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Son dönem kalp yetersizliklerinin cerrahi tedavisinde yeni bir alternatif metod olarak Dr. Randos Batista tarafýndan tanýmlanan "parsiyel sol ventrikülektomi" iþlemine ait Türkiye'nin ilk klinik olgularýndan biri takdim edilmektedir. Ýdiyopatik dilate kardiyomiyopatili 54 yaþýndaki erkek hasta NYHA klas IV'te idi. Preoperatif olarak sol ventrikül end-diyastolik volümü 530 mL, end-diyastolik çap 10.5 cm ve MUGA ile ölçülen ejeksiyon fraksiyonu % 11 idi. Kardiyopulmoner bypass altýnda çarpan kalpte sol ventrikül lateral duvarý ile mitral lifletler rezekte edilerek, primer onarýldý. Postoperatif 1. haftanýn sonunda, klinik ve hemodinamik verilerde önemli düzelmeler saptandý. Postoperatif 8. günde hastaneden taburcu edilen hasta halen 2. ayýnda hayattadýr.

This report is on one of the first clinical applications of partial left ventriculectomy operation in Turkey. The procedure was deseribed by R. Batista as an alternative new method in surgical treatment of heart failure. The 54-year-old male patient with idiopathic dilated cardiomyopathy, was in NYHA class IV. Preoperatively, left ventricular end-diastolic volume was 530 mL and end-diastolic diameter was 10.5 cm on echocardiographic evaluation. The left ventricular ejection fraction estimated by MUGA was 11%. At operation, left ventricular lateral wall and mitral leaflets were resected in the beating heart with cardiopulmonary bypass. Mitral valve was replaced with a prosthetic valve and the left ventricle was repaired primarily with suture. We have observed an Ýmportant improvement in clinical and hemodynamic findings after one week. He was discharged from hospital at the postoperative 8th day and is presently surviving in the postoperative second month.

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Mitral yetersizliðinin derecelendirilmesi tedavi seçenekleri açýsýndan önemlidir. Son zamanlarda proksimal akým konverjans yöntemiyle mitral yetersizliðinin kantitatif olarak deðerlendirilebileceði gösterilmiþtir. Biz çalýþmamýzda mitral yetersizliðinde proksimal akým konverjans yöntemi ile yetersizlik akým hacmini belirlemeyi ve bunu hemodinamik çalýþmalarla karþýlaþtýrmayý amaçladýk. Çalýþmaya yaþ ortalamalarý 26.1±8.7 yýl olan 34'ü erkek (%74), 12'si kadýn (%26) olmak üzere toplam 46 olgu alýndý. Tüm olgularda kalp kateterizasyonu ve iþlemden 6 ila 10 saat sonra ekokardiyografik inceleme yapýldý. Hemodinamik deðerlendirmeye göre yetersizlik akým hacimleri karþýlaþtýrýldýðýnda 4. derece ile 3. derece ve 3. derece ile 2. derece arasýnda istatistiksel olarak anlamlý fark varken (p<0.05) 2. derece ile 1. derece arasýnda yetersizlik akým hacimleri arasýndaki fark istatistiksel olarak anlamsýzdý (p>0.05). Mitral yetersizliðinin derecelendirilmesinde hemodinamik çalýþma ve proksimal akým konverjans yöntemi arasýndaki korelasyon r=0.80 olarak belirlendi. Hemodinamik derecelendirme ile yetersizlik akým hacmi arasýndaki korelasyon ise r=0.76 olarak hesaplandý. Sonuç olarak, renkli Doppler ile proksimal akým konverjans yöntemi kullanýlarak yetersizlik akým hacminin hesaplanmasý hemodinamik olarak ciddi derecede mitral yetersizlikli hastalarý güvenilir olarak belirleyebilir. Bu yöntem mitral yetersizliðini deðerlendirmede noninvazif alternatif bir yöntem olarak deðer taþýmaktadýr.

