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Objectives: Left ventricular (LV) dyssynchrony parameters are still being investigated to guide and optimize treatment in heart failure. We investigated the prognostic importance of LV systolic dyssynchrony in nonischemic dilated cardiomyopathy (DCM) using tissue Doppler echocardiography.
Study design: The study included 62 patients (39 males, 23 females; mean age 40 years; range 9 to 77 years) with nonischemic DCM. All the patients were examined by electrocardiography, echocardiography including tissue Doppler imaging (TDI), and angiography. The patients were evaluated in two groups depending on the intraventricular delay (IVD) of ≤65 msec (group 1, 10 patients) and >65 msec (group 2, 52 patients). The primary endpoint was defined as overall mortality during a mean follow-up period of 1,253±177 days (range 943 to 1583 days).
Results: Group 2 patients had a significantly longer mean IVD (129±68 msec vs. 57.5±8.7 msec; p=0.013), higher rate of left bundle branch block (30.8% vs. 10%; p=0.05), longer QRS duration (145±29 msec vs. 129±23 msec; p=0.02), and higher mortality (55.8% vs. 10%; p<0.0001). Sudden cardiac death was seen in one patient in group 1, compared to 12 patients in group 2. All the remaining deaths (n=17) occurred in group 2. In ROC analysis, the cutoff level for IVD was 65 msec for predicting clinical endpoint (specificity 72%, sensitivity 46%). Kaplan-Meier survival analysis showed a significantly lower survival in group 2 (p=0.045). In multivariate analysis, admission IVD was the only significant independent predictor of mortality (p<0.001).
Conclusion: Our results showed that increased IVD was associated with increased risk for death in patients with nonischemic DCM, independent from the QRS width and LV ejection fraction. These patients might be considered earlier for cardiac resynchronization therapy.

Objectives: Mean platelet volume has been reported as a predictor of unfavorable prognosis in patients with ST-segment elevation myocardial infarction (MI). We evaluated the relationship between admission mean platelet volume and the response to fibrinolytic therapy using the TIMI frame count in patients with acute ST-segment elevation MI.
Study design: The study included 87 patients (58 males, 29 females; mean age 55±11 years) who received fibrinolytic therapy within the first 12 hours of symptom onset for acute ST-segment elevation MI. Venous blood samples were obtained to determine admission mean platelet volume and fibrinolytic therapy was administered. Coronary angiography was performed within the first 72 hours and the TIMI frame count was measured for infarct-related artery. TIMI frame counts of <40 and ≥40 were defined as complete and incomplete reperfusion, respectively.
Results: Reperfusion was complete in 35 patients (40.2%) and incomplete in 52 patients (59.8%). The mean TIMI frame counts were 31.8±5.9 and 61.2±15.3 in patients with complete and incomplete reperfusion, respectively (p<0.01). Patients with complete reperfusion had a significantly lower mean platelet volume (9.4±0.4 fl vs. 9.7±0.3 fl; p=0.016). There was a highly significant correlation between mean platelet volume and incomplete reperfusion (r=0.742, p<0.0001).
Conclusion: High levels of admission mean platelet volume might be associated with insufficient reperfusion response to fibrinolytic therapy in patients with acute ST-segment elevation MI.

Objectives: We evaluated our initial experience with percutaneous closure of ventricular septal defects (VSD) in adult patients.
Study design: Percutaneous closure of VSDs in adult patients was launched in 2007 in our center. This study included the first five patients (3 women, 2 men; mean age 32.6 years; range 17 to 44 years) with a perimembranous (n=4) or muscular (n=1) VSD. Before percutaneous intervention, all the patients were assessed by transthoracic (TTE) and, when necessary, transesophageal (TEE) echocardiography, heart catheterization, and ventriculography. Percutaneous closure was performed under fluoroscopy and TEE or TTE guidance using the Amplatzer device (perimembranous asymmetric VSD occluder in perimembranous VSDs and muscular VSD occluder in muscular VSD).
Results: The mean VSD diameter was 7.4 mm (range 5 to 11 mm) by echocardiography, and 8.2 mm (range 6 to 11 mm) by ventriculography. The mean left ventricular end-diastolic diameter was 47.2 mm, and the mean distance between the VSD and the aorta was 5.6 mm. Percutaneous closure was successful in all the patients. Ventriculography obtained immediately after the procedure showed minimal passage from the interventricular septum in three patients, but there was no passage on control TTE examination on the first day after the procedure. Aortic, tricuspid, and mitral valves showed normal function. No rhythm problems were seen. All the patients were discharged within one or two days after the procedure.
Conclusion: Percutaneous closure of VSDs has become a good alternative to surgical repair in recent years, with high success rates and low morbidity. The results of percutaneous closure of VSDs are also successful in adult patients.

