Cardiac resynchronization therapy restores ventricular synchrony and has beneficial effects on left ventricular systolic function. Recent studies revealed a reverse remodeling in left ventricle with cardiac resynchronization therapy. However, changes in left atrial remodeling and effects spontaneous echo contrast (SEC) have not been adequately evaluated. The aim of this study was to investigate the long-term effects of cardiac resynchronization therapy on left atrial SEC, left atrial reverse remodeling, left atrial total emptying fraction, left ventricular systolic function and reverse remodeling in patients with dilated cardiomyopathy and left bundle-branch block. Material and methods: Fifteen patients with New York Heart Association Class III to IV, a left ventricular ejection fraction < 35%, complete left bundle-branch block, and a QRS >150 ms underwent implantation of biventricular pacemaker devices. Transthoracic and transesophageal echocardiography (TEE) were performed one week and before one and six months of pacemaker implantation. Exercise testing was performed with Naughton protocol one week before and one and six months after pacemaker implantation. Parameters one and six months after biventricular pacemaker implantation were compared with basal parameters. Results: After biventricular pacemaker implantation, significant clinical improvement and significant increase in exercise duration were observed in all patients. Left ventricular end-systolic and end-diastolic dimensions and left ventricular end-systolic and end-diastolic volumes significantly decreased one and six months after biventricular pacemaker implantation. Left ventricular ejection fraction, fractional shortening and cardiac index also increased after implantation. Mitral regurgitation was significantly reduced after implantation. Left atrial minimum and left atrial maximum volumes significantly decreased one and six months after biventricular pacemaker implantation. There was no change in left atrial maximum long diameter measured from the apical 4-chamber view. Left atrial minimum long diameter from the apical 4-chamber view significantly diminished six months after implantation. Left atrial diameter measured from parasternal long axis view progressively decreased in the follow-up period. Left atrial total emptying fraction increased, and frequency and intensity of SEC gradually decreased after biventricular pacemaker implantation. We concluded that cardiac resynchronization therapy results in atrial and ventricular reverse remodeling, increases atrial total emptying fraction and left ventricular systolic function, and reduces frequency and intensity of atrial SEC

Peak oyxgen consumption (VO2) during cardiopulmonary exercise testing (CPX) is a powerful independent prognostic marker to risk stratify patients with heart failure. Recently, percent predicted peak VO2 was found to be a more useful predictor of one-year outcome than peak VO2 alone. In this study, we aimed to evaluate the prognostic value of percent achieved of predicted peak VO2 for patients with chronic heart failure. Methods: One hundred-two patients with chronic heart failure (NYHA II-III) were studied. All patients performed CPX, and their peak VO2 values were measured. Predicted peak VO2 values were also estimated according to Wasserman's formula. Finally, percent achieved of predicted peak VO2 (measured/predicted peak ) VO2 values of each patient were calculated. Patients were divided into two groups, according to their percent achieved of predicted peak VO2 value, patients with a percent achieved of predicted peak VO2 > 50% (group 1), and patients with a percent achieved of predicted peak 50% (group 2). During a mean follow-up period of 13.6±6.2 months, mortality in each group were noted, and findings were evaluated with Kaplan-Meier survival analysis. Results: Eighty-six patients (84%) were men, and 16 (16%) were women with mean age of 60.7±9. Among them 68 (67%) had ischemic, and 34 (33%) had nonischemic dilated cardiomyopathy. One-year survival rate was 76% for the group 2, and 94% for the group 1 (p=0.02). Whereas, one-year survival rates were 70% for patients with peak VO2 14 ml/kg/min, and 98% for patients with peak VO2 > 4 ml/kg/min (p=0.001). We conclude that. percent achieved of predicted peak VO2 can be used as a useful prognostic marker for patients with chronic heart failure, but it is not superior to peak VO2 >14 ml/kg/min for one-year survival estimation.

