Objective: This study aims to explore the impact of sodium-glucose cotransporter-2 (SGLT-2) inhibitors, a newer class of oral antidiabetic drugs, on atrial electromechanical delay (EMD) in patients with type 2 diabetes mellitus (DM).This is particularly relevant given the significantly higher incidence of atrial fibrillation (AF) in diabetic patients compared to the general population.Atrial electromechanical delay is recognized as an important factor influencing the development of atrial fibrillation.Methods: This study included 30 type 2 DM patients (53.3% female, mean age 60.07 ± 10.03 years), initiating treatment with SGLT-2 inhibitors.The patients were assessed using echocardiography at baseline and again at 6 months, focusing on basic echocardiographic parameters and atrial electromechanical delay times (EMD) measured via tissue Doppler imaging.Results: No significant changes were observed in intra-atrial EMD times.However, significant reductions were noted in interatrial EMD times, decreasing from 15.13 ± 5.87 ms to 13.20 ± 6.12 ms (P = 0.029).Statistically significant shortening occurred in lateral pulmonary acceleration (PA) times (from 58.73 ± 6.41 ms to 54.37 ± 6.97 ms, P < 0.001), septal PA times (from 50.90 ± 6.02 ms to 48.23 ± 5), and tricuspid PA times (from 43.60 ± 6.28 ms to 41.30 ± 5.60 ms, P = 0.003).Additionally, there was a significant reduction in the E/e' ratio from 8.13 ± 4.0 to 6.50 ± 2.37 (P = 0.003). Conclusion:SGLT-2 inhibitors might positively influence atrial electromechanical conduction, reducing DM-related functional impairments and the risk of arrhythmias, particularly AF.

OBJECTIVE:The use of cardiac implantable electronic devices has increased in recent years. It has also brought some issues. Among these, the complications of cardiac implantable electronic devices infection and pocket hematoma are difficult to manage. It can be fatal with the contribution of patient-related risk factors. In this study, we aimed to find mortality rates in patients who developed cardiac implantable electronic devices infection and pocket hematoma over 5 years. We also investigated the risk factors affecting mortality in patients with cardiac implantable electronic devices. METHODS:A total of 288 cardiac implantable electronic devices patients were evaluated. Demographic details, history, and clinical data of all patients were recorded. Cardiac implantable electronic devices infection was defined according to the modified Duke criteria. The national registry was used to ascertain the mortality status of the patients. The patients were divided into two groups (exitus and survival groups). In addition, the pocket hematoma was defined as significant bleeding at the pocket site after cardiac implantable electronic devices placement. RESULTS:The cardiac implantable electronic devices infection was similar in both groups (p=0.919), and the pocket hematoma was higher in the exitus group (p=0.019). The exitus group had higher usage of P2Y12 inhibitors (p≤0.001) and novel oral anticoagulants (p=0.031). The Cox regression analysis, including mortality-related factors, revealed that renal failure is the most significant risk factor for mortality. Renal failure was linked to a 2.78-fold higher risk of death. CONCLUSION:No correlation was observed between cardiac implantable electronic devices infection and mortality, whereas pocket hematoma was associated with mortality. Furthermore, renal failure was the cause of the highest mortality rate in patients with cardiac implantable electronic devices.

