Kardiak resenkronizasyon tedavisi (CRT), ilaç tedavisine dirençli, intra ve/veya interventriküler iletim gecikmesi olan kalp yetmezliði vakalarýnda yaþam kalitesini artýran ve mortaliteyi azaltan etkili bir tedavi yöntemidir. Bu iþlemde sol ventrikül, koroner sinüs (KS) elektrodu tarafýndan uyarýlýr. Bu tekniðin en önemli problemi, optimal KS lead pozisyonunun saðlanmasý ve dislokasyonlarýn önlenmesidir. % 8-10 vakada KS elektrodunun yerleþtirilmesi ve stabilizasyonu imkansýz hale gelebilmektedir. New York Heart Association (NYHA), evre 3-4 kronik kalp yetmezliði ve sol dal blok’u olan 66 yaþýndaki hastaya CRT takýlmasý kararý verildi. Posterolateral koroner sinüse implante edilen elektrodun iki kez yerinden çýkmasý nedeniyle middle kardiyak vene yerleþtirilen ve koroner stent ile stabilize edilen olgu sunuldu.

CRT is an effective treatment method for patients with severe drug refractory heart failure combined with intraventricular conduction disease that has been shown improve life quality and decrease mortality. In this issue, pacing of left ventricle is accomplished by coronary sinus (CS) electrode. The main difficulty of this technique is to reach the optimal lead position and to avoid electrode dislocation. 8-10% of the cases, CS lead implantation and stabilization may be impossible. CRT was planned at 66 year-old- male patient who has NYHA grade 3-4 symptoms and left bundle branch block. The case reported because of departing of the lead twice from posterolateral branch of CS, the lead was implanted in middle cardiac vein and stabilized by coronary stent.

Ülkemizde Saðlýk Bakanlýðý tarafýndan helikopter hava ambulans sistemi kurulmaya baþlandý. Ülke genelinde 15 il, merkez olarak belirlendi. Bu illerden birer saatlik uçuþ mesafeleri ile tüm Türkiye kapsama alýnmaktadýr. Hastanemizde bu sisteme baðlý olarak Kasým 2008’ den itibaren 2 adet helikopter ambulans sürekli olarak konuþlandýrýldý. Akut miyokard infarktüsü (AMÝ) geçirmekte olan hastalarda reperfüzyon tedavisinin çabuk kullanýmý ile yaþam süresi uzatýlabilmektedir. Bu nedenle hastalarýn hýzlýca bir hastaneye nakledilmeleri çok önemlidir. AMÝ baþlangýcý ile reperfüzyon tedavisi arasýndaki gecikmelerin nedenlerinden iki tanesi hastane öncesi ve hastaneler arasý nakillerdir. AMÝ geçiren 2 olgu hastanemize helikopter ambulans ile nakledilerek primer perkütanöz koroner giriþim (PKG) yapýldý. Bu yazýda, AMÝ olgularýnda PKG için MÝ tedavi sistem programlarý ve hasta naklinde hava ambulansýnýn rolü tartýþýldý.

Ministery of Health has been established air ambulance system in Turkey. Fifteen provinces throughout Turkey has been determined as centers of the system. One-hour flight distances from these centers altogether cover whole country. Since October 2008, two helicopter ambulances has been deployed continously in our hospital as part of this nationwide system. Prompt use of reperfusion therapy improves survival of acute myocardial infarction (AMI) patients. Accordingly rapidly transporting the patient to a hospital is very important. Two components of the delay from the onset of AMI to reperfusion therapy includes prehospital and interhospital transportation. Two cases with (AMI) were transferred to our hospital by helicopter ambulances for primary percutaneous coronary intervention (PCI). In this report AMI care systems for PCI and and the role of air transportation has been discussed.

Amaç: Ýkiboyutlu (2B) ekokardiyografik yöntemlerle, prostetik mitral kapak deðiþiminden sonra görülebilen paravalvüler kaçak (PVK) yeri tam olarak gösterilememektedir. Bu çalýþmada, protez kapak deðiþimi sonrasý PVK geliþen olgularda, PVK kaynaðýnýn ve boyutunun gösterilmesinde gerçek zamanlý üçboyutlu transözofageal ekokardiyografinin (3B TÖE) deðeri araþtýrýldý.
Ça­lýþ­ma pla­ný: Çalýþmaya, mekanik kapak deðiþiminden ortalama 8.3±3.8 yýl sonra PVK geliþen 13 hasta (7 kadýn, 6 erkek; ort. yaþ 56±10; daðýlým 37-71) alýndý. Dokuz hastada (69.2%) atriyal fibrilasyon bulunurken, dört hasta (%30.8) normal sinüs ritmindeydi. Dört hastada (%30.8) hemoliz vardý. Ýki hastada hafif, altý hastada orta, beþ hastada ileri derecede PVK vardý. Ýkiboyutlu TÖE ile PVK saptanmasýndan hemen sonra hastalara 3B matriks dizilimli TÖE transdüser ile gerçek zamanlý 3B TÖE yapýldý. Paravalvüler kaçak yeri, aort kapaðýna göre konumlandýrýlan saat kadraný düþünülerek iþaretlendi ve ayrýþma boyutlarý ölçüldü.
Bul­gu­lar: Ýkiboyutlu TÖE’de ortalama PVK geniþliði 3.00±0.92 mm ölçüldü. Gerçek zamanlý 3B TÖE’de ise ayrýþma boyu 13.6±8.8 mm, geniþliði 3.88±2.04 mm bulundu. Paravalvüler kaçak yeri 3B TÖE’de sýrasýyla posteriyor ve anteriyor anülüs taraflarýnda, 12-03 (n=7) ve 06-09 (n=3) saatleri arasýnda ve mitral arka yaprak anülüsünün posteromedial ve anterolateral komissürlerinde yoðunlaþmaktaydý.
So­nuç: Ýkiboyutlu TÖE’de PVK’nin sadece geniþliðinin ölçülebildiði göz önüne alýndýðýnda, gerçek zamanlý 3B TÖE ile PVK’nin hem yeri belirlenebilmekte, hem de defektin boy ve geniþliði hesaplanabilmektedir.

