Objectives: The goal of this study was to evaluate the relationship between admission hemoglobin levels and left ventricular systolic functions in patients admitted with first ST-segment elevated myocardial infarction (STEMI).
Study design: The study was conducted prospectively in three centers in 483 consecutive patients (402 men, 81 women; mean age 56.5±11.2 years; range 24 to 74 years) with first STEMI. All patients were evaluated by echocardiography after a mean of 2.4 days of admission. Evaluation of left ventricular systolic functions included measurements of ejection fraction (EF), wall motion score index (WMSI), and tissue Doppler S wave velocities at four different localizations (anterior, inferior, lateral, posterior septum). Hemoglobin levels were measured within one hour of admission. Anemia was defined according to the World Health Organization criteria (hemoglobin <13.0 g/dl in men and <12.0 g/dl in women). Echocardiographic characteristics of the patients with and without anemia were compared.
Results: Anemia was detected in 67 patients (13.9%). There were no significant differences between patients with and without anemia with respect to left ventricular end-systolic and end-diastolic diameters, wall thickness, WMSI, and EF. The mean EF in the anemic group (47.5%) was lower than that of the patients without anemia (48.5%), but this difference was not significant. All Sm velocities were lower in the anemic group, but only septal mitral annular Sm velocity reached statistical significance (p=0.048). There was no correlation between hemoglobin levels and EF (r=0.027, p=0.55).
Conclusion: Our findings suggest that mild to moderate anemia has no deleterious effect on systolic function in patients with first STEMI.

Objectives: We aimed to compare the level of platelet inhibition using the platelet function analyzer (PFA)-100 in patients receiving low and medium doses of aspirin.
Study design: On a prospective basis, 159 cardiology outpatients (83 men, 76 women; mean age 60.9±9.9 years) taking 100 mg/day or 300 mg/day aspirin at least for the previous 15 days were included. Of these, 79 patients (50%) were on 100 mg and 80 patients (50.3%) were on 300 mg aspirin treatment. Blood samples were collected between 09: 30 and 11: 00 hours in the morning. Platelet reactivity was measured with the PFA-100 system. Incomplete platelet inhibition was defined as a normal collagen/epinephrine closure time (<165 sec) despite aspirin treatment.
Results: Baseline clinical and laboratory characteristics of the patient groups taking 100 mg or 300 mg aspirin were similar. The overall prevalence of incomplete platelet inhibition was 22% (35 patients). The prevalence of incomplete platelet inhibition was significantly higher in patients treated with 100 mg of aspirin (n=24/79, 30.4%) compared with those treated with 300 mg of aspirin (n=11/80, 13.8%) (p=0.013). In univariate analysis, female sex (p=0.002) and aspirin dose (p=0.013) were significantly correlated with incomplete platelet inhibition. In multivariate analysis, female sex (OR: 0.99; 95% CI 0.9913-0.9994; p=0.025) and aspirin dose (OR: 3.38; 95% CI 1.4774-7.7469; p=0.003) were found as independent factors predictive of incomplete platelet inhibition.
Conclusion: Our findings suggest that treatment with higher doses of aspirin can reduce incomplete platelet inhibition especially in female patients.

Objectives: Imbalance between oxidative stress and antioxidant defense has been demonstrated in patients with slow coronary flow (SCF). The aim of this study was to investigate the effect of nebivolol treatment on oxidative stress parameters in SCF patients.
Study design: The study included 32 patients (10 females, 22 males; mean age 53.3±5.2 years) with SCF and 32 control subjects (14 females, 18 males; mean age 50.6±5.2 years) with normal coronary arteries on angiography. Coronary slow flow was determined by the TIMI frame count method. Patients with SCF received nebivolol treatment (5 mg/day) for six months. Blood samples were analyzed for malondialdehyde (MDA) and serum nitric oxide (NO) levels, and erythrocyte catalase (CAT) and erythrocyte superoxide dismutase (SOD) activities in the control group and, in SCF patients, at baseline and after six months of nebivolol treatment.
Results: The two groups were similar with respect to age, body mass index, blood pressure, heart rate, and lipid profile. Smoking was more frequent in the SCF group compared to the controls. TIMI frame counts measured from the left anterior descending, circumflex, and right coronary arteries were significantly higher in the SCF group (p<0.0001). Baseline MDA and NO levels, and SOD and CAT activities were significantly different between the two groups, with significantly increased MDA (p<0.0001), and significantly decreased SOD (p<0.0001), CAT (p<0.001), and NO (p<0.001) in the SCF group. After six months of nebivolol treatment, all oxidative stress parameters showed significant improvements compared to the baseline values (p<0.0001 for MDA, SOD, CAT, and NO) and approximated to the values of the control group.
Conclusion: Our results show that nebivolol treatment may be beneficial to improve oxidative stress parameters in patients with SCF, which is considered to be an early stage of atherosclerosis.

