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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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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