Objectives: Two-dimensional (2D) echocardiographic approaches are not sufficient to determine the origin of paravalvular leak (PVL) that occurs after prosthetic mitral valve replacement (MVR). In this study, we investigated the role of real-time three-dimensional transesophageal echocardiography (RT-3D TEE) in detecting the origin and size of PVL occurring after prosthetic MVR.
Study design: The study included 13 patients (7 females; 6 males; mean age 56±10 years; range 37 to 71 years) who developed PVL within a mean of 8.3±3.8 years following mechanical prosthetic MVR. Nine patients (69.2%) had atrial fibrillation, and four patients (30.8%) had normal sinus rhythm. Four patients (30.8%) had hemolysis. Paravalvular leak was mild, moderate, and severe in two, six, and five patients, respectively. Real-time 3D TEE was performed using a 3D matrix-array TEE transducer immediately after detection of PVL on 2D TEE examination. Localization of PVL was made using a clock-wise format in relation to the aortic valve and the size of dehiscence was measured.
Results: The mean PVL width measured by 2D TEE was 3.00±0.92 mm. The mean length of dehiscence was 13.6±8.8 mm, and the mean width was 3.88±2.04 mm on RT-3D TEE. The PVLs were mainly localized in the posterior and anterior annular positions between 12 to 03 hours (n=7) and 06 to 09 hours (n=3) on RT-3D TEE, respectively, which corresponded to the posteromedial or anterolateral sectors of the posterior annulus.
Conclusion: Considering that only the width of the PVL defect can be assessed by 2D TEE, delineation by RT-3D TEE includes the localization of PVL together with the length and width of the defect.

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Amaç: Ülkemizde pulmoner arter hipertansiyonlu (PAH) hastalarýn prognozuna ait veriler sýnýrlýdýr. Bu çalýþmada, multidisipliner yaklaþýmla ileriye dönük olarak takip edilen PAH’li hastalarda taný ve tedavi deneyimimiz deðerlendirildi. Ça­lýþ­ma pla­ný: Hastanemizin Pulmoner Hipertansiyon Çalýþma Grubu tarafýndan iki yýl boyunca ileriye dönük olarak izlenen 51 hasta (32 kadýn, 19 erkek; ort. yaþ 45.4±9.7) çalýþmaya alýndý. Hastalarýn taný daðýlýmý þu þekildeydi: Ýdiyopatik/ailesel PAH (n=9), bað doku hastalýklarý ile iliþkili PAH (n=16), doðuþtan kalp hastalýklarý ile iliþkili PAH (n=11), pulmoner veno-okluziv hastalýk (n=1), kronik tromboembolik pulmoner hipertansiyon (n=10) ve diðer nedenler (n=4). Hastalar üç ayda bir klinik olarak ve altý dakika yürüme testi, transtorasik ekokardiyografi ve BNP düzeyleriyle deðerlendirildi.
Bul­gu­lar: Ortalama pulmoner arter basýncý 54.7±18.8 mmHg bulundu. Taný anýnda fonksiyonel kapasite dokuz hastada (%17.7) NYHA sýnýf II, 28 hastada (%54.9) sýnýf III, 14 hastada (%27.5) sýnýf IV idi. Otuz yedi hastaya (%72.6) spesifik farmakolojik ajanlar ile tedavi uygulandý. On dokuz hastanýn (%51.4) tedavisinde deðiþiklik yapýldý. Dokuz hastada (%17.7) tedaviyle NYHA sýnýfýnda en az bir basamak azalma görülürken, 25 hastanýn (%49) fonksiyonel kapasitesinde deðiþiklik olmadý. On yedi hastada (%33.3) klinik kötüleþme izlendi ve bu hastalarýn 11’i (toplam grubun %21.6’sý) kaybedildi. Ölen tüm hastalarýn NYHA fonksiyonel kapasitesi sýnýf III-IV idi. Ölen ve yaþayan hastalar arasýnda ortalama pulmoner arter basýncý (72.5±18.7 mmHg ve 49.8±21.2 mmHg), taný anýndaki BNP düzeyi (293.8±88.3 pg/ml ve 141.6±62.1 pg/ml) ve altý dakika yürüme mesafesi (123.8±41.3 m ve 200.7±52.1 m) anlamlý derecede farklýlýk gösterdi (p<0.05).
So­nuç: Son 20 yýlda sonlaným noktalarýnda iyileþmelere raðmen PAH tanýsý hastalýðýn ancak geç döneminde konmakta ve hastalarýn çoðunluðunda þiddetli iþlevsel ve hemodinamik sorunlar yaratmaktadýr.

