Objectives: We investigated mean platelet volume (MPV) in patients with slow coronary flow (SCF) and its possible relationship with clinical presentation.
Study design: The study included 50 patients with SCF and otherwise normal coronary arteries and 22 patients (control group) with normal coronary arteries. In the SCF group, there were 26 patients with stable angina pectoris (SAP), and 24 patients with unstable angina pectoris (USAP). Coronary blood flow was measured using the TIMI frame count. To determine MPV, blood samples with K3 EDTA were processed after one hour of venipuncture. The relationship between MPV and SCF was sought.
Results: The mean TIMI frame count was markedly increased in patients with SCF compared to controls (p<0.0001). No significant differences existed between the groups with regard to white blood cell and platelet counts. Patients with SCF had significantly higher MPV values compared to controls (9.4±2.3 fl vs 8.1±2.0 fl, p=0.014). In subgroup analysis, MPV was significantly increased only in patients presenting with USAP, compared to patients with SAP (p=0.044) and controls (p=0.002). There was a positive correlation between the mean TIMI frame count and MPV in patients with SCF (r=0.32, p=0.01). In multivariate analysis, MPV was the only independent predictor of SCF (p=0.006, odds ratio=1.305, 95% CI=0.985-1.730).
Conclusion: Our findings show that MPV is increased in patients with SCF, and SCF patients presenting with USAP exhibit significantly increased MPV values, suggesting an altered platelet reactivity and aggregation which may require effective anti-platelet therapy in this patient subgroup.

Objectives: We investigated the relationship between high sensitivity C-reactive protein (hs-CRP) activity and autonomic nervous activity using heart rate variability in smokers.
Study design: The study consisted of 136 healthy subjects, including 66 smokers (35 women, 31 men; mean age 36 years) and 70 nonsmokers (43 women, 27 men; mean age 34 years). Serum samples were collected from all the subjects. Three-channel, 24-hr Holter monitoring was performed to derive the mean heart rate, standard deviation of normal NN intervals (SDNN), standard deviation of 5-minute mean NN intervals (SDANN), root mean square differences of successive NN intervals (RMSSD), high- (HF) and low- (LF) frequency power components, and the LF/HF ratio.
Results: In smokers, the mean duration of smoking was 13.6±8.2 years (range 3 to 45 years), and the mean number of cigarettes consumed per day was 16.3±7.1 (range 5 to 40). Smokers exhibited significantly higher mean heart rate, hs-CRP and fibrinogen levels, mean platelet volume, white blood cell count, LF, and LF/HF ratio, with significantly lower SDNN, SDANN, RMSSD, and HF values. In smokers, hs-CRP was correlated with the number of cigarettes consumed per day, duration of smoking, fibrinogen level, mean platelet volume, white blood cell count, LF, and LF/HF ratio, and inversely correlated with HF, SDNN, and SDANN. Even smoking a single cigarette resulted in an acute, 0.07-fold increase in the hs-CRP level (p<0.0001). In linear regression analysis, both the number of cigarettes consumed per day (=0.52, p=0.011) and duration of smoking (=0.073, p<0.0001) had an independent effect on the hs-CRP level.
Conclusion: Smoking both impairs the sympathovagal balance and increases the hs-CRP activity in otherwise healthy smokers, the combination of which would probably contribute to a higher rate of cardiovascular events.

Objectives: Nonalcoholic fatty liver disease (NAFLD) is an important complication of metabolic syndrome (MS). We investigated the possible relationship between NAFLD and angiographical severity of coronary artery disease (CAD) in patients with MS.
Study design: This prospective study included 80 patients (35 men, 45 women; mean age 63±10 years; range 42 to 80 years) with a diagnosis of MS according to the ATP III criteria. All patients underwent abdominal ultrasonography to detect NAFLD. Coronary angiography was performed for stable angina pectoris (n=48), unstable angina pectoris (n=21), and prognostic reasons (n=11). The severity of CAD was assessed by the number of vessels involved (vessel score) and the severity score (Gensini score). Significant stenosis was defined as 70% or greater reduction in lumenal diameter.
Results: Ultrasonography revealed NAFLD in 43 patients (53.8%). Patients with NAFLD had significantly higher body mass index, waist circumference, and serum triglyceride level, and significantly lower HDL-cholesterol level (p<0.001). Coronary angiography showed significantly higher vessel (2.5±0.9 vs 1.0±1.0) and CAD severity scores (90.2±40.0 vs 36.4±28.9) in patients with NAFLD (p<0.001). Univariate analysis showed that the presence of NAFLD (r=0.61, p<0.001), grade of NAFLD (r=0.42, p<0.001), and patient age (r=0.36, p=0.002) were significantly correlated with the CAD severity score. In multivariate linear regression analysis, the presence of NAFLD was the only independent factor affecting the CAD severity score (: 1.35, p<0.001).
Conclusion: The presence of NAFLD is associated with more severe CAD, requiring that patients with MS be investigated for the presence of NAFLD and those with NAFLD be attentively followed-up for the presence and severity of CAD.

