/plasminogen activator inhibitor-1 complex (tPA/PAI), prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin complex, and D-dimer. Associations between biomarkers and MBG (0-1 vs 2-3) were examined. Receiver operating characteristic (ROC) analysis determined cut-offs; multivariable models evaluated independence.ResultsMean age was 61.2 ± 11.8 years; 87.5% were male. Comorbidities included hypertension (47.9%) and hyperlipidemia (33.3%). MBG distribution was: MBG 3 (33.3%), MBG 1 (25.0%), MBG 0 (22.9%), MBG 2 (18.8%). Patients with MBG 0-1 had significantly higher tPA/PAI and F1 + 2 than those with MBG 2-3 (p = .003 and p < .001, respectively). Admission troponin and CK-MB were also higher in MBG 0-1 (p = .049 and p = .026). ROC analysis showed tPA/PAI < 9.4 μg/dL predicted MBG 2-3 (AUC = 0.752; 95% CI 0.606-0.865; sensitivity 72.0%, specificity 69.57%), and F1 + 2 ≤ 14 580 pmol/L predicted MBG 2-3 (AUC = 0.973; 95% CI 0.880-0.999; p < .001). Lower admission troponin and CK-MB also predicted MBG 2-3. In multivariable analysis, no biomarker remained independently associated with MBG.ConclusionsLower post-reperfusion tPA/PAI and F1 + 2 levels are associated with higher MBG (better microvascular reperfusion) in STEMI. Although not independently predictive, these readily measurable markers-particularly tPA/PAI-may complement reperfusion assessment when direct angiographic evaluation is unavailable. Larger, multicenter studies with standardized sampling are warranted to validate cut-offs and clinical utility.

Right ventricular (RV) dilatation and dysfunction are usually present in heart transplant (HTx) patients and worsened with residual pulmonary hypertension (PH). We aimed to determine the ability of different echocardiographic modalities to evaluate RV function in comparison with cardiac magnetic resonance (CMR) and their relations with pulmonary hemodynamics in HTx patients.

Increasing fragility with the aging population compels less invasive procedures. Even if cardiac surgeries are getting minimally invasive with new techniques and technological development in the fi eld, many valve surgery candidates suffer from being qualifi ed as inoperable due to fragility, unstable circulatory system, and to be post-myocardial infarction and their life is in danger every day that they are not operated. The main purpose of this case-based role model study is to invent a new technique for implanting a transapical mitral valve NeoChord implantation with new tools.

Transcatheter aortic valve implantation (TAVI) is a safe and effective alternative to surgical valve replacement in intermediate and even in low-risk patient cohorts. Direct aortic (DAo) route may be used in patients with severe peripheral vascular disease. Here, we present an 88-year old patient hospitalized with cardiogenic shock. Echocardiography revealed severe aortic valve stenosis with aortic valve area 0.5 cm², mean gradient of 55 mmHg, and peak gradient 92 mmHg. TAVI was considered by the Institutional Heart Team. Multislice computed tomography (MSCT) revealed severe peripheral vascular disease, decreased calibration of abdominal aorta, and multiple large vulnerable atherosclerotic plaques. The patient was scheduled for a DAo TAVI. A 26-mm Medtronic CoreValve Evolut R valve was implanted after predilatation with median sternotomy. The patient was discharged after 96 hours. Although transfemoral (TF) access is used as the default approach for TAVI, it was contraindicated in our patient owing to severe peripheral vascular disease and decreased calibration of the abdominal aorta at its narrowest point (4.5 mm) with multiple large vulnerable atherosclerotic plaques. Careful preprocedural MSCT evaluation is essential and directly affects the success of the procedure. MSCT is also mandatory to confirm the best cannulation zone that must be met for a successful DAo TAVI.