Objectives: Information is limited on the prognosis of patients with pulmonary arterial hypertension (PAH) in Turkey. We evaluated our multidisciplinary diagnostic and therapeutic experience in PAH patients.
Study design: The study included 51 patients (32 women, 19 men; mean age 45.4±9.7 years) who were prospectively monitored during a two-year period by the PAH Working Group in our hospital. The diagnoses were as follows: idiopathic/familial PAH (n=9); PAH associated with connective tissue disease (n=16), congenital heart disease (n=11), and with pulmonary veno-occlusive disease (n=1); chronic thromboembolic pulmonary hypertension (n=10), and other causes (n=4). The patients were assessed every three months with clinical examination, six-minute walk test, transthoracic echocardiography, and BNP levels.
Results: The mean pulmonary artery pressure was 54.7±18.8 mmHg. Functional capacity was NYHA class II in nine patients (17.7%), class III in 28 patients (54.9%), and class IV in 14 patients (27.5%). Thirty-seven patients (72.6%) received treatment with specific pharmacological agents, in whom 19 patients (51.4%) required modifications during treatment. Nine patients (17.7%) benefited from treatment with decreases of at least one NYHA class, whereas NYHA class remained unchanged in 25 patients (49%). Seventeen patients (33.3%) exhibited clinical deterioration, of whom 11 died with an overall mortality of 21.6%. Patients who died were all in NYHA class III or IV and significantly differed from those who survived with respect to mean pulmonary artery pressure (72.5±18.7 mmHg vs. 49.8±21.2 mmHg), BNP level at the time of diagnosis (293.8±88.3 pg/ml vs. 141.6±62.1 pg/ml), and six-minute walk distance (123.8±41.3 m vs. 200.7±52.1 m) (p<0.05).
Conclusion: Despite relative improvements in the end points over the last two decades, PAH is detected late in the course of the disease, resulting in severe functional and hemodynamic problems in the majority of patients.

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Amaç: Kalp yetersizliði (KY) olan hastalarda serum adiponektin düzeyleri NYHA fonksiyonel kapasite sýnýflarýna göre deðerlendirildi.
Ça­lýþ­ma pla­ný: Fonksiyonel kapasitesi NYHA sýnýf II-IV olan, KY’li 49 hasta (40 erkek, 9 kadýn; ort. yaþ 63) çalýþmaya alýndý. Tüm hastalarda ekokardiyografik inceleme yapýldý ve serum adiponektin düzeyleri ölçüldü. Sonuçlar NYHA sýnýflarý arasýnda ve klinik ve ekokardiyografik olarak KY saptanmayan 41 kiþilik (24 erkek, 17 kadýn; ort. yaþ 54.2) kontrol grubuyla karþýlaþtýrýldý.
Bul­gu­lar: Fonksiyonel kapasite 13 hastada (%26.5) NYHA sýnýf II, 23 hastada (%46.9) sýnýf III, 13 hastada (%26.5) sýnýf IV idi. Kontrol grubu ile karþýlaþtýrýldýðýnda, KY hastalarýnda ortalama yaþ anlamlý derecede daha yüksek (p=0.001), beden kütle indeksi daha düþük (p=0.004), sol ventrikül ejeksiyon fraksiyonu (EF) daha düþük (%33.2±7.7 ve %64.9±4.3; p=0.0001), serum adiponektin düzeyi daha yüksek (4.0±3.2 µmgr/dl ve 2.4±2.3 µmgr/dl; p=0.009) bulundu. Sol ventrikül EF ve serum adiponektin düzeyi NYHA gruplarý arasýnda anlamlý farklýlýk gösterdi (p=0.001 ve p=0.004). NYHA sýnýf II’de ortalama 2.6±2.6 µmgr/dl olan serum adiponektin düzeyi sýnýf IV’de 6.8±3.7 µmgr/dl’ye yükseldi. NYHA sýnýflarýnýn ikili karþýlaþtýrmasýnda, EF ikili tüm gruplar arasýnda anlamlý farklýlýk gösterirken, serum adiponektin düzeyi, NYHA II-III gruplarý dýþýnda, diðer gruplar arasýnda anlamlý derecede farklýydý (NYHA II-IV, p=0.003; NYHA III-IV, p=0.008). Korelasyon analizinde, serum adiponektin düzeyi EF ile anlamlý negatif iliþki (r=-0.380, p=0.0001), NYHA sýnýfý ile anlamlý pozitif iliþki gösterdi (r=0.423, p=0.0001).
So­nuç: Kalp yetersizliði olan hastalarda serum adiponektin düzeyi anlamlý artýþ göstermekte ve bu artýþ fonksiyonel kapasite kötüleþtikçe, EF’deki azalma ile birlikte, daha belirgin olmaktadýr.

Objectives: We aimed to evaluate serum adiponectin levels in relation to the NYHA functional capacity class in patients with heart failure (HF).
Study design: The study included 49 patients (40 males, 9 females; mean age 63 years) with HF, whose functional capacity was NYHA class II to IV. Echocardiographic examination was performed and serum adiponectin levels were measured. The results were compared in relation to the NYHA classes and with those of 41 control subjects (24 males, 17 females; mean age 54.2 years) without HF.
Results: Functional capacity was NYHA class II in 13 patients (26.5%), class III in 23 patients (46.9%), and class IV in 13 patients (26.5%). Compared to the control group, the HF group exhibited a significantly higher mean age (p=0.001), lower body mass index (p=0.004), decreased left ventricular ejection fraction (EF) (33.2±7.7% vs. 64.9±4.3%; p=0.0001), and increased serum adiponectin level (4.0±3.2 µmg/dl vs. 2.4±2.3 µmg/dl; p=0.009). Both EF (p=0.001) and adiponectin level (p=0.004) showed significant differences between the NYHA groups, with the latter showing a sharp increase from 2.6±2.6 µmg/dl in class II to 6.8±3.7 µmg/dl in class IV. In all paired comparisons between the three NYHA groups, EF and serum adiponectin level exhibited significant differences except for the serum adiponectin level for NYHA class II and III (for NYHA class II and IV, p=0.003; for class III and IV, p=0.008). In correlation analysis, serum adiponectin level was in a significantly inverse correlation with EF (r=-0.380, p=0.0001), and a positive correlation with the NYHA class (r=0.423, p=0.0001).
Conclusion: Serum adiponectin levels significantly increase in patients with HF, in parallel with deterioration in functional capacity and with significant decreases in EF.