Distribution of global coronary risk and of differences in the main risk factors in Turkey?s geographic regions were analyzed in a cross-sectional manner based on available data of the cohort of 2001/02. A point score that had been devised for the individual based on the Framingham and PROCAM risk scores and validated on the data of the Turkish Adult Risk Factor Study was used. Aside from major risk factors such as systolic blood pressure, total cholesterol and smoking status, HDL-cholesterol, waist circumference, C-reactive protein (CRP), fasting insulin, and prevalences of metabolic syndrome (MS) and coronary heart disease (CHD) were evaluated. Mean individual risk score in various regions varied between 15.7 and 17.7. The two regions with extreme risk scores corresponded to a difference of about 28-30% in absolute risk. The Marmara region demonstrated highest risk in both genders, while lowest risk was observed in Eastern Anatolia in men and the Black Sea region in women. Compared to the low risk category (<18 points in men, <21 points in women), individuals with high risk (?23 points in men, ?27 points in women) exhibited a 13-fold higher CHD likelihood. MS was observed with highest prevalence (48%) in the Mediterranean region, lowest in Eastern Anatolia (23%). Considering men and women combined, smoking was noted most in Central Anatolia, systolic pressure and total cholesterol levels in the Marmara region, whereas lowest HDL-cholesterol and highest CRP concentrations were noted in the Mediterranean region. It was concluded that, though differences in global coronary risk were modest across the regions, the Marmara region, followed by the Mediterranean region ranked highest. Main components of risk in the latter region were formed by those of insulin resistance, while risk appeared to originate chiefly from blood pressure and high LDL-cholesterol levels among residents of the Marmara region.

Surgical strategy and approach are important in patients with aortic coarctation associated with intracardiac anomalies. In this study, surgical technique, indications and results of the single stage repair of aortic coarctation and intracardiac defects via median sternotomy were discussed. Between January 1987 and August 2002, 158 patients with aortic coarctation or interrupted aortic arch (IAA) underwent surgery. In 17 of them who had associated intracardiac anomalies, single stage approach via median sternotomy were performed. Their ages ranged from 1 month to 13 years (mean 2.2 ± 3.3 years). Ventricular septal defect (VSD) and aortic stenosis were the most common associated lesions. Aortic coarctation was repaired under cardiopulmonary bypass initially and then intracardiac repair was performed. A short period of total circulatory arrest was necessary in two patients with IAA and one patient with extensive arcus hypoplasia. Among the patients who underwent single stage repair of aortic coarctation and intracardiac anomalies,a two month old baby with interrupted aortic arch, VSD and pulmonary hypertension died due to septicemia (5,8 %). Long period of ventilatory support was needed in one patient. One patient underwent reoperation due to severe residual coarctation gradient at the postoperative second month. Single stage repair via median sternotomy can be performed with low mortality and morbidity in patients with aortic coarctation and intracardiac anomalies. According to our opinion this approach should be the procedure of choice, because it is a safe and cost effective method. Also the patients can be avoided from the hazards of recurrent procedures.

Objective: Angiotensin II is well known to have several effects on cardiovascular autonomic functions. However, there is no data regarding the head to head comparison of the effect of angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers, the major drugs to inhibit angiotensin II, on heart rate variability (HRV). The aim of this study is to compare the effects of a single dose ACE inhibitor (captopril: 25 mg) and an angiotensin receptor blocker (valsartan: 80 mg) on HRV parameters. Material and Methods: The effects of a single oral dose of captopril, valsartan and placebo on 9 healthy male individuals (mean age 28±2 years) were studied in a double blind crossover placebo controlled study on three occasions. Frequency and time domain parameters of HRV were measured during supine position and during handgrip exercise before and after taking each agent. Results: Baseline blood pressure values, heart rates and HRV parameters were not found statistically different on each occasion. With captopril but not valsartan administration, heart rate at supine position decreased significantly in comparison with the baseline values without a change in HRV parameters (865±33 vs. 917±39, p=0.038). When compared to placebo during handgrip exercise, captopril caused a significant increase in the standard deviation of R-R interval (SDNN), which is a global HRV marker (50±5 ms vs. 58±5 ms, p=0.035, respectively). Conclusion: Captopril not only increases vagal tone at rest without altering vagal modulation but also increases SDNN during handgrip exercise. However these effects are not observed with valsartan.