Traditional parameters have limited value to estimate left ventricular filling pressure (LVFP) in orthotropic heart transplant (OHT) recipients. We hypothesized that global longitudinal strain (GLS), diastolic, and systolic strain rate (SR) would be depressed in OHT recipients with elevated LVFP and could overcome the limitations of traditional parameters. We studied consecutively OHT patients at the time of endomyocardial biopsies and retrospectively pretransplantation studies conforming to the same protocol. Comprehensive echocardiography with strain measurements was performed. Results were compared with pulmonary capillary wedge pressure (PCWP) obtained from right heart catheterization that was performed just after the echocardiography study. In all, 74 studies were performed in 50 OHT recipients. Mean PWCP was 11.8 +/- 4.3 mm Hg (range: 4 to 25 mm Hg). Several parameters, but not left atrial volume index, mitral inflow velocities, annular velocities, and their ratio (E/e'), were different between studies with normal (n = 47) and elevated PCWP (n = 27). Area Under Curve for GLS (0.932*), E/e'SR (0.849*), and systolic SR (0.848*) (*p 0.0001) were more accurate than traditional parameters for predicting PCWP 12 mm Hg. GLS, systolic SR and E/e'SR remained accurate regardless of LV ejection fraction and allograft vasculopathy. Meanwhile, E/e' was accurate to predict PWCP in native failing hearts before transplantation. Changes in GLS and E/e'SR tracked accurately changes in PCWP. In conclusion, traditional indices of diastolic function perform poorly in OHT recipients, whereas GLS and E/e'SR provide reliable means of LVFP, irrespective of ejection fraction and allograft vasculopathy. These parameters also track reasonably well the changes in LVFP. (c) 2020 Elsevier Inc. All rights reserved.

OBJECTIVE:Risk stratification and prompt treatment are essential for the management of acute coronary syndromes (ACS) and prediction of future prognosis. Subclinical vascular inflammation and novel biomarkers play an important role in the clinical evaluation of ACS patients.METHODS:We enrolled patients who were admitted to emergency service with unstable angina or non- ST segment elevated ACS (NSTE-ACS) in the study population. Coronary artery disease (CAD) complexity was determined via evaluation of angiographical views and peripheral venous blood samples were collected to measure highly sensitive C-reactive protein (hs-CRP) and soluble form of Lectin-like OxLDL receptor-1 (sLOX-1) levels.RESULTS:A total of 40 patients were enrolled in the study population, mean age was 65.1±13.8 years and male gender percentage was 52.5%. Twenty-nine of patients had NSTE-ACS and 11 patients had unstable angina presentation. The modified Gensini scores were higher for patients with elevated hs- CRP and sLOX-1 levels.CONCLUSION:Vascular inflammation displays the onset of ACS and it is related to more complex CAD in these patients. An increase in sLOX-1 expression is closely related to anatomical complexity of CAD in ACS.

Introduction Respiratory and cardiac functions in association with skeletal and neurophysiologic systems can be evaluated with cardiopulmonary exercise testing (CPET). Compared to treadmill exercise test, CPET provides more comprehensive data about the hemodynamic response to exercise. Materials and Methods We aimed to evaluate the relationship with CPET findings and coronary lesions identified on angiography in patients with angina pectoris who underwent teradmill exercise, CPET and coronary angiography (CAG). By this way we sought to examine the CPET parameters that might be predictive for coronary artery disease (CAD) before diagnostic exercise test results and ischemia symptoms develop. Thirty patients in whom CAG was planned because of symptoms and exercise test results were enrolled in the study. Oxygen consumption (VO2), carbondioxide production (VCO2), minute ventilation (VE), maximum work rate (WR), DVO2/DWR and O2 pulse (VO2/HR) values were calculated. Significant CAD was defined as ≥ 50% narrowing in at least one of the coronary arteries. Result The mean age was 60.4 ± 8.9 years ve 21 (65.6%) of subjects were male. On CAG, CAD was detected in 19 (59.4%) patients. Maximum heart rate, heart rate reserve (HRR), VE/VCO2 measured at anaerobic threshold (AT) and VO2(mL/kg/min) were significantly differed in patients with CAD than those without (p= 0.031; p= 0.041; p= 0.028; p= 0.03 respectively). Peak VO2, VO2/WR and O2 pulse values were higher in patients with normal angiographic results than those with CAD but the difference did not reach to statistical significance. Conclusions The findings of our study indicate that among CPET parameters AT VE/VCO2, ATVO2 (mL/kg/dk) and HRR can have predictive value in the diagnosis of CAD. We think that these parameters might be used in the evaluation of patients with angina and dyspnea suspected of CAD. In conclusion parameters obtained during the test that are not influenced by patient's effort might increase the value of CPET in the diagnosis CAD.