Objectives: The most important cause of increased mortality in end-stage renal disease (ESRD) is cardiovascular diseases. We investigated the prognostic value of cardiac troponin T (cTnT) and homocysteine in the long-term follow-up of ESRD patients.
Study design: The study included 78 patients (54 males, 24 females; mean age 53.2±16.6 years) with ESRD, who had been on hemodialysis treatment for at least three months. Baseline troponin T and homocysteine levels were measured and the patients were followed-up from March 2002 to May 2007 for major adverse cardiovascular events (MACE).
Results: Major adverse cardiovascular events occurred in 26 patients (33.3%), including cerebrovascular events (n=3, 3.9%), congestive heart failure (CHF) (n=18, 23.1%), coronary artery disease (CAD) (n=19, 24.4%), and death (n=19, 24.4%). Two-thirds of diabetic patients developed MACE and the mean age in the MACE group was significantly greater (p<0.001). Troponin T levels were significantly higher in patients who developed MACE (0.21±0.43 ng/ml vs 0.06±0.28 ng/ml, p=0.002), whereas homocysteine levels did not differ significantly between the two groups (p=0.82). For a cutoff value of 0.10 ng/ml, cTnT was ≥0.1 ng/ml in 17 patients (21.8%), and <0.10 ng/ml in 61 patients (78.8%). Patients having a cTnT level of ≥0.10 ng/ml showed significantly higher rates of MACE (64.7% vs 24.6%; p=0.003), CHF (47.1% vs 16.4%; p=0.02), and death (52.9% vs 16.4%; p=0.004). There was also a greater tendency to CAD in this group (41.2% vs 19.7%, p=0.10). In multivariate logistic regression analysis, age and diabetes mellitus were the independent predictors of MACE development.
Conclusion: Homocysteine levels cannot predict MACE in ESRD patients in the long-term follow-up. Despite a significantly higher incidence of MACE in patients with high cTnT levels, cTnT was not an independent predictor of cardiovascular outcome.

Objectives: Although right ventricular (RV) systolic dysfunction is an important indicator for the severity of mitral stenosis (MS), its diagnosis is difficult before systemic signs of venous congestion occur. We assessed the association between tissue Doppler (TDI)-derived isovolumic myocardial acceleration (IVA) and the severity of MS.
Study design: The study included 112 MS patients (79 mild to moderate, 33 severe MS). Two-dimensional and Doppler echocardiographic parameters (mitral valve area, transmitral diastolic gradients, pulmonary artery pressure, RV fractional shortening, pulmonary flow acceleration time, tricuspid valve annular systolic excursion) were calculated. Additionally, TDI-derived systolic velocities of the tricuspid annulus (IVA, peak myocardial velocity during isovolumic contraction-IVV, peak systolic velocity during ejection period-Sa) were recorded. The results were compared with those of 60 age- and sex-matched healthy controls.
Results: All TDI-derived systolic velocities (IVV, Sa and IVA) were significantly decreased in patients with MS (p<0.0001). However, IVA was the only parameter to distinguish the severity of MS (p<0.0001). It also showed significant correlations with the following parameters with which IVV and Sa were not correlated: mitral valve area (r=0.79, p<0.0001), mean (r=-0.54, p<0.0001) and maximum (r=-0.58, p<0.0001) transmitral diastolic gradients, pulmonary artery pressure (r=-0.54, p<0.0001), and left atrial diameter (r=-0.68, p<0.0001). The ROC curve analysis showed that an IVA of <2.9 m/sec2 predicted MS patients with 86% sensitivity, 87% specificity, and an IVA of <2 m/sec2 predicted severe MS with 82% sensitivity and 77% specificity.
Conclusion: Tissue Doppler-derived right ventricular IVA may be used as an adjunctive, alternative noninvasive parameter to determine the severity of MS in patients without signs of systemic venous congestion.

A 45-year-old man presented with gradual dyspnea, abdominal distension, and pedal edema of six-month history. A lateral chest x-ray demonstrated severe, dense calcification of the pericardium. Two-dimensional and pulsed-wave Doppler echocardiography demonstrated signs of constrictive pericarditis. Chest computed tomography showed diffuse, incomplete calcification of the pericardium and a dilated superior vena cava. The patient refused pericardiectomy, so medical treatment was instituted.