Evaluation of mitral regurgitation is Ýmportant in regard to treatment alternatives. Recent studies revealed that mitral regurgitation may be evaluated quantitatively by the proximal flow convergence area method. In this study we aimed to calculate the rcgurgitant volume by proximal flow convergence method, and to compare this with hemodynamic studies. The study group consisted of 46 patients comprising 34 males (74%) and 12 females (26%) with a mean age of 26. 1±8.7 years. All patients underwent cardiac catheterization with echocardiographic examination after 6 to 10 hours. Regurgitant flow volumes were compared to hemodynamic classification, while statistically significant difference was found between fourth, third, and second degrees of mitral regurgitation (p<0.05), but there was no significant difference between second and first-degree mitral regurgitation. The correlation coefficient between the grades of mitral regurgitation estimated by hemodynamic study and proximal flow convergence method was 0.80, and the correlation coefficient among hemodynamic classification of mitral regurgitation and regurgitant flow volume calculated by proximal flow convergence method was 0.76. In conclusion, assessment of regurgitant flow volume by proximal flow convergence method with color Doppler echocardiography can accurately determine hemodynamically moderate to severe mitral regurgitation. This method is a valuable noninvasive alternative to evaluate mitral regurgitation.

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Propafenonun atriyal fibrilasyon ve filatteri sinüs ritmine döndürmede etkili olduðu bilinmektedir. Ancak kontrollü klinik çalýþmalarda propafenonun bu konudaki etkinliði hakkýnda çeliþkili sonuçlar bulunmaktadýr ve ayrýca ilacýn kalp yetmezliði olan hastalardaki güvenliliði tam olarak bilinmemektedir. Bu çalýþmada propafenonun atriyal fibrilasyon ve flatterli hastalarda sinüs ritmini saðlamadaki etkinliði ve güvenliliði plasebo kontrollü, randomize, tek kör ve çarpaz karþýlaþtýrmalý olarak deðerlendirildi. Akut (<72 saat) ya da kronik (72 saat) atriyal fibrilasyon ya da flatterli 60 hasta çalýþmaya alýndý. Bu hastalardan 12'sinde NYHA klas III veya IV olmak üzere 28'inde kalp yetmezliði bulunmaktaydý. Hastalar ilk ilaç olarak propafenon (2 mg/kg 10 dakikada intravenöz bolus) ya da plasebo almak üzere randomize edildi. Ýlk ilaç verilmesinden 60 dakika sonra sinüs ritmi saðlanamadýðýnda ikinci ilaç uygulandý. Hastalar her iki ilaç uygulamasýnýn ardýndan birer saat süreyle elektrokardiyografik olarak monitorize edildiler ve 15, 30, 45 ve 60. dakikalarda kan basýnçlarý ölçüldü; 12 kanallý yüzeyel EKG'leri ve bir dakikalýk ritm þeritleri çekildi. Propafenon alan 59 hastadan 20'si (%34), plasebo alan 50 hastadan ise 4'ü (%8) sinüs ritmine döndü (p<0.001). Propafenonun akut atriyal fibrilasyondaki baþarýsý % 64.5 (20/31) bulundu. Sinüse dönüþ süresi ortalama 15 ± 9 dakika idi. Atriyal flatterli ya da kronik atriyal fibrilasyonlu hastalarda ise propafenon plasebodan daha etkili bulunmadý. NYHA klas III ve IV kalp yetmezliði olan 12 hastanýn tümünde kronik atriyal fibrilasyon vardý ve bu hastalardan sinüs ritmine dönen olmadý. Klas II kalp yetmezliði olan 16 hastanýn 5'inde aritmi öyküsü akuttu ve bu hastalarýn 4'ü (%80) sinüs ritmine döndü. Sinüse dönmeyen, ancak geliþ kalp hýzlarý 100/dakikanýn üzerinde olan hastalarda propafenon ile kalp hýzýnda anlamlý yavaþlama oldu (p<0.0005). Propafenona ait önemli yan etki geliþmedi; kalp yetmezliði olan hastalarda klinik kötüleþme gözlenmedi. Sonuçta, (1) intravenöz bolus propafenonun akut atriyal fibrilsyonu sinüs ritmine döndürmede baþarýlý olduðu, ancak atriyal flatter ve kronik atriyal fibrilasyon olgularýnda etkisiz kaldýðý; (2) sinüse dönmeyen olgularda kalp hýzýný anlamlý olarak yavaþlattýðý; (3) orta ve aðýr derecede kalp yetmezliði olan hastalarda da güvenli olabileceði kanýsýna varýldý.