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Amaç: Obezite artmýþ kardiyovasküler hastalýk ve risk faktörleri ile iliþkilidir. Obezite saðlýklý olduðu düþünülen kadýnlarda sýk karþýlaþýlan bir sorundur. Bu çalýþmada obez kadýnlarda obezite ile koroner akým rezervi (KAR) arasýndaki iliþki araþtýrýldý.
Ça­lýþ­ma pla­ný: Çalýþmaya, diabetes mellitus ve klinik koroner arter hastalýðý olmayan 80 ardýþýk kadýn hasta (ort. yaþ 55.6±10.2) alýndý. Tüm olgularda beden kütle indeksi (BKÝ) ölçüldü ve BKÝ ≥30 kg/m2 olanlar obez olarak kabul edildi. Beden kütle indeksine göre hastalar normal kilolu (n=13; 18.5-24.9 kg/m2), fazla kilolu (n=32; 25-29.9 kg/m2), obez (n=32; ≥30-39.9 kg/m2) ve aþýrý obez (n=3; ≥40 kg/m2) olarak sýnýflandýrýldý. Zirve diyastolik koroner akým, distal sol ön inen koroner arterden dipiridamol infüzyonu öncesi ve sonrasýnda transtorasik nabýz dalga Doppler ile ölçüldü ve hiperemik zirve diyastolik hýzýn baþlangýç zirve diyastolik hýza oraný KAR olarak kabul edildi.
Bul­gu­lar: Otuz beþ kadýn (%43.8) obez olarak kabul edildi. Koroner akým rezervi obez kadýnlarda obez olmayanlara göre anlamlý derecede düþük bulundu (2.2±0.5 ve 2.5±0.4; p=0.022). En düþük KAR deðeri BKÝ ≥40 kg/m2 olan kadýnlarda gözlendi; fazla kilolu kadýnlar ve normal kilolu kadýnlarda KAR benzer bulundu. Koroner akým rezervi, BKÝ (r=-0.314, p=0.005), bel çevresi (r=-0.316, p=0.005) ve C-reaktif protein (CRP) (r=-0.342, p=0.011) ve adiponektin (r=0.410, p=0.011) düzeyleriyle anlamlý iliþki gösterdi. Regresyon analizinde KAR düþüþünü öngören baðýmsýz etkenler þunlardý: BKÝ (p=0.017), bel çevresi (p=0.048), sistolik kan basýncý (p=0.025), açlýk kan þekeri (p=0.035) ve adiponektin düzeyi (p=0.037). ROC analizinde, KAR’daki bozulmayý öngörmede kullanýlabilecek BKÝ kesim deðeri ≥30 kg/m2 bulundu (duyarlýk %76, özgüllük %72; ROC alaný 0.805, p<0.001, %95% GA 0.669-0.96).
So­nuç: Obez kadýnlarda KAR deðerindeki düþüþ mikrovasküler disfonksiyon varlýðýnýn bir göstergesidir. Obezitenin tedavisi aterosklerozun önlenmesi için önemlidir.

Objectives: Obesity is associated with an increased rate of cardiovascular disease and risk factors. It is a common problem in apparently healthy women. We aimed to investigate the association between obesity and coronary flow reserve (CFR) in obese women.
Study design: The study included 80 consecutive women (mean age 55.6±10.2 years) without diabetes mellitus and clinical coronary artery disease. Body mass index (BMI) was calculated and obesity was defined as BMI ≥30 kg/m2. Based on BMI, the patients were grouped as normal weight (n=13; 18.5-24.9 kg/m2), overweight (n=32; 25-29.9 kg/m2), obese (n=32; ≥30-39.9 kg/m2), and morbid obese (n=3; ≥40 kg/m2). Peak diastolic coronary flow velocities were measured in the distal left anterior descending artery by transthoracic pulsed wave Doppler echocardiography at baseline and after dipyridamole infusion and CFR was calculated as the ratio of hyperemic to baseline peak diastolic velocities.
Results: There were 35 obese women (43.8%). Coronary flow reserve was significantly lower in obese women than in nonobese subjects (2.2±0.5 vs. 2.5±0.4; p=0.022). The lowest CFR was seen in patients with a BMI of ≥40 kg/m2; overweight women did not differ significantly from women of normal weight. Coronary flow reserve was correlated with BMI (r=-0.314, p=0.005), waist circumference (r=-0.316, p=0.005), C-reactive protein (CRP) (r=-0.342, p=0.011), and adiponectin level (r=0.410, p=0.011). In regression analysis, BMI (p=0.017), waist circumference (p=0.048), systolic blood pressure (p=0.025), fasting glucose (p=0.035), and adiponectin level (p=0.037) were found to be independent predictors for impaired CFR. In ROC analysis, the cut-off value for BMI to predict impaired CFR was ≥30 kg/m2, with 76% sensitivity and 72% specificity (ROC area 0.805, p<0.001, 95% CI 0.669-0.96).
Conclusion: Impaired CFR in obese women suggests the presence of microvascular dysfunction. Treatment of obesity is important for the prevention of atherosclerosis.