Spontaneous atraumatic axillary artery bleeding is an unusual clinical entity. Axillary artery bleeding is associated with a high mortality rate. Vascular fragility is defined as a decrease in blood vessel resistance, and increased vascular fragility is one of the reasons for arterial bleeding. In this report, we present a case of spontaneous axillary artery bleeding in a heart transplant recipient.

OBJECTIVES:Endomyocardial biopsy sampling is used to check acute rejection after cardiac transplant. However, it may lead to tricuspid valve injury and cardiac perforation; therefore, less invasive tools may be useful. Right heart catheterization provides valuable information about cardiac hemodynamics. Herein, we aimed to determine the correlation of right heart catheterization parameters with acute rejection and death during cardiac transplant follow-up.MATERIALS AND METHODS:We retrospectively evaluated follow-up right heart catheterization and endomyocardial biopsy results from 47 adult patients who underwent cardiac transplant at Başkent University Faculty of Medicine between 2004 and 2016. Right heart catheterization parameters were compared between deceased and surviving patients and were correlated with acute cellular and humoral rejection. Averaged right heart catheterization parameters were correlated with death. We used Cox regression analysis to determine risk of death and acute cellular rejection and Kaplan-Meier survival analysis to determine any survival differences associated with pulmonary hypertension.RESULTS:There were 47 patients (38 males, 9 females) with a mean age of 44 ± 10 years at transplant. In our patient group, 18 patients (38.3%) died at a median time of 11.2 months. Ninety endomyocardial biopsy samples (22.1%) showed cellular rejection, and 61 samples (4.5%) showed humoral rejection. The deceased patients had significantly greater mean and systolic pulmonary artery pressures, which were significantly correlated with acute cellular rejection. Death was significantly correlated with averaged values of mean and systolic pulmonary artery pressures. Our Cox regression analysis revealed that pulmonary hypertension was significantly associated with risk of death and acute cellular rejection. A Kaplan-Meier survival analysis revealed that pulmonary hypertension was associated with a significantly lower median survival.CONCLUSIONS:Pulmonary artery pressures are significantly correlated with acute cellular rejection and death after cardiac transplant. Pulmonary hypertension significantly increases the risk of death and shortens survival after cardiac transplant.

Objective: Resistin, a cysteine-rich peptide, is associated with atherosclerosis and diabetes. Resistin levels increase corresponding to coronary artery disease (CAD) and heart failure severity. Since resistin level tends to elevate with symptomatic heart failure, it is expected to be associated with left ventricular end-diastolic pressure (LVEDP). However, there is no relevant literature on the relationship between resistin levels and LVEDP. We aimed to evaluate the association between resistin levels and LVEDP, severity of CAD, carotid intima-media thickness (CIMT), and echocardiographic diastolic dysfunction parameters. Methods: For this study, 128 euvolemic patients with creatinine clearance >50 mg/dL and without acute coronary syndrome, who had typical chest pain or were stress test positive, were enrolled. Resistin level was measured by Enzyme-linked immunosorbent assays (ELISA) method. Severe CAD is defined as >= 50% stenosis in one of the major coronary arteries. LVEDP was measured during left heart catheterization. Results: After coronary angiography, 60 patients (46.9%) had severe CAD. The mean LVEDPs were similar for patients with and without severe CAD (p=0.480). The resistin levels did not differ between the groups (p=0.154). The resistin levels did not correlate with LVEDP (r=-0.045, p=0.627), ejection fraction (EF; r=0.110, p=0.228), the Gensini score (r=-0.091, p=0.328), and CIMT (r=0.082, p=0.457). No significant correlation was found between the echocardiographic diastolic dysfunction parameters and resistin levels. Conclusion: There was no significant correlation between resistin level and LVEDP, CAD severity, echocardiographic diastolic dysfunction parameters, and CIMT. Further studies are warranted to determine the efficacy of resistin in clinical use.