Propafenone has been claimed to be effective in converting atrial fibrillation and flutter to sinus rhythm. However, controlled clinical trials have reported conflicting results, and data about the safety of propafenone in the setting of heart failure are lacking. The aim of the present study was to evaluate the efficacy and safety of intravenous propafenone in converting atrial fibrillation and flutter to sinus rhythm, in patients with and without heart failure. Sixty patients with acute (<72 h) or chronic (>72 h) atrial fibrillation or flutter were included in a randomized, placebo-controlled, conditional cross-over study. T wenty-eight patients had heart failure of whom 12 were in NYHA class III and IV. Patients received intravenous propafenone (2 mg/kg in 10 min) and placebo subsequently with a 1-h interval if sinus rhythm was not achieved. The patients' rhythm was contiuously monitored for 1 h and a 12-lcad electrocardiogram, a 1-min continuous rhythm strip and vital signs were recorded at baseline and 15, 30, 45 and 60 min after the administration of each drug. Twenty of the 59 patients (34 %) treated with propafenone converted to sinus rhythm while only 4 of the 50 patients (8%) treated with placebo converted (p<0.001). Propafenone was more effective in patients with acute atrial fibrillation with a success rate of 64.5 % (20/31 ). The mean time to conversion was 15 ± 9 min. The conversion rate with propafenone was not significantly different from placebo in patients with atrial flutter and chronic atrial fibrillation. While none of the 12 patients with NYHA Class III or IV heart failure and chronic atrial fibrillation responded to propafenone, 4 of the 5 patients (80%) with NYHA Class II heart failure and acute atrial fibrillation converted to sinus rhythm. Propafenone significantly decreased (p<0.0005 vs placebo) mean ventricular rate in nonresponders with baseline heart rate of more than 100 beats/min. No clinically significant adverse effect occurred. We conclude that (l) intravenous propafenone treatment is effective for converting acute atrial fibrillation, however, it seems unlikely to be beneficial in atrial flutter and in chronic atrial fibrillation, (2) propafenone decreases ventricular rate in nonresponders, (3) single-dose propafenone is relatively safe even in modrate to severe heart failure

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Çalýþmamýzýn amacý, akut miyokard infarktüsü (AMÝ) geçiren hastalarda iskemik alaný azaltma giriþimlerinden sonra reperfüzyon ile kurtarýlan miyokard miktarýný ve eðer oluþuyorsa reperfüzyon hasarýný miyokard perfüzyon sintigrafisi ile deðerlendirmekti. Çalýþmaya AMÝ ile baþvuran yaþ ortalamasý 57.1±2.0 olan 7'si kadýn, 18'i erkek toplam 25 hasta alýndý. Hastalarýn tümüne acil servise müracaatlarýndan sonra ilk bir saat içerisinde 10 mCi 99m-Tc tetrofosmin enjeksiyonu ve koroner anjiyografi (KAG) yapýldý. KAG sonucuna göre 17 hastaya sadece trombolitik tedavi (11/17) veya trombolitik tedavi ile birlikte perkütan transluminal koroner anjiyografi (PTCA) (6/17) uygulandý. 8 olguya rekanilazasyon giriþiminde bulunulmadý. 99m-tc tetrofosmin enjeksiyonundan sonra ortalama 3.1 ± 0.3 saatte tüm hastalara miyokard perfüzyon SPECT çalýþmasý yapýldý. 24-48 saat sonra kontrol KAG'leri yapýlan hastalarýn miyokard sintigrafileri 12-26 günler arasýnda (ort. 16.8±0.8 gün) tekrarlandý. Geliþ EKG'lerine göre olgularýn 8'inde akut anterior, 17'sinde akut inferior MÝ bulgularý saptandý. KAG'de infarktüsten sorumlu arter 8 olguda sol ön inen arter 11 olguda sað koroner arter ve 6 olguda sirkumfleks arter idi. Trombolitik tedavi uygulanan 17 hastanýn (6'sýna PTCA da yapýldý) 4'ü (%24) ile, rekanalizasyon giriþiminde bulunulmayan 8 hastanýn 3'ünde (%38) olmak üzere toplam 7 hastada kontrol KAG'de infarktüsten sorumlu arterin açýlmamýþ olduðu görüldü. Kurtarýlan miyokard alaný reperfüzyon giriþimi yapýlan olgularda 24.3±8.5 pixel, kurtulma indeksi % 14.2 idi. Buna karþýlýk reperfüzyon yapýlmayan olgularda ise sadece 1.0±9.8 pixellik miyokard kurtulmuþtu. Kurtulma indeksi % 0.7 olarak hesaplandý. Sonuç olarak 99m-Tc tetrofosmin ile yapýlan miyokard sintigrafisinin rekanalizasyonun faydasýnýn gösterilmesinde, noninvazif ve kolay uygulanabilirliði nedeniyle deðerli bir yöntem olduðu kanaatine varýldý.