BACKGROUND:Hypertrophic cardiomyopathy is a common genetic heart disease and up to 40%-60% of patients have mutations in cardiac sarcomere protein genes. This genetic diagnosis study aimed to detect pathogenic or likely pathogenic sarcomeric and non-sarcomeric gene mutations and to confirm a final molecular diagnosis in patients diagnosed with hypertrophic cardiomyopathy.METHODS:A total of 392 patients with hypertrophic cardiomyopathy were included in this nationwide multicenter study conducted at 23 centers across Türkiye. All samples were analyzed with a 17-gene hypertrophic cardiomyopathy panel using next-generation sequencing technology. The gene panel includes ACTC1, DES, FLNC, GLA, LAMP2, MYBPC3, MYH7, MYL2, MYL3, PLN, PRKAG2, PTPN11, TNNC1, TNNI3, TNNT2, TPM1, and TTR genes.RESULTS:The next-generation sequencing panel identified positive genetic variants (variants of unknown significance, likely pathogenic or pathogenic) in 12 genes for 121 of 392 samples, including sarcomeric gene mutations in 30.4% (119/392) of samples tested, galactosidase alpha variants in 0.5% (2/392) of samples and TTR variant in 0.025% (1/392). The likely pathogenic or pathogenic variants identified in 69 (57.0%) of 121 positive samples yielded a confirmed molecular diagnosis. The diagnostic yield was 17.1% (15.8% for hypertrophic cardiomyopathy variants) for hypertrophic cardiomyopathy and hypertrophic cardiomyopathy phenocopies and 0.5% for Fabry disease.CONCLUSIONS:Our study showed that the distribution of genetic mutations, the prevalence of Fabry disease, and TTR amyloidosis in the Turkish population diagnosed with hypertrophic cardiomyopathy were similar to the other populations, but the percentage of sarcomeric gene mutations was slightly lower.

OBJECTIVE:Cardiac autonomic neuropathy is a serious microvascular complication of type 2 diabetes mellitus that affects a significant portion of patients. Due to decreased parasympathetic activity, the sympathetic nervous system becomes dominant, causing several problems that lead to increased cardiovascular morbidity and mortality. Sodium-glucose cotransporter-2 inhibitors have been shown to reduce sympathetic nervous system activity previously. This is a promising finding for restoring the impaired sympathovagal balance in cardiac autonomic neuropathy. The aim of this study is to evaluate the effect of at least 6 months of sodium-glucose cotransporter-2 inhibitor treatment on sympathetic nervous system activity with sympathetic activity index and heart rate variability parameters in patients with type 2 diabetes mellitus.METHODS:Holter-electrocardiogram recordings of 50 patients who were using an sodiumglucose cotransporter-2 inhibitor (empagliflozin or dapagliflozin) for at least 6 months and 50 patients who did not were analyzed retrospectively. The sympathetic activity index and heart rate variability parameters of these 2 groups, which were similar in terms of age, gender, hemoglobin A1c, and duration of diabetes, were compared.RESULTS:The ratio of low-frequency to high-frequency power reflecting the sympathovagal balance [-1.495 (-2.165/-1.196) vs. -1.224 (-1.619/-0.863), P=.008] and sympathetic activity index [1.44 (1.06/2.76) vs. 2.47 (1.42/3.68), P=.009] was lower in the sodiumglucose cotransporter-2 inhibitor group than in the control group. In addition, the sympathetic activity index was correlated with the ratio of low-frequency to high-frequency power (r=0.418, P < .001).CONCLUSION:Sodium-glucose cotransporter-2 inhibitor treatment for at least 6 months was found to result in lower values of sympathetic activity index and the ratio of low-frequency to high-frequency power in patients with type 2 diabetes mellitus. These findings indicate lower sympathetic nervous system activity, which supports the sympathoinhibitor effects of sodiumglucose cotransporter-2 inhibitors.

OBJECTIVE:To investigate the relationship between chronic total occlusion (CTO) development and oxidative stress markers in stable coronary artery patients.STUDY DESIGN:A cohort study.PLACE AND DURATION OF STUDY:Cardiology Clinic, Kahramanmaras Sutcu Imam University Medical Faculty, between January 2018 and December 2019.METHODOLOGY:Patients, who underwent coronary angiography for stable chest pain, were consecutively included. The study group consisted of those with CTO and the control group from those without CTO. Serum total oxidant/anti-oxidant, dynamic thiol/disulfide, antioxidant (ascorbate, alfa-tocopherol, beta-carotene) vitamin levels, and routine biochemistry tests of the patients were compared.RESULTS:The study group (24 men, 5 women, mean age 63.79 ± 9.21 years) and control group (23 men, 6 women, mean age 61.38 ± 8.20 years) consisted of 29 patients each. The oxidative stress markers (total thiol, native thiol, disulfide, reduced thiol ratio, oxidized thiol ratio, thiol oxidation-reduction ratio, total antioxidant status, total oxidant status, and vitamin E) were found to have similar values between the groups. However, of the anti-oxidative vitamins, vitamin C, vitamin A and vitamin C/vitamin E ratio were significantly lower in the CTO group and predicted a CTO lesion (AUC: 0.084, p<0.001, 95% CI: 0.007-0.162; AUC: 0.285, p=0.005, 95% CI: 0.154-0.416 and AUC: 0.181, p <0.001, 95% CI: 0.062-0.299, respectively).CONCLUSION:The lower serum vitamin C and vitamin A levels and low vitamin C/vitamin E ratio may be useful in predicting the risk of CTO in stable patients with non-critical stenosis in coronary angiography.KEY WORDS:Chronic total occlusion, Oxidative balance, Stable coronary artery disease, Vitamin A, Vitamin C, Vitamin C / vitamin A ratio.