Acute anterior myocardial infarction (MI) due to left main coronary artery thrombosis is a rare entity with a very high mortality rate. A 72-year-old male patient was admitted with chest pain of two-hour onset that appeared during syncope. Electrocardiography showed first-degree AV block, right bundle branch block, left anterior fascicular block, ST-segment elevation of 5 mm in lead aVR, and significant ST depression in anterior derivations, suggesting acute anterior MI. Coronary angiography showed total occlusion of the left main coronary artery. During consultation for emergency operation, he developed hypotension. An intra-aortic balloon pump was inserted and inotropic support was initiated. He required several attempts of cardioversion due to persistent attacks of ventricular tachycardia. He developed respiratory arrest, requiring endotracheal intubation mechanical ventilation. The patient died due to recurrent attacks of ventricular fibrillation and subsequent development of asystole during primary percutaneous coronary intervention.

Exercise-induced ST-segment elevation without Q waves is a rare situation. Its frequent causes are slow coronary flow leading to serious myocardial ischemia, significant coronary stenosis, and coronary vasospasm. Effort-related combined anterior and inferior ST elevation is even rarer. A 49-year-old man was admitted with exercise-induced chest pain. During exercise stress test, he developed typical retrosternal chest pain with combined anterior and inferior ST elevation on electrocardiography. Coronary angiography showed an anomalous left circumflex coronary artery arising from the right sinus of Valsalva. A plaque and diffuse spasm were noted in the middle portion of the left anterior descending coronary artery. Intracoronary nitroglycerin administration resulted in complete resolution of the spasm. The patient was discharged on medical therapy.

A 21-year-old male patient underwent radiofrequency catheter ablation for refractory attacks of supraventricular tachycardia. One month after the procedure, he developed recurrent atrioventricular nodal re-entrant tachycardia, for which percutaneous cryoablation was performed. Programmed atrial stimulation at the end of cryoablation did not induce an atrio-His (AH) jump or tachycardia. During a four-month follow-up without any medications, the patient was free of any signs of tachycardia.

Unilateral diaphragm paralysis (UDP) is an important and often unrecognized cause of dyspnea. We report a 72-year-old man in whom UDP was incidentally detected by transthoracic echocardiography. He was asymptomatic at rest, but experienced dyspnea on exertion. Chest radiography was not pathognomonic in this case because the heart silhouette obscured the left diaphragmatic contour. Transthoracic echocardiography showed an extrinsic compression to the right atrium. Right atrial collapse was obvious during heart movements with variation upon respiratory movements. There was no pericardial effusion nor any solid mass lesion. Fluoroscopic sniff test demonstrated a significant paradoxical elevation of the paralyzed right diaphragm in inspiration. Thoracic and abdominal computed tomography scans did not show any other pathology. The diagnosis was made as idiopathic UDP.

Coexistence of partial anomalous pulmonary venous drainage (PVD) and pulmonary atresia with ventricular septal defect (PA-VSD) is very rare with the exception of heterotaxy syndromes. We presented two cases of PA-VSD in which partial anomalous PVD was detected during pulmonary artery angiography. One was a six-month-old girl who underwent cardiac catheterization to evaluate the chance of unifocalization. There were true pulmonary arteries and three major aortopulmonary collaterals. It was noted that the right upper pulmonary vein was in direct continuity with the right atrium. The second case was a 12-year-old girl who was previously diagnosed as having PA-VSD and absence of true pulmonary arteries, for which she had undergone two subsequent aortopulmonary shunt operations four years before. During cardiac catheterization, confluent but hypoplastic true pulmonary arteries and multiple minor aortopulmonary collaterals were detected. The right and left upper pulmonary veins were draining to the right atrium. It should be known that, albeit very rare, partial anomalous PVD may be present in PA-VSD cases, requiring careful evaluation of pulmonary venous drainage during echocardiographic and angiographic studies.

Mechanical valve thrombosis is a life-threatening complication, occurring in 0.5% to 8% of left-sided mechanical prosthetic valves, and in 20% of tricuspid valve prostheses. Although surgery is the first-line treatment modality particularly in symptomatic obstructive mechanical valve thrombosis, it is associated with high rates of morbidity and mortality. Fibrinolytic therapy and thrombolytic therapy have also been used as an alternative to surgical treatment. The risk for cerebral thromboembolism associated with thrombolytic therapy seems to be the main limitation for its use in left-sided mechanical valve thrombosis. In this article, we reviewed the treatment alternatives in obstructive mechanical valve thrombosis in the light of relevant studies, with a brief presentation of our experience.