Cachexia is a devastating condition in several chronic diseases, including chronic heart failure, cancer, AIDS, severe liver disease. The most practical and useful definition of cardiac cachexia is nonintentional and nonedematous weight loss of >7.5% of the premorbid normal weight in chronic heart disease patients occuring over a time period of >6 months. There is a general loss of whole body tissues but the loss is more prominent for lean tissue. Cachexia is also a powerful independent predictor of mortality. Its pathogenetical factors include insufficient nutrition, malabsorbtion, deconditiong (compromised physical activitity), cytokines, neurohormonal changes. Currently no acceptable and effective therapy exists for this condition. (Arch Turk Soc Cardiol 2003;31:347-56) Key words: Cardiac cachexia, cytokine, heart failure Kaşeksi; kalp yetersizliği, maligniteler, ağır karaciğer hastalığı ve romatoid artrit gibi birçok kronik hastalıkta görülebilen yıkıcı bir durumdur. Kaşeksi terimi, Yunanca kakos (kötü) ve hexis (durum) kelimelerinin bir araya getirilmesiyle türetilmiştir. Yaklaşık 2300 yıl önce Kos Adası?nda yaşayan Hipokrat tarafından: ?et tükenir ve suya döner,... omuzlar, klavikulalar, göğüs ve bacaklar erir. Bu hastalık ölümcüldür....? cümleleriyle tanımlanmıştır(1). Kronik kalp yetersizliği (KKY) hastalarında kaşeksi varlığı prognozun kötü olduğunu göstermekte ve mortalitenin bağımsız bir göstergesi olarak kabul edilmektedir(2). Prognoz üzerindeki olumsuz etkisi kesin olmakla birlikte, kaşeksinin tanımından patogenezine ve klinik yaklaşımına kadar hemen her alanda belirsizlikler mevcuttur. Bu makalede kalp yetersizliği hastalarında kardiyak kaşeksinin tanımı, patogenezi ve tedavisi konusundaki güncel bilgiler incelenmeye çalışılmıştır. Tanım Kardiyak kaşeksinin en iyi tanımı hakkında fikir birliği bulunmamaktadır. Klinik çalışmalarda kaşeksi tanımlamalarında birçok farklı belirteç kullanılmıştır. Bu belirteçlerden en sık kullanılanlar şunlardır: ? Kilo/boy indeksi ya da vücut kitle indeksi (VKİ=kilo/boy2): Kaşeksi diyebilmek için VKİ<24 kg/m2 olması gerekir(2). ? Önceden hazırlanmış cetvellerden cinsiyet, yaş ve boya göre hastanın ideal kitle yüzdesinin hesaplanması(3). Buna göre yapılan kaşeksi tanımlamalarından biri hasta kilosunun ideal vücut ağırlığının %80- 85?inden daha düşük olması durumudur (4). ? Kilo kaybına göre yapılan derecelendirme: En pratik, kapsamlı ve sık kullanılan tanım kilo kaybına göre yapılandır. Daha kapsamlı ve pratik diğer bir tanım ise KKY hastalarında kaşeksiye neden olabilecek başka bir hastalık (kanser, hipertiroidi, karaciğer hastalığı, vb) ödemin çözülmesine bağlı olmayan, hastalık öncesi normal ağırlığa göre istem dışı olarak %7.5?ten fazla kilo kaybı olmasıdır(5). Bu tanımlamada kaşektik durum şiddetine göre de sınıflandırılabilir: İleri derecede kaşeksi; kilo kaybının %15?den fazla olması, ya da %7.5? dan fazla kilo kaybı ile birlikte ölçülen kilonun ideal vücut ağırlığının %85?inden az olmasıdır. Orta ya da başlangıç derecesindeki kaşekside; kilo kaybı %7.5-15 arasında ya da kilo kaybı %7.5?dan fazla ve ölçülen kilo ideal vücut ağırlığının %85?ine eşit ya da büyüktür. Derecelendirmede kullanılan %7.5 değeri kesin kanıta dayanmayan bir sınır değerdir. SOLVD çalışmasının sonuçları analiz edildiğinde >%6 kilo kaybının sürvideki azalmayı daha doğru öngördüğü saptanmıştır

Anomalous origin of one or more coronary arteries occurs in about 0.6-1.15 % of patients undergoing coronary angiography. In the present paper, we report a patient with an extremely rare congenital coronary artery anomaly, in whom the left circumflex artery arising as a terminal extension of the right coronary artery. The main stem and obtuse marginal branches of the circumflex artery were normal and well developed. To our knowledge, this is the second case of a coronary artery anomaly reported in the medikal literatür in which the left circumflex artery arises as a terminal extension of the right coronary artery.