Background: Coronary stents are commonly used to treat obstructive coronary artery disease. It is currently difficult to reliably predict in-stent restenosis. The aim of this study was to examine the relationship between bare metal stent restenosis and red cell distribution width (RDW), neutrophil/lymphocyte ratio (N/L ratio). It was the first study that used a control group with a normal coronary angiogram. Methods: We enrolled patients who underwent coronary angiography between June 2012 and September 2013 in our center. We enrolled a cohort of 210 consecutive patients, of which 130 had a coronary artery stent and 80 had a normal coronary angiogram. Results: The mean age of the study group was 62 (38-86) years. The mean RDW levels of patient group with no-restenosis were significantly higher than the control group but there was no significant difference between the mean RDW levels of the restenosis group and the other subgroups (14.9 (11.7-17.6), 15.5 (10.9-20.4), 15.4 (11.7-20.1), respectively). N/L ratio was significantly higher in patients with stent restenosis 2.32(1.49-5.35) compared to the other two groups whereas there was no significant difference between the control group and non-restenosis group with respect to N/L ratio. (1.71(0.84-7.89), and 2.09(0.89-9.15), respectively). Conclusions: According to our findings, RDW was not a predictor of stent restenosis or coronary artery disease. On the other hand, our findings support the hypothesis that N/L ratio is an indicator of inflammation that plays a role in-stent restenosis.

Introduction Non-invasive alternatives to endomyocardial biopsy (EMB) are highly desirable to monitor acute cellular rejection (ACR). In the present study, we aimed to test the hypothesis that echocardiographic strain quantification, by tracking subtle alterations in myocardial function, is useful and superior to invasive hemodynamic measurements to detect ACR. Materials and Methods All patients underwent serial surveillance EMBs, catheterizations and echocardiography examination according to our institutional protocol. Data from the first rejection episodes were compared with the data obtained after treatment. Patients without rejection during follow-up were also included for comparison. All tests were performed within 48 hours of each other. In addition to standard 2D and Doppler echocardiographic measurements, global longitudinal and circumferential strain (GLS, GCS) were assessed from 16 segments, from digitally stored echocardiograms by using the Velocity Vector Imaging software on Syngo Workplace (Siemens Healthcare GmbH, Erlangen/Germany). Results We observed 16 grade 1R, 14 grade 2R and 1 grade 3R and 18 no rejection. Time to first rejection was 3 months (interquartile range: 3-36). Only GLS and GCS were significantly reduced during grade 1R. During grade ≥2R, GLS, GCS, tricuspid annular peak systolic excursion, cardiac index were significantly reduced, right atrial and systolic pulmonary artery pressures were significantly increased as compared to no rejection. The negative and positive predictive values of the best fit cut-off of GLS (<17%) were 98% and 43% for grade ≥2R, 84% and 70% for any rejection. In the multivariate logistic regression analysis including the most pertinent variables according to univariate analyses, GLS and GCS emerged as independent determinants of any rejection (p=.015 and p=.004, respectively). Despite successful treatment, strain values remained significantly lower than the values of no-rejection group (GLS 17.0% [14.7% - 18.3%] vs 18.9% [16.8% - 22.1%]; p=.006, GCS 25.5% [22% - 27.8%] vs 29.0% [24.0% - 33.4%]; p=.01).Conclusions Echocardiographic strain, but not hemodynamic assessment by cardiac catheterization, is a sensitive tool to detect first rejection episode after HTx. However, incomplete normalization of strain after treatment necessitate intra-individual comparisons on serial follow-up are warranted. Strain is a promising marker of ACR however it needs to be tested in larger series.

Abstract Objective: Osteopontin is a component of atherosclerotic lesions, secreted by monocytes, macrophages and endothelial and vascular smooth muscle cells, which together are responsible for neointimal proliferation. We examined whether elevated plasma osteopontin concentration was associated with in-stent restenosis in patients with coronary artery disease. Subjects and methods: We enrolled 91 patients who underwent coronary artery stenting, and 60 control patients with normal findings on coronary angiography, between June 2012 and September 2013. For patients with stents, we measured plasma osteopontin concentration at the first follow-up coronary angiogram. For controls, plasma osteopontin concentration was measured at the time of angiography. Results: Of the 91 patients who had undergone coronary artery stenting, 31 (34.1%) had developed in-stent restenosis and the mean time passed to control coronary angiography was 36.7 months (±SD 35.1 months). Mean plasma osteopontin concentration in this group was 2721.4 ± 1787.8 pg/ml, significantly higher than the 60 patients (65.9%) with no in-stent restenosis (1770.4 ± 1208.2 pg/ml, p = .011) and the 60 patients with a normal coronary angiogram (1572.4 ± 904.8 pg/ml, p = .002). There was no significant difference in mean osteopontin concentration between the patients with no in-stent restenosis and the control group (p = .312). Conclusions: Elevated plasma osteopontin concentration is associated with in-stent stenosis in patients with coronary artery disease. Further studies will be needed to establish whether osteopontin can predict in-stent restenosis and guide clinical management strategies.