Objectives: The aim of our study was to evaluate the influence of lung resection on cardiac functions by using tissue Doppler echocardiography.
Study design: Nineteen consecutive patients (15 males, 4 females; mean age 55±8 years) undergoing major lung surgery (16 lobectomy, 3 pneumonectomy) were evaluated in a prospective design. Malignant lung cancer (n=15, 79%) was the major cause for lung surgery. Exclusion criteria were a history of myocardial infarction, angina, atrial fibrillation, valvular heart disease, major arrhythmias, diastolic dysfunction, heart surgery, and FEV1/FVC ratio lower than 60%. Two-dimensional Doppler echocardiography and tissue Doppler imaging (TDI) were performed one or two days before surgery and 4±2 weeks postoperatively.
Results: Compared to the preoperative measurements, right and left atrial and ventricular dimensions did not differ after surgery (p>0.05). Left ventricular ejection fraction, left ventricular end-systolic and end-diastolic volumes were preserved postoperatively. The following Doppler parameters showed significant changes after surgery: mitral A wave (92±23 cm/sec vs. 105±27 cm/sec, p=0.005), mitral E/A ratio (1.0±0.2 vs. 0.8±0.2, p=0.001), tricuspid A wave (65±19 cm/sec vs. 80±30 cm/sec, p=0.006), and tricuspid E deceleration time (327±68 msec vs. 274±51 msec, p=0.01). Concerning TDI parameters, there were significant differences in mitral E´/A´ ratio (1.0±0.4 vs. 0.8±0.3, p=0.03) and tricuspid E´ wave (9±2 cm/sec vs. 8±3 cm/sec, p=0.03) after surgery.
Conclusion: Findings of our study suggest that systolic functions are preserved but diastolic functions are affected after major lung resection in a relatively short time period.

Objectives: Atrial fibrillation (AF) is a common problem in cardiac surgery patients. We evaluated the mid-term results of patients who underwent open heart surgery and radiofrequency ablation (RFA).
Study design: The study included 79 patients (53 females, 26 males; mean age 53±11 years; range 32 to 76 years) who underwent concomitant RFA for AF during open heart surgery under cardiopulmonary bypass. The majority of patients were in NYHA class III (n=68, 86.1%) and had (n=67, 84.8%) rheumatic heart disease. The mean preoperative AF duration was 47±41 months. The most frequent procedure involved the mitral valve (64 replacements, 11 reconstructions). A unipolar probe was used in 60 patients (76%) and a bipolar probe in 19 patients (24.1%). The mean follow-up period was 20.8±14.7 months (range 1 to 59 months).
Results: The mean perfusion and cross-clamp times were 102.4±15.7 min (range 48 to 171 min) and 76.1±25.0 min (range 27 to 145 min), respectively. In-hospital mortality occurred in two patients (2.5%) and late mortality occurred in three patients (3.8%). One patient (1.3%) required implantation of a permanent pacemaker. During discharge, 58 patients (73.4%) were in sinus rhythm, of which nine (15.3%) developed recurrent AF within a mean of 5.3±4.4 months (range 2 to 12 months). Transient atrial flutter was seen in three patients (3.8%). Logistic regression analysis showed no risk factor to significantly affect early or late AF recurrence. Six- and 12-month rates of AF-free rhythm were 94.3±3.9% and 87.6±5.9% for operations performed by the year 2006 and 95.2±3.3% and 92.2±4.4% afterwards, respectively (p=0.0001). There was no significant difference with respect to survival between patients discharged with AF and in sinus rhythm (p>0.05).
Conclusion: Radiofrequency ablation is increasingly performed for the treatment of AF, yielding more successful results.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIF) is an uncommon but serious complication of aortic valve endocarditis. A 23-year-old woman was referred to our institution with the diagnosis of aortic valve endocarditis thought to be complicated by an aortic root abscess. Two-dimensional transthoracic echocardiography revealed a vegetation attached to the left coronary cuspis of the aortic valve and a false aneurysm-like structure in the MAIF at the left ventricular outflow tract. The diagnosis of MAIF pseudoaneurysm was confirmed by three-dimensional echocardiography. The patient died a few hours after admission because of worsening of her neurological status. An abscess-like structure detected in a patient with aortic valve endocarditis should be differentiated from a pseudoaneurysm of the MAIF.

Mitochondrial disorders have been recognized as important secondary causes of cardiomyopathies. Differentiation of these cases from primary cardiomyopathies is important since the pathogenesis, accompanying systemic manifestations, and prognosis may be different. The typical cardiac manifestation of mitochondrial disorders is hypertrophic cardiomyopathy. We report on an 11-year-old girl with severe obstructive hypertrophic cardiomyopathy and mild myopathy of the lower extremities. Surgical left ventricular septal myectomy was performed and ragged red fibers typical of mitochondrial disorders were detected on histological examination of the resected myocardial sample. Subsequent electron microscopic examination revealed ultrastructurally abnormal mitochondria in the skeletal muscle biopsy, though respiratory chain enzyme analysis was normal. Cardiomyopathy may be the presenting or the sole manifestation of a mitochondrial disorder. Nonobstructive hypertrophic cardiomyopathy has been considered to be the typical cardiac phenotype of mitochondrial disorders, and cases with left ventricular outflow tract obstruction have only rarely been reported.