The aim of the study was to assess the value of myocardial perfusion scintigraphy (MPS) with 99m-Tc tetrofosmin to determine the salvaged myocardial tissue after reperfusion procedures in patients with acute myocardial infarction (AMI). The study group consisted of 25 patients (7 female, 18 male , mean age 57. 1 ± 2.0 years) who were admitted to the hospital within 12 hours of onset of AMI. On admission, 10 mCi 99m-Tc tetrofosmin was given and coronary angiography (CAG) was performed to all patients. Reperfusion procedures applied to 17 patients were either thrombolytic therapy or thrombolytic therapy with percutaneous transluminal coronary angioplasty (PTCA), whereas reperfusion was not applied to 8 patients. MPS was performed to all patients within an average of 3.1±0.3 hours following the tetrofosmin injection. Control CAGs were performed 24-48 hours later and MPS were repeated on 12-26 days of the AMI. Localization of the AMI was inferior in 17, anterior in 8 and the infarct-related artery was left anterior descending artery in 8, circumflex artery in 6 and right coronary artery in 11 patients. By means of control CAGs it was deduced that in 4 of the 17 patients who received thrombolytic therapy, (PTCA was performed 6 of them) and in 3 of the 8 patients who received no reperfusion procedures the infaret-related artery was not patent. Salvage index was 14.2% in patients who received trombolytic therapy and 0.7% in the other group. Therefore MPS with 99mTc tetrofosmin is a valuable method to show the benefits of reeanalization.

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Uzman sistemler, genellikle yapay zeka teknikleri ile geliþtirilen, belirli bir alana ait problemlerin etkin bir þekilde çözümünde o alana ait çok miktarda ve yüksek kalitede özel bilgiler kullanan güçlü bilgisayar programlarýdýr. Bu dizgelerde bilgiler tanýmlamalar, iliþkiler ve kurallar þeklinde bulunur. Bu çalýþmada, kalp cerrahisi erken postoperatif dönemde rastlanan sorunlarda taný ve tedavide danýþman olarak kullanýlmak üzere geliþtirilen ve YBD (Yoðun Bakým Danýþmaný) adý verilen yeni bir uzman sistem geliþtirilmiþtir. YBD bir bilgi tabaný, bir veri tabaný ve bir çýkarým mekanizmasýndan oluþmakta ve myokardiyal depresyon, kardiyak tamponat, yetersiz operasyon/onarým, hipovolemi, cerrahi kanama ve pýhtýlaþma defekti konularýnda danýþmanlýk yapabilmektedir. YBD'nin diðer önemli özellikleri, karar verirken izlediði yolu istenildiðinde açýklayabilmesi ve gereðinde yeni bilgiler ekleyerek bilgi tabanýný yenileyebilmesidir. Bu danýþman uzman sistem Prolog programlama dili ortamýnda geliþtirilmiþtir. Pamukkale Üniversitesi Týp Fakültesi Göðüs Kalp ve Damar Cerrahisi Anabilimdalý'nda opere edilen ilk 41 olgu erken postoperatif dönemde YBD bulgu tabanýnda örneklenmiþtir. Bu dönemde yapýlan deðerlendirmeler ve uygulanan tedaviler ile YBD önerileri arasýnda tam bir paralellik gözlenmiþtir. Sonuçta, YBD'nýn kalp cerrahisi postoperatif yoðun bakým uygulayabileceði düþünülmüþtür.