Objectives: We investigated the efficacy and outcome of primary percutaneous coronary intervention (PCI) in patients admitted with cardiogenic shock and ST-elevation myocardial infarction (STEMI).
Study design: We reviewed 91 consecutive patients (66 males, 25 females; mean age 61±11 years) treated with primary PCI for cardiogenic shock due to STEMI. All clinical, angiographic data, and in-hospital and long-term outcomes were collected. The patients were classified into two groups depending on the presence (n=59, 64.8%) or absence (n=32, 35.2%) of in-hospital mortality.
Results: Hospital nonsurvivors were older (mean age 62.7±11.1 vs. 57.7±11.4 years; p=0.04) and exhibited higher frequencies of diabetes mellitus (DM), renal failure, and history of myocardial infarction. Multi-vessel disease (p=0.004) and circumflex artery involvement (p=0.03) were more frequent and the rates of tirofiban administration (p=0.02) and stenting (p=0.007) were lower in nonsurvivors. Procedural success rate was substantially lower in nonsurvivors (39% vs. 84.4%; p<0.001). Of 32 survivors, cardiovascular mortality occurred in only three patients (9.4%) during a median follow-up of 26 months. In multivariate regression analysis, unsuccessful procedure (OR 7.2, 95% CI 1.77-29.27; p=0.006) and DM (OR 3.92, 95% CI 1.13-13.62; p=0.03) were the independent predictors of in-hospital mortality.
Conclusion: Mortality rate is considerably higher and successful procedure yields a two-fold decrease in in-hospital mortality in patients with cardiogenic shock complicated by STEMI. Unsuccessful procedure and DM represent as two independent predictors of in-hospital mortality.

Objectives: The objective of this study was to evaluate the first applications and results of transcatheter aortic valve implantation (TAVI) in Turkey, which is a new technology for the treatment of aortic valve stenosis.
Study design: We performed TAVI in eight severely symptomatic patients (5 women, 3 men; mean age 81.6±6.7 years; range 71 to 95 years) between May 1 and December 31, 2009. All the patients had severe aortic stenosis (mean valve area 0.6 cm2, systolic peak/mean gradients 80.5±22.1/50.0±16.1 mmHg). Two patients had severe coronary artery disease that required intervention during TAVI. All the patients presented a high surgical risk (EuroSCORE 31.1±9.8 and STS score 12.8±7.9). The Edwards Sapien bioprosthetic valve was implanted through the transfemoral approach in seven patients, and transapical approach in one patient.
Results: All prosthetic valves were of appropriate size, were implanted in appropriate locations, and functioned perfectly. Two patients with severe coronary stenosis underwent successful simultaneous percutaneous coronary intervention before TAVI. Following TAVI, the mean aortic valve area increased to 1.5±0.1 cm2 (p<0.01), and systolic/mean gradients decreased to 27.6±9.6/14.6±5.8 mmHg (p<0.01). One patient underwent permanent pacemaker implantation due to persistent atrioventricular block, and two patients had transient atrioventricular block. Two patients died; one on the first day following transapical implantation, and the other after six months of implantation. The mean NYHA functional class decreased from preoperative 3.8±0.3, to 1.1±0.3 after a mean follow-up of 3.5±2.5 months (range 1 to 8 months) (p<0.01).
Conclusion: Early results of TAVI are successful in patients with inoperable aortic valve stenosis due to high surgical risk. The results of randomized studies with longer follow-up will clarify widespread use of this technique.

Baroreflex failure syndrome is a rare disorder seen after bilateral carotid body tumor resection. Iatrogenic injuries to the baroreceptor reflex arc cause fluctuations in blood pressure with hypertensive attacks or hypotensive episodes. A 43-year-old woman underwent bilateral carotid body tumor resection with one-week interval for a hypervascular tumor, 78x50x45 mm in size, at the right carotid artery bifurcation and a smaller tumor (50x30x20 mm) in the contralateral neck. Blood pressure of the patient became significantly unstable after excision of the second tumor, with hypertensive attacks up to 220/140 mmHg, accompanied by episodes of severe frontal headache, nausea, vomiting, skin flushing, and synchronous sinus tachycardia of 130 beats/min. Intermittent episodes of hypotension and bradycardia were also noted. The patient was clinically diagnosed as having baroreflex failure syndrome. The symptoms of the patient improved with medical therapy including clonidine, low dose beta-blocker, metoprolol, and a sedative. During 10 months of follow-up, she was generally well with residual episodes of hypertension about twice a month. In patients with bilateral carotid body tumors, unilateral excision of the greater tumor and a conservative approach for the contralateral tumor seem to be a more convenient approach to prevent baroreflex failure.

A 33-year-old male patient presented with complaints of atypical chest pain and exertional dyspnea of two-month history. Examinations to uncover these symptoms (physical examination, blood tests, electrocardiography, transthoracic echocardiography, coronary angiography, right heart catheterization) showed no abnormality, except for echocardiographic appearance of hypoechogenic areas suggesting widespread pericardial effusion involving the anterior and posterior cardiac walls and mild pulmonary stenosis. Cardiac magnetic resonance imaging (MRI) performed for further evaluation of the pulmonary gradient revealed fatty infiltration surrounding the whole heart, infiltration into the myocardium, and causing indentation of the proximal pulmonary artery. Since no pathologic condition associated with this radiologic appearance could be found, lipomatous infiltration was thought based on these cardiac MRI findings.

A 41-year-old male bodybuilder was admitted with acute inferior myocardial infarction. The patient had been using oxymetholone and methenolone to increase his performance for 15 years and quitted smoking three years before. He underwent successful primary percutaneous coronary intervention (PCI) and bare metal stenting for total occlusion of the proximal right coronary artery. Angiography also showed a critical lesion in the left anterior descending (LAD) coronary artery. Five hours after primary PCI, the patient had severe right flank pain. Abdominal computed tomography showed a large renal infarction in the right kidney. Subcutaneous enoxaparin was added to dual antiplatelet treatment. Doppler renal ultrasound performed on the eighth day showed findings of reperfusion in the right kidney and normal-size kidneys. Transthoracic echocardiography demonstrated disappearance of previously detected thrombus remnant in the left ventricle and only mild hypokinesia around the apical and middle segments of the inferior and inferoseptal walls. The