Myotonic dystrophy type 1 (MD1) is an autosomal dominant disorder characterized by myotonia, progressive muscular weakness, cataract, and cardiac involvement. Cardiac involvement is common and includes conduction system abnormalities, supraventricular and ventricular arrhythmias, and less frequently, myocardial dysfunction and ischemic heart disease. A 54-year-old woman with a previous diagnosis of MD1 was admitted with palpitation, blood pressure of 157/118 mmHg, and a heart rate of 220 beat/min. Electrocardiography (ECG) showed ventricular tachycardia. Within minutes, hemodynamic collapse developed and electrical cardioversion was performed. Immediately following cardioversion, ECG showed atrial fibrillation, a slightly prolonged QT interval, and intraventricular conduction delay. After intravenous infusion of amiodarone, the rhythm converted to sinus. Transthoracic echocardiography showed significantly depressed left ventricular function, an ejection fraction of 25%, and normal coronary arteries. During electrophysiological study, atrium-His interval and His-ventricle interval were 120 msec was 54 msec, respectively, and monomorphic ventricular flutter was induced. An implantable cardioverter-defibrillator was placed. She was discharged in sinus rhythm.

Cardiac resynchronization therapy (CRT) is an effective treatment in patients with severe refractory heart failure combined with intraventricular conduction disease, improving quality of life and decreasing mortality. In CRT, pacing of the left ventricle is accomplished by a coronary sinus (CS) electrode. The main challenge for this technique is to achieve and maintain an optimal lead position so that no dislocation occurs. Cardiac resynchronization therapy was planned in a 66-year-old male patient with NYHA (New York Heart Association) class 3-4 symptoms and left bundle branch block. After two dislocations of the pacing lead from the posterolateral CS, the lead was implanted in the middle cardiac vein and stabilized by coronary stenting. During a six-month follow-up, no further dislocation occurred and pacing parameters were normal.

Head-up tilt test is used for assessing patients with vasovagal syncope. A 45-year-old man was examined for two syncopal and three presyncopal episodes during the past three months, all of which preceded by nausea and sweating. Examinations including electrocardiography and echocardiography showed normal findings. A head-up tilt table testing was performed at an angle of 75 degrees. At about 12 minutes, syncope associated with bradycardia and asystole was observed. He became hypotensive, and there was a ventricular asystolic pause lasting 18 seconds, associated with loss of consciousness. He was placed in the supine position and cardiac massage was started. After 25 seconds, he slowly returned to sinus rhythm and regained consciousness. The patient was treated with dual-chamber pacemaker implantation. During one year of follow-up, no major events occurred.

Air ambulance system has been established throughout the country by the Ministry of Health of Turkey. Fifteen provinces are determined as centers of the system so that all the country is covered within at the most one-hour flight distance. As part of this nationwide system, two helicopter ambulances have been deployed in our hospital since November 2008. Prompt use of reperfusion therapy improves survival of patients sustaining acute myocardial infarction (AMI). Two components of delay from the onset of AMI to reperfusion therapy are prehospital and interhospital transportations. We presented the first two cases of AMI whose transfers were made by a helicopter ambulance for primary percutaneous coronary intervention. One patients (age 58 years, male) presented to a state hospital 47 km away from Ankara about an hour after the onset of chest pain. Time to reach the patients by a helicopter ambulance was 28 minutes and transfer to our center was 14 minutes. The other patient (age 76 years, male) was admitted within 15 minutes of the onset of chest pain to a state hospital 58 km away from Ankara. Reaching the patient by a helicopter ambulance and transferring him to our center took 30 minutes and 16 minutes, respectively. Door-to-balloon times were 16 minutes and 18 minutes, respectively. Infarct-related coronary artery patency was achieved in both cases.

Egg has been accepted as a symbol of high cholesterol diet for years and its consumption has been a matter of debate for cardiovascular health. Clinical studies have yielded conflicting results, increasing the amplitude of arguments. This article reviews the current literature related to egg consumption and summarizes the merits and demerits of egg consumption on a scientific basis. Current guidelines recommend to restrict dietary cholesterol consumption to 200 mg daily for cardiovascular health. Therefore, when making dietary suggestions especially for patients with cardiovascular disease, diabetes, severe risk factors and hypercholesterolemia, or a family history of premature atherosclerosis, we should keep in mind that an average egg yolk contains >200 mg cholesterol even though its negative effect on serum lipid levels is less than that of other sources of dietary cholesterol.

letter to the editor

Coronary slow flow is a frequent phenomenon where TIMI frame count has been the standard of measure. Hovewer from a methodological point of view TIMI frame count method involves some limitations which have to be considered and standardized by design.

There is a suspicion about the lipid-lowering treatment in a patient with elevated nonalcoholic fatty liver disease-induced transaminase. In this letter, we will cover on this topic.