In this study, a new expert system named lCC (lntensive Care Consultant) is developed to play a consultant role in the diagnosis and the treatment of problems encountered in early postoperative period of cardiac surgery. lCC consists of a knowledge base, a data base and an inference engine and provides consultative advice about myocarclial depression, cardiac tamponade, inadequate operation, hypovolemia, surgical hemorrhage and coagulation defect. Other Ýmportant features of ICC are the capability of explaining the processes of decision making, and adding new knowledge and updating its knowledge base. The system is developed in Prolog programming language environment. Forty-one patients were sampled by this expert system in the early postoperative period in Thoracic and Cardiovascular Surgery Department of the Medical Faculty of Pamukkale University. During this period, the approaches and treatments were exactly matched with ICC's advices. Thus ICC may decrease the risk in diagnoses and treatment when usedl in cardiac surgery postoperative intensive care unit. It may also be helpful in training of junior doctors

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Ýmplantabl kardiyoverler defibriltörlü (ÝKD) hastalarýn % 15-20'sinde ayný zamanda kalýcý kalp piline ihtiyaç vardýr. Ýdiopatik dilate kardiyomiyopati, tekrarlayan ventriküler taþýkardi ve trifasiküler bloðu olan hastamýzda ani ölümü önlemek ve atrioventriküler iletiyi azaltarak sol ventrikül fonksiyonlarýný düzeltmek amacýyla çift odaccýklý kalp pili özelliði olan ÝKD taktýk. Bu makalenin amacý; hastamýzýn Türkiye'deki ilk ve halen tek olgu olmasý nedeniyle, çift odacýklý kalp pili özelliði olan ÝKD'lerin klinik kullanýmýný vurgulamaktýr.

Patients having implantable cardioverter defibrillators (ICD), also require cardiac pacemakers in 15-20 % of the cases. We implanted ICD with DDD pacemaker function, to a patient with idiopathic dilated cardiomyopathy, reentrant ventricular tachycardia and trifaseicular block. The aim was to diminish the risk of sudden death and improve left verticular function with decrement of the atrioventricular conduction. Since this is the first and the only case in Turkey, the aim of this article was to point out the clinical usage of ICDs with DDD pacemaker function.

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Ventrikül septum rüptürü (VSR), akut miyokard infarktüsünün (AMI) nadir görülen fatal bir komplikasyonudur. Bu yazýda, 70 yaþýnda, erkek bir VSR olgusu sunulmaktadýr. Olgunun göðüs aðrýsý anamnezi olmamakla birlikte koroner anjiyografide anterior miyokard enfarktüsü geçirmiþ olduðuna dair çok kuvvetli bulgular elde edilmiþtir. Sessiz miyokard iskemisinin, aðrý ile birlikte olan klinik formlar kadar dramatik komplikasyonlarla sonuçlanabileceði vurgulanmaktadýr.

Ventricular septal rupture (VSR) is a rare fatal complication of acute myocard ial infarction (AMI). Here, we present a case of a 70-year-old man in whom VSR had developed after a presumed silent anterior myocardial infarction which was retrospectively proven by the coronary angiographic findings. This case emphasizes that silent myocardial ischemia may have similar severe complications as symptomatic clinical forms of myocardial ischemia.

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