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Amaç: Bu çalýþmada, çokkesitli bilgisayarlý tomografi (ÇKBT) ile belirlenen koroner arter kireçlenmesinin, plazma osteopontin, serum fetuin-A ve visfatin düzeyleri ile iliþkili olup olmadýðý araþtýrýldý.
Ça­lýþ­ma pla­ný: Çalýþmaya, koroner arter hastalýðý þüphesiyle ÇKBT ile incelenen 64 ardýþýk hasta (51 erkek, 13 kadýn; ort. yaþ 49.5±10.9; daðýlým 33-78) alýndý. Hastalarýn koroner kalsiyum skorlarý (KKS) Agatston ölçüm yöntemi kullanýlarak hesaplandý. Açlýk kan örneklerinde plazma osteopontin, serum fetuin-A ve visfatin düzeyleri ölçüldü ve bunlarýn kalsiyum skorlarýyla iliþkisi araþtýrýldý.
Bul­gu­lar: Otuz iki hastada (%50) koroner kireçlenme saptandý. Ortalama KKS 146.5±333.7 Agatston ünitesi (AÜ) bulundu; bu deðer koroner arter hastalýðý için orta derecede riski göstermekteydi. On hastada (%15.6) skor 400 AÜ’nün üzerindeydi. Ortalama fetuin-A, visfatin ve osteopontin düzeyleri sýrasýyla 25.6±6.4 ng/ml, 19.7±47.2 ng/ml ve 20.4±16.1 ng/ml bulundu. Serum visfatin ve fetuin-A düzeyleri kalsiyum skoruyla anlamlý iliþki göstermezken (r=0.15, p=0.37 ve r=0.17, p=0.22), plazma osteopontin düzeyi kalsiyum skoruyla orta derecede iliþki gösterdi (r=0.35; p=0.008). Koroner kireçlenmeyi öngörmek için yapýlan ROC analizinde, eðri altýndaki en büyük alan osteopontine aitti (0.741; p=0.004); bunu fetuin-A (0.574; p=0.31) ve visfatin (0.580; p=0.27) izlemekteydi. Osteopontin için kesim deðeri 18.45 ng/ml (duyarlýlýk %72, özgüllük %73) bulundu.
So­nuç: Bulgularýmýz KKS ile plazma osteopontin düzeyi arasýnda iliþki olabileceðini göstermektedir. Koroner kireçlenmeyi daha güçlü þekilde öngörmeyi saðlayacak metabolik parametreler için araþtýrmalar sürdürülmelidir.

Objectives: We investigated whether coronary calcification detected by multislice computed tomography (MSCT) was correlated with plasma osteopontin, serum fetuin-A, and visfatin levels.
Study design: The study included 64 consecutive patients (51 males, 13 females; mean age 49.5±10.9 years; range 33 to 78 years) who underwent MSCT for suspected coronary artery disease. Coronary artery calcification (CAC) scores of the patients were calculated using the Agatston scoring method. Plasma osteopontin, serum fetuin-A, and visfatin levels were measured from fasting blood samples and correlations were sought with calcium scores.
Results: Coronary calcification was detected in 32 patients (50%). The mean CAC score was 146.5±333.7 Agatston units (AU), indicating an intermediate risk for coronary artery disease. In 10 patients (15.6%), the CAC score exceeded 400 AU. The mean fetuin-A, visfatin, and osteopontin levels were 25.6±6.4 ng/ml, 19.7±47.2 ng/ml, and 20.4±16.1 ng/ml, respectively. Serum visfatin (r=0.15, p=0.37) and fetuin-A (r=0.17, p=0.22) were not correlated with the CAC score, whereas plasma osteopontin level showed a moderate correlation with the CAC score (r=0.35; p=0.008). In ROC analysis, the area under the curve for identification of CAC was greatest for osteopontin (0.741; p=0.004), followed by fetuin-A (0.574; p=0.31), and visfatin (0.580; p=0.27). The cut-off value was 18.45 ng/ml for osteopontin, with a sensitivity of 72% and specificity of 73%.
Conclusion: Our results suggest that there might be an association between CAC and plasma osteopontin levels. Research should continue to find out a metabolic parameter that will strongly indicate coronary calcification.

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Kalp yetersizliði nedeniyle kardiyoverter defibrilatör (ICD) yerleþtirilen veya kardiyak resenkronizasyon tedavisi/defibrilatör uygulanan hastalarda göðüsiçi impedans ölçümlerine dayalý izlem tedavinin önemli bir parçasý haline gelmiþtir. Bununla birlikte, göðüsiçi impedans ölçümleri kalp yetersizliði dýþýndaki nedenlerden de etkilenebilmektedir. Bu yazýda, 54 yaþýnda bir erkek hastada, iskemik olmayan dilate kardiyomiyopati ve ileri derecede bozulmuþ sol ventrikül sistolik fonksiyonlarý nedeniyle baþarýlý biventriküler ICD yerleþtirilmesinden sonra göðüsiçi impedans düþüþüne yol açan alýþýlmamýþ bir neden bildirildi. Ýzlemi sýrasýnda hasta, kalp yetersizliðine dair semptom ve bulgular olmaksýzýn, birkaç kez OptiVol sývý indeksindeki artýþa baðlý olarak oluþan OptiVol alarmý sonucu baþvurdu. Göðüsiçi impedans düþüþüne yol açan nedeni ortaya çýkarmak için yapýlan incelemelerde, hastanýn sýk olarak irritabl baðýrsak sendromu ataklarý geçirdiði görüldü. Bu sorunun karýniçi basýncý artýrarak diyafram yükselmesine ve göðüsiçi organ basýsýna yol açtýðý, göðüsiçi impedansýn da bu nedenle düþtüðü sonucuna varýldý.