OBJECTIVESCoronary vasospasm in heart transplant recipients occurs through various mechanisms. It has been linked to allograft rejection and coronary vasculopathy, which can result in mortality during follow-up. Here, we investigated the prevalence of coronary vasospasm among heart transplant recipients undergoing surveillance coronary angiography procedures.MATERIALS AND METHODSThis study was prospectively performed at Başkent University Faculty of Medicine by retrospectively analyzing medical information of patients who underwent bicaval heart transplant between 2003 and 2016 and subsequently had coronary angiography to rule out allograft vasculopathy. We analyzed prevalence of coronary vasospasm, affected vessels, underlying vessel properties, and treatment modalities. Coronary vasospasm was defined as transient diffuse or localized luminal narrowing, either spontaneously or catheter-induced, relieved spontaneously or with nitroglycerine.RESULTSForty-one coronary angiography procedures were performed using the standard Judkins technique. Among these, 5 patients showed coronary vasospasm a mean of 2 years after cardiac transplant. All vasospasm episodes involved the left anterior descending artery, with 2 also involving the circumflex artery and 1 involving the right coronary artery. The degree of luminal narrowing ranged from mild to severe. Episodes that involved the left anterior descending artery more often diffusely involved most of the vessel. In 3 patients, vasospasms were recurrent. Three patients had underlying coronary artery disease, which was relieved in 2 patients who progressed by stent implant. Neither ischemic events nor reduction of ejection fraction was observed during follow-up. There were also no occurrences of cellular or humoral rejection or death in any of the patients with vasospasm.CONCLUSIONSCoronary vasospasm is common in heart transplant recipients. It may be diffuse or localized and occur spontaneously or because of underlying coronary artery disease. Factors, including allograft vasculopathy, associated with coronary vasospasm remain to be determined, and further related research is needed.

Expected life-spans increase all over the world and in our clinical experience we see atherosclerotic vascular diseases and malignant neoplasms more commonly. Herein, we want to present a case with coexistence of acute myocardial infarction and new diagnosed rectum cancer. Close monitoring is essential in these patients however stent thrombosis can be seen and patient and relatives should be informed about the risks and possible treatment choices in a detailed way.

OBJECTIVES:Residual pulmonary hypertension challenges the right ventricular function and worsens the prognosis in heart transplant recipients. The complex geometry of the right ventricle complicates estimation of its function with conventional transthoracic echocardiography. We evaluated right ventricular function in heart transplant recipients with the use of 3-dimensional echocardiography in relation to systolic pulmonary artery pressure.MATERIALS AND METHODS:We performed 32 studies in 26 heart transplant patients, with 6 patients having 2 studies at different time points with different pressures and thus included. Right atrial volume, tricuspid annular plane systolic excursion, peak systolic annular velocity, fractional area change, and 2-dimensional speckle tracking longitudinal strain were obtained by 2-dimensional and tissue Doppler imaging. Three-dimensional right ventricular volumes, ejection fraction, and 3-dimensional right ventricular strain were obtained from the 3-dimensional data set by echocardiographers. Systolic pulmonary artery pressure was obtained during right heart catheterization.RESULTS:Overall mean systolic pulmonary artery pressure was 26 ± 7 mm Hg (range, 14-44 mmHg). Three-dimensional end-diastolic (r = 0.75; P < .001) and end-systolic volumes (r = 0.55; P = .001)correlated well with systolic pulmonary artery pressure. Right ventricular ejection fraction and right atrium volume also significantly correlated with systolic pulmonary artery pressure (r = 0.49 and P = .01 for both). However, right ventricular 2- and 3-dimensional strain, tricuspid annular plane systolic excursion, and tricuspid annular velocity did not.CONCLUSIONS:The effects of pulmonary hemodynamic burden on right ventricular function are better estimated by a 3-dimensional volume evaluation than with 3-dimensional longitudinal strain and other 2-dimensional and tissue Doppler measurements. These results suggest that the peculiar anatomy of the right ventricle necessitates 3-dimensional volume quantification in heart transplant recipients in relation to residual pulmonary hypertension.