Background: Cardiac autonomic neuropathy is a frequent complication of type 2 diabetes mellitus. Cardiac autonomic neuropathy, in which sympathetic tone predominates over parasympathetic activity, increases both cardiovascular morbidity and mortality and unfortunately has no definitive treatment. Sodium-glucose cotransporter-2 inhibitors have been suggested to reduce sympathetic nervous system activity, based on the results from previous studies. In this study, we aimed to investigate the effect of 24-week treatment with dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, on cardiac autonomic function measures in patients with type 2 diabetes mellitus and cardiac autonomic neuropathy. Methods: Dapagliflozin 10 mg/day (n=42) or non-sodium-glucose cotransporter-2 inhibitor oral antidiabetic(s) (n=38) was added to the treatment of patients whose glycemic control could not be achieved with existing treatments. The patients with definite or confirmed cardiac autonomic neuropathy diagnosed by cardiovascular autonomic reflex tests underwent 24-hour Holter-electrocardiogram recordings to obtain heart rate variability and heart rate turbulence parameters before starting additional medication and after a 24-week treatment period. Results: In-group analyses showed that dapagliflozin 10 mg/day for 24 weeks improved heart rate variability and heart rate turbulence parameters and decreased the frequency of ventricular premature beats relative to their baseline values. No such findings were observed in the control group despite similar glycemic control. Comparisons between dapagliflozin group and the control group showed that these effects of dapagliflozin were significantly better than non-sodium-glucose cotransporter-2 inhibitor oral antidiabetics. Conclusion: Dapagliflozin improves measures of cardiac autonomic function compared to the control group in type 2 diabetic patients with cardiac autonomic neuropathy. This intergroup benefit, demonstrated for the first time, may be promising for the regression of cardiac autonomic neuropathy with sodium-glucose cotransporter-2 inhibitors.

Aim Cardiac autonomic dysfunction is encountered in approximately 25 % of patients with metabolic syndrome (MetS). 24 hr Holter-ECG based heart rate variability (HRV) and heart rate turbulence (HRT) parameters are used to evaluate cardiac autonomic function. We aimed to investigate the relationship between a novel insulin resistance marker, triglyceride glucose (TyG) index and cardiac autonomic dysfunction in patients with MetS.Material and methods We examined a total of 400 non-diabetic subjects, 136 with MetS and 264 without MetS. All underwent TyG index calculations, and 24 hr Holter-ECG recordings for the measurement of HRV and HRT parameters.Results HRV and HRT parameters were lower or higher in patients with MetS than in subjects without MetS, indicating cardiac autonomic dysfunction. We observed significant correlations between TyG index and measures of cardiac autonomic function. Multiple linear regression analysis showed that the TyG index was an independent predictor of almost all HRV and HRT parameters.Conclusion This study demonstrates the independent relationship between cardiac autonomic dysfunction and the TyG index, a novel marker of insulin resistance in non-diabetic patients with MetS.