Monitoring intrathoracic impedance has become an integral part of follow-up of patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy/defibrillator due to heart failure. However, several noncardiac factors may influence intrathoracic impedance. We report on an unusual cause of decrease in intrathoracic impedance in a 54-year-old male patient following successful implantation of biventricular ICD for heart failure symptoms due to nonischemic dilated cardiomyopathy and severely impaired left ventricular systolic function. During the follow-up period, the patient presented several times with the OptiVol alarm due to an increase in the OptiVol fluid index, in the absence of symptoms or signs of heart failure. Further inquiry into the possible causes of decreased intrathoracic impedance revealed that the patient had frequent episodes of irritable bowel syndrome, which increased intra-abdominal pressure, leading to elevation of diaphragm and subsequent compression of intrathoracic organs, and thus to a decrease in intrathoracic impedance.

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Ventrikül miyokardýnda süngerimsi yapý (noncompaction) kardiyomiyopati geliþimine yol açan morfogenetik bir anomalidir. Baþka doðumsal anomalilerle birlikteliði sýktýr. Süngerimsi miyokardýn yaygýn klinik bulgularý kalp yetersizliði semptomlarý, ventrikül taþiaritmileri ve tromboembolik olaylardýr. Bu durumun ekokardiyografik tablosu oldukça özgün olmasýna karþýn, atlandýðý olgular da olmaktadýr. Bu yazýda, çocukluðundan beri interventriküler septal defekt ya da interventriküler septumun apikal kýsmýnýn güdük kalmasýyla karakterize büyümüþ “tek ventrikül” tanýsýyla takip edilmekte olan 27 yaþýnda bir erkek hasta sunuldu. Hastanýn son ekokardiyografik incelemesinde, belirgin trabeküller ve bu trabeküllerin arasýnda kalan derin girintilerle karakterize süngerimsi miyokart saptandý. Bu olgudan çýkarýlmasý gereken ders, kardiyologlarýn, süngerimsi miyokart da dahil olmak üzere, eþlik eden doðuþtan anomalilerin saptanmasý konusunda daha fazla sabýrlý olmalarý gerektiðidir; çünkü, bu durumlar hastalarýn klinik ve prognostik sonuçlarýný etkilemektedir.

Noncompaction of the ventricular myocardium (NVM) is a morphogenetic anomaly that leads to the development of cardiomyopathy. It is often associated with other congenital cardiac malformations. Common clinical presentations of NVM involve heart failure symptoms, ventricular tachyarrhythmias, and thromboembolic events. Although the peculiar echocardiographic picture is characteristic for this entity, it may often be misdiagnosed. In this case report, we describe a 27-year-old man who had been followed-up since childhood, with the diagnosis of interventricular septal defect or enlarged “single ventricle” with a very small rudiment of the apical part of the interventricular septum. On his last echocardiographic examination, NVM was detected with heavy trabeculations and intertrabecular recesses. This case suggests that physicians should be more patient to detect other congenital abnormalities including NVM, which may influence the clinical and prognostic outcome of these patients.

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On yedi yaþýndaki bir erkek hasta, intihar amacýyla yaklaþýk 20 tablet (toplam 6000 mgr) propafenon ve 24 tablet trimetoprim (toplam 1920 mgr)-sulfametoksazol (toplam 9600 mgr) içtikten sonra bir saat içinde, kusma, bulantý ve bilinç kaybýyla baþka bir merkeze getirildi. Burada, uygulanan bikarbonat, salin infüzyonu ve inotropik desteðe raðmen hastada siyanoz, orta derecede asidoz ve sonuçta kardiyorespiratuvar arest geliþti. Hasta baþarýlý resüsitasyon ve ventilasyon giriþimleriyle yaþama döndürüldükten ve sinüs ritmine döndükten sonra merkezimize sevk edildi. Ýlk muayenede kalp hýzý düzenli ve 55 atým/dk, kan basýncý 70/45 mmHg olan hastanýn 12 derivasyonlu elektrokardiyografisinde sinüs bradikardi, aþýrý derecede geniþlemiþ QRS kompleksi (260 msn) ve sað dal bloku paterni izlendi. Ýntravenöz salin, bikarbonat ve dopamin tedavisi ve mekanik solunum desteðiyle hastanýn sinüs ritmi, hemodinamik parametreleri ve asidozu hýzla düzeldi. Elektrokardiyogramda QRS süresinin azaldýðý (230 msn) görüldü. Üçüncü günde yeterli hemodinamik dengesi saðlanan hasta normal elektrokardiyografik bulgularla taburcu edildi.

A 17-year-old male ingested about 20 tablets of propafenone (total 6,000 mg) and 24 tablets of trimethoprim (total 1,920 mg) - sulfamethoxazole (total 9,600 mg) with suicidal intent. Within one hour, he was brought to a hospital with vomiting, nausea, and loss of consciousness, where he developed cyanosis and mild acidosis, and eventually cardiorespiratory arrest, despite bicarbonate, saline infusion, and inotropic support. Fortunately, he was fully resuscitated and ventilated, and sinus rhythm was restored. He was then transported to our center. On admission, his heart rate was regular with 55 beats/min and blood pressure was 70/45 mmHg. The 12-lead electrocardiogram (ECG) showed sinus bradycardia, extreme widening of the QRS complex (260 msec) with a right bundle branch block pattern. Intravenous saline, bicarbonate, and dopamine were administered, and respiration was supported mechanically, which resulted in rapid restoration of sinus rhythm and improvement in hemodynamic parameters and acidosis. A subsequent ECG showed shortening of the QRS duration (230 msec). He was discharged with an appropriate hemodynamic balance on the third day with normal ECG findings.

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Giriþimsel kardiyolojideki geliþmelerle birlikte, süperiyor vena kava sendromunun (SVKS) tedavisinde, altta yatan etyoloji malign veya benign da olsa, perkütan stent tedavisi etkin bir tedavi yöntemi olmaya baþlamýþtýr. Kýrk sekiz yaþýndaki kadýn hasta SVKS’yi gösterir tipik semptom ve bulgular ile kliniðimize baþvurdu. Hastaya perkütan yolla endovasküler stent uygulandý. Ýþlem sonrasýnda kan akýmýnýn tamamen saðlanmasý ile birlikte semptomlarýn da hýzla kaybolduðu gözlendi. Altý aylýk takibi sýrasýnda hastanýn herhangi bir semptomu yoktu ve bilgisayarlý tomografide stentin tamamen açýk olduðu görüldü.

With the advances in interventional cardiology, percutaneous treatment by stenting has become a reasonable strategy in superior vena cava syndrome (SVCS), whether the underlying disease is malign or benign. We present a 48-year-old woman with typical signs and symptoms of SVCS, who was treated with endovascular stenting by the percutaneous approach. We obtained both procedural success with complete restoration of blood flow and immediate relief of symptoms. During a follow-up period of six months, the patient was free of symptoms and computed tomography demonstrated complete stent patency.

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Restriktif kardiyomiyopatiye neden olan endomiyokardiyal fibrozis tropik iklimlerde sýk gözlenir ve genellikle çocuklarda ve genç eriþkinlerde görülür. Bacaklarda þiþlik ve çabuk yorulma yakýnmasý ile baþvuran 19 yaþýndaki erkek hastanýn transtorasik ekokardiyografisinde sað kalp boyutlarýnda geniþleme, sol ventrikülde restriktif akým örneði, sað ventrikül içinde 60 mmHg gradiyent yaratan ve obliterasyona neden olan doku yoðunlaþmasý saptandý ve manyetik rezonans görüntülemede sað ventrikül giriþ bölgesinde doku artýþý izlendi. Hastanýn sýnýf II düzeyindeki fonksiyonel kapasitesi, medikal tedaviye iyi yanýt alýnmasý ve ameliyat mortalitesi riskinin yüksek olmasý nedeniyle cerrahi rezeksiyon düþünülmedi. Sunulan olgunun en ilginç noktasý, sað ventrikül giriþ bölgesindeki doku yoðunluðunun obstrüksiyona neden olarak sað ventrikül içinde basýnç farký yaratmasý ve bu durumun baþka bir merkezde idiyopatik pulmoner hipertansiyon olarak deðerlendirilmesine yol açmýþ olmasýdýr.

Endomyocardial fibrosis is a cause of restrictive cardiomyopathy and it generally occurs in tropical regions more commonly affecting children and young adults. A 19-year-old male patient presented with edema in the lower extremities and fatigue. Transthoracic echocardiography showed dilated right heart chambers, restrictive physiology in the left ventricle, and increased tissue growth in the right ventricle that caused a 60-mmHg gradient and obliteration. Magnetic resonance imaging confirmed the presence of increased tissue formation in the right ventricular inflow region. Surgical resection was not considered taking into account the functional capacity of the patient (class II), disappearance of symptoms following medical treatment, and the high risk for operative mortality. The presented case may arouse interest in that increased tissue growth in the right ventricle inflow region caused a gradient in the right ventricle, leading to an incorrect diagnosis, at another center, as idiopathic pulmonary hypertension.

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Sonradan geliþen pulmoner darlýk eriþkinlerde nadir görülen ve þüphe edilmediði taktirde kolaylýkla atlanabilen bir durumdur. Daha da nadir olan ekstrensek pulmoner darlýk, sýklýkla göðüs kitlelerinin sað ventrikül çýkýþ yolu üzerinde yol açtýklarý dinamik olmayan obstrüksiyon nedeniyle ortaya çýkmaktadýr. Yirmi yaþýnda bir kadýn hasta, baþka bir merkezde transtorasik ekokardiyografi ve göðüs bilgisayarlý tomografisi ile saptanan ve ana pulmoner yapýda basýya yol açan, 5.5x5.5x7 cm büyüklüðünde bir mediyastinal kitle nedeniyle merkezimize sevk edildi. Transtorasik ekokardiyografi ile tekrar incelenen hastada, pulmoner kapaðýn hemen sonrasýnda ana pulmoner artere basý yapan bir kitle görüldü. Devamlý dalga Doppler ile incelemede, basý bölgesindeki pulmoner arterde tepe sistolik gradiyent 65 mmHg, ortalama gradiyent 37 mmHg ölçüldü. Hastaya orta hat sternotomi ile açýk torakotomi uygulandý. Ameliyatta, en büyük çapý 15 cm ölçülen kitlenin perikarda sýký bir þekilde tutunduðu, sol frenik siniri tamamen sardýðý izlendi; pulmoner arter ve aortun dýþ duvarýnda invazyon vardý. Kitle sadece kýsmi olarak çýkarýlabildi ve histopatolojik taný evre IIa sklerozan Hodgkin lenfoma olarak kondu. Ameliyat sonrasýnda kemoterapi ve radyoterapi uygulanan hastada remisyon bulgularý görüldü; hastanýn kardiyak yakýnmasý yoktu.

Acquired pulmonary stenosis is rare in adults and may be missed unless a high index of suspicion is present. Extrinsic pulmonic stenosis is even rarer and predominantly caused by external thoracic masses creating non-dynamic obstruction of the right ventricular outflow tract. A 20-year-old female was referred to our center with a cystic mass detected by transthoracic echocardiography and thoracic computed tomography, in the superoanterior mediastinum, 5.5x5.5x7 cm in size, causing main pulmonary trunk compression. Repeat transthoracic echocardiography demonstrated a mass causing compression of the main pulmonary artery immediately after the pulmonary valve. Continuous wave Doppler showed a peak systolic gradient of 65 mmHg and a mean gradient of 37 mmHg in the pulmonary artery at the site of compression. She underwent an open thoracotomy via a midline sternotomy. The mass was firmly attached to the pericardium. Its largest diameter was 15 cm; it surrounded the left phrenic nerve completely and invaded the outer wall of the pulmonary artery and aorta. The mass could only be partly dissected. The pathological diagnosis of the mass was stage IIa nodular sclerosing Hodgkin’s lymphoma. The patient received postoperative chemotherapy and thoracal radiotherapy. She was in remission without any cardiac complaint.