Aim    The autonomic nervous system plays an important role in the pathogenesis of vasovagal syncope, but studies on the effect of basal autonomic tone have found confusing results. The aim of this study was to investigate the effect of basal autonomic functions, as assessed by heart rate variability (HRV) and heart rate turbulence (HRT), in patients with vasovagal syncope.Material and methods    Patients who underwent head-up tilt test (HUTT) due to unexplained syncope and who had a 24 hr Holter ECG recording in the same period were retrospectively analyzed. Patients with diabetes, a history of myocardial infarction, heart failure, orthostatic hypotension, atrial fibrillation, or use of vasoactive drugs, such as beta blockers, were excluded from the study. 161 patients who met these criteria were included in the study. Time domain HRV parameters from Holter ECG recordings and HRT parameters from patients with sufficient number of ventricular premature contractions were measured.Results    The age of the patients varied from 16 to 75 yrs (mean: 44.8±18.5 yrs). HUTT results of 60 (37.2 %) patients were evaluated as positive. There were no significant differences in the basal demographic, clinical, or laboratory findings of the tilt-positive and tilt-negative patient groups. Likewise, there were no significant differences between the time domain HRV parameters and HRT parameters of both groups.Conclusion    HRV and HRT parameters reflecting basal autonomic function were not different between HUTT positive and HUTT negative patient groups. These findings suggest that basal autonomic functions have no effect on vasovagal syncope pathogenesis.

Aim: Transcatheter aortic valve implantation has been used widely as an alternative treatment method for patients with symptomatic aortic stenosis carrying high surgical risk. Despite technological advances and increased experience, its early and late mortality rate is still relatively high and it is important to predict upcoming cardiac events and mortality for the management of patients. In this study, we aimed to investigate the clinical and laboratory parameters affecting mortality after these procedures performed in our clinic. Material and Methods: The patients who underwent TAVI due to severe AS between May 2015 and March 2019 were investigated retrospectively. Demographic, echocardiographic and laboratory data of all patients were recorded. During the follow-up period (mean: 556 days), patients were divided into 2 groups; deceased patients (group 1, n=13) and living patients (group 2, n=34). The data of the patients before TAVI procedure were compared between the two groups. Results: Among demograhic data, the ratio of chronic kidney disease was significantly higher in the deceased group. Among echo parameters, left ventricular ejection fraction was significantly lower and pulmonary artery pressure was significantly higher in the deceased group. Of laboratory parameters, blood urea nitrogen and creatinine levels were significantly higher and toral protein levels were significantly lower in the deceased group. Additionally, leukocyte, uric acid, CRP and CRP/albumin ratio were significantly higher and albumin was significantly lower in the deceased patients. Conclusion: The presence of chronic kidney disease, low left ventricular EF, high pulmonary artery pressure, high CRP levels, increased CRP/albumin ratio and high uric acid levels preceding TAVI may be helpful to determine the risk of mortality after the TAVI procedure.

Introduction: This study aimed to investigate the relationship between all-cause mortality and markers of hematological mortality in post-procedure follow-up of patients who underwent percutaneous coronary intervention (PCI) due to severe left main coronary artery (LMCA) disease. Patients and Methods: Between January 2015 and August 2019, a retrospective cohort study was performed based on the data of 166 consecutive patients (43 females, 123 males) who were diagnosed with severe LMCA disease as a result of coronary angiography performed in our clinic. The study population was followed median 631.00 (270.75-1172.00) days, was divided into two groups as deceased (group 1, n= 42, 25.3%) and living (group 2, n= 124, 74.6%). Results: Fasting blood glucose, blood urea nitrogen (BUN), creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), uric acid, C-reactive Protein (CRP)/Albumin ratio, leukocyte, neutrophil, erythrocyte distribution width percentage (RDW) values were found to be higher (p< 0.05) and triglyceride, total protein, albumin, hemoglobin, hematocrit values were lower in the deceased group (p< 0.05). In logistic regression analysis, statistical significance of all of these parameters disappeared. Conclusion: Advanced age, presence of chronic renal failure (CRF), FBS, BUN, creatinine, AST, ALT, uric acid, CRP/Albumin ratio, leukocyte, and neutrophil height may be helpful in determining increased mortality risk after percutaneous LMCA interventions.

Objective: Widely used method is blinded puncture of subclavian vein, but the complication rate is high in this method. In this study, we aimed to demonstrate the effect of roadmap use during implantation of permanent pacemaker on the success rate, speed of puncture and complications. Methods: The study was designed as a prospective randomized controlled study. Totally, 125 devices were implanted to the patients included in the study, and 518 punctures were performed for implantation of these devices. 186 punctures were performed in roadmap group and 332 punctures were performed in conventional group. Two groups were compared with regard to clinical and demographic features, speed and success of puncture and complications. Results: Baseline characteristics were similar between groups. Median duration of intervention for each puncture was 27 (15/46) s in roadmap group and 56 (30/100) s in conventional group. The number of attempts for a successful puncture was detected as 1 (1/2) in roadmap group and 2 (2/4) in conventional group. Arterial puncture incidence was 10.3% in roadmap group and 37% in conventional group (P < 0.001 for all). Considering complications, the incidence of pneumothorax and intramuscular puncture was seen lower significantly (P = 0.046 and P = 0.006, respectively). Conclusion: Number of attempts for successful puncture, time needed for successful puncture, number of arterial puncture and complication rate was significantly lower in patients undergoing pacemaker implantation by roadmap technique. Based on these data, roadmap technique may take the place of conventional method of puncture.

Unexpected and unexplained out-of-hospital cardiac arrests have a poor prognosis. Difficulties encountered during the differential diagnosis phase may delay the administration of specific treatment for treatable and reversible causes of cardiac arrest. Massive pulmonary embolism is a reversible cause of cardiac arrest, but without proper management it has a high mortality rate. Presently described is the case of a 53-year-old female patient with a massive pulmonary embolism.

OBJECTIVE:Diffuse coronary artery disease (CAD) is a challenging issue in clinical cardiology practice. There are limited data about percutaneous revascularization in these patients.METHODS:This study was an observational clinical evaluation. The records of patients with diffuse CAD revascularized with new-generation drug-eluting stents (DES) were researched retrospectively. Patients treated with multiple, overlapping new-generation DES (at least 60mm in length per vessel) were included. The incidence of major adverse cardiac events (MACE), defined as cardiac death, stent thrombosis, non-fatal myocardial infarction, and target lesion revascularization (TLR), at the end of the first year following the index procedure was recorded.RESULTS:A total of 71 patients (with 75 coronary vessels) treated with new-generation DES for diffuse CAD were enrolled in the study. Zotarolimus-eluting stents were used in 48 vessels and biolimus A9-eluting stents were used in 27 vessels. The median total stent length per vessel was 75.0 mm (60.0-106.0) and the median number of stents implanted was 3 (2-4) for each vessel. The cumulative incidence of MACE at the end of the first year was 11.2% (8 patients). The presence of diabetes mellitus (DM) and ST-segment elevated myocardial infarction (STEMI) were defined as independent clinical risk factors related to MACE development.CONCLUSION:Coronary artery revascularization with new-generation drug-eluting stents can be a good choice in the treatment of selected patients with diffuse CAD. DM and STEMI were found to be related to poorer clinical outcomes with this treatment option in our study.

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.

OBJECTIVETo investigate the association of epicardial adipose tissue thickness with irritable bowel syndrome.METHODSThis case-control and observational study was conducted in Recep Tayyip Erdogan University between January and December 2014, and comprised patients of irritable bowel syndrome and healthy controls who underwent a complete transthoracic echocardiographic examination as well as measurements of epicardial adipose tissue. They were screened for psychiatric or organic bowel diseases for the sake of precise diagnosis. Epicardial fat thickness was measured perpendicularly in front of the right ventricular free wall at end-diastole.SPSS 15 was used to analyse the data.RESULTSOf the 75 subjects, 44(59%) were patients and 31(41%) were controls. There was no statistically significant difference between the groups except epicardial adipose tissue thickness, which was significantly elevated in patients (p<0.001). C-reactive protein was significantly higher in patients (p=0.002). Epicardial adipose tissue (p<0.001) and haematocrit (p<0.05) were independent predictors of irritable bowel syndrome.CONCLUSIONSIncreased epicardial adipose tissue thickness, and accompanying low-grade inflammation appeared to be involved in irritable bowel syndrome pathogenesis.

A 53 year old female patient admitted to emergency department with respiratory failure, loss of consciuosness and circulatory collapse. There was no pulse or rhythm at admission. We could able to take pulse after 10 minutes cardiopulmonary resuscitation. We learned from her relatives that she had an arthroscopy procedure 5 days ago and she was sedentary at home after procedure. During resuscitation we performed bedside transthoracic echocardiography because of the high possibility of pulmonary embolism and transthoracic echocardiography revealed severe dilatation of right sided cardiac chambers. We assumed that massive pulmonary embolism as the most possible factor for circulatory collapse and we decided to give thrombolytic treatment and first bolus dosage of Reteplase (third generation thrombolytic agent) was given as 10 unite during on-going cardiopulmonary resuscitation. Massive amounts of intravenous hidration via central venous accesses was also started to support cardiac output. We also started inotropic agents as Dopamine and Dobutamine via central venous access. Second bolus dosage of Reteplase as 10 unite more was given 30 minutes later and blood pressure and pulse stabilized in the following hours. Suspected massive pulmonary embolism was documented with thoracic computerized tomography after stabilization of the patient. She was extubated on the following day and discharged from hospital after 1 week of hospitalization.

Objective Heart fatty acid binding protein (HFABP) is a low-molecular-weight free protein that is abundant in the intracytoplasmic space of myocytes. Due to its unique features, serum HFABP levels may increase in myocardial ischaemia. The aim of this study was to evaluate the effect of myocardial ischaemia induced by dobutamine stress echocardiography (DSE) on serum HFABP levels. Methods and results A total of 30 consecutive patients with suspected myocardial ischaemia underwent DSE examination. HFABP levels were measured immediately before and 1 hour after DSE. HFABP rose significantly in individuals in the DSE positive group (1.66 ± 1.18 ng/ml vs 2.65 ± 1.34 ng/ml, P = 0.004), but remained unchanged in the DSE negative group (1.61 ± 0.77 ng/ml vs 1.85 ± 0.76 ng/ml, P = 0.066). Conclusion Serum HFABP levels increased significantly at 1 hour in the presence of ischaemia induced by DSE in patients with stable clinical coronary syndromes. No such increase was evident in the absence of ischaemia.

Objective: Cardiac autonomic nervous dysfunction (CAND), a severe complication of diabetes, has also been shown to affect prediabetic patients. The role of isolated impaired fasting plasma glucose (IFG), a subtype of prediabetes, is not clear in the pathogenesis of CAND. The aim of this study was to examine the relationship between isolated IFG and cardiac autonomic function using heart rate variability (HRV) and heart rate turbulence (HRT) indices derived from 24-h Holter–electrocardiogram recordings. Methods: This observational, prospective, cross-sectional study examined 400 consecutive subjects divided into three groups according to oral glucose tolerance test results: the control group [Group I, fasting plasma glucose (FPG) <100 mg/dL and normal glucose tolerance, n=193], the isolated IFG group (Group II, FPG ≥100 and <126 mg/dL, n=134), and the isolated impaired glucose tolerance (IGT), both IFG and IGT, or newly diagnosed diabetes’ group (Group III, n=73). Patients with non-sinus rhythm, known diabetes mellitus, coronary artery disease, heart failure, severe valvular disease, or receiving medical therapy that may affect HRV and HRT indices were excluded. Time domain HRV parameters, turbulence onset (TO), turbulence slope (TS), and HRT category were examined. Chi-square, one-way analysis of variance, Kruskal–Wallis H, and Mann–Whitney U tests were used to compare variables where appropriate. The correlation between Holter data and FPG levels was analyzed using the Spearman’s test. Multiple linear regression analysis was performed to identify independent predictors of the HRV and HRT parameters. Results: Median (interquartile range 25–75) FPG levels in Groups I, II, and III were 89 (83/93) mg/dL, 109 (104/116) mg/dL, and 174 (150.5/197) mg/dL, respectively. There were significant differences in HRV and HRT parameters between and among all groups. While HRV parameters and TS decreased from Group I to Group III, TO and HRT category gradually increased. Additionally, FPG level was significantly correlated with SDNN, r=–0.220; SDNN index, r=–0.192; SDANN, r=–0.207; RMSSD, r=–0.228; pNN50, r=–0.226; TO, r=0.354; and TS, r=–0.331 (all p<0.001). Conclusion: CAND, as detected by both HRV and HRT, appear to be present in the isolated IFG subtype of prediabetes.