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Türk yetiþkinlerinde koroner kalp hastalýðý (KKH) morbidite ve mortalitesinin diðer toplumlardan farklý biçimde yüksek olduðuna iliþkin TEKHARF Çalýþmasý bilgisi, yakýn zamanda daha güçlü biçimde doðrulanmýþtýr. Bu derlemede, anýlan gözlemin altýnda yatan kandaki koruyucu proteinlerin iþlevlerini yitirmesinin, hatta proenflamatuvar ve aterojen niteliklere bürünmesi olayýnýn, toplumumuzda metabolik sendrom (MetS) yaygýnlýðýna eþlik eden dislipidemi, oksidatif süreç ve sistemik yangý sonucuna baðlanabileceði üzerinde duruldu. Koruyucu iþlevlerinde bozukluk gözlemlenen proteinler yüksek yoðunluklu lipoprotein (HDL) parçacýklarý ile, bunun üzerinde yer alan apolipoprotein (apo) A-I, A-II ve C-III, ayrýca, adiponektin olup dünyada ilk kez genel nüfusta tarif edilmektedir. MetS, tip 2 diyabet ve KKH’den oluþan kardiyometabolik riskte, kanda C-reaktif protein (CRP), apoB, apoC-III, fibrinojen yüksekliði ve adiponektin düþüklüðü gibi yangý göstergelerinin rolü, bunlarýn MetS’e dair ATP-III tanýmýndan baðýmsýzlýk oraný ve bunda cinsiyet farklýlýðý TEKHARF Çalýþmasý’ndan çýkan yayýnlara dayanarak açýklanmaktadýr. Üstelik, adiponektin disfonksiyonu ve HDL parçacýklarý ile ilgili proteinlerin koruyuculuk bozukluklarýnýn halkýmýzda kardiyometabolik riski büyük ölçüde artýrdýðý, KKH riskini yetiþkinlerimizin yarýsýnda geleneksel risk faktörleri kadar veya daha fazla yükselttiði bildirilmektedir. Sigara içiciliðinin Türk kadýnlarýnda, baþta CRP olmak üzere, disfonksiyonlu apoA-I ve viseral yað birikimi üzerine olumlu etkileri aracýlýðýyla, hipertansiyon, MetS ve diyabet geliþmesini azalttýðýnýn altý çizilmektedir. Olaðanüstü önemi içeren bu bilgiler, orta yaþlý Türk yetiþkinlerinde kalp-damar saðlýðýna iliþkin önlem ve tedavi stratejilerinde köklü deðiþikliklere hýzla gidilmesi yolunda ilgili ve yetkililere ýþýk tutmaktadýr.

Knowledge obtained from the Turkish Adult Risk Factor (TARF) study on higher morbidity and mortality rates compared to other populations from coronary heart disease (CHD) among Turkish adults has been confirmed recently with greater power. This review provides insight that the dysfunctions of the protective serum proteins, attaining pro-inflammatory and atherogenic features, may be attributed to atherogenic dyslipidemia, oxidative stress, and systemic inflammation associated with the high prevalence of metabolic syndrome (MetS) among Turks. The mentioned protective protein dysfunctions, firstly described in a general population to date, are high-density lipoprotein (HDL), apolipoprotein (apo) A-I, A-II, and apoC-III, apart from adiponectin. Based on published findings of the TARF study, this review discusses the role of inflammatory mediators such as elevated C-reactive protein (CRP), apoB, apoC-III, fibrinogen, and low adiponectin serum levels in cardiometabolic risk comprising MetS, type 2 diabetes, and CHD, the degree of independence of these mediators from the ATP-III-defined MetS, and the influence of sex. Moreover, it is emphasized that dysfunctions of adiponectin and protective proteins related to HDL particles increase not only cardiometabolic risk significantly but also CHD risk among half of Turkish adults in a magnitude similar to or greater than that associated with traditional risk factors. Also underlined is the observation that cigarette smoking reduces the risk in Turkish women for the development of hypertension, MetS, and diabetes by mediation of positive effects on dysfunctional apoA-I, visceral fat accumulation and, above all, CRP levels. This knowledge is of utmost importance and sheds light to authorities and those concerned on the necessity of urgent and radical modifications regarding strategies in prevention and management of cardiovascular health of middle-aged Turks.

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24 yaþýnda saðlýklý erkek, akut koroner sendrom ön tanýsý ile acil servise gönderilmiþ. Hasta acil servise, öðle yemeðinden hemen sonra ani baþlayan kusma, midesinden boyun ve omuzlarýna yayýlan göðüs aðrýsý þikayeti ile müracaat etti. Ilk muayenesinde herhangi bir patoloji saptanmadý. Bazal EKG, normal sinus ritmi ve V1-4 de patolojik Q dalgasý vardi.

A 24-year-old, previously healthy man was referred to our emergency department with initial diagnosis of acute coronary syndrome. He admitted to the emergency room with vomiting and sudden onset of chest pain,which arising from epigastrium, radiated to neck and shoulders beginning immedietaly after lunch. The initial examination did not show any specific finding. A baseline electrocardiogram taken at an initial hospital revealed a normal sinus rhythm with Q waves in leads V1-4.

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Editöre mektup olduðundan boþ býrakýldý

Editöre mektup olduðundan boþ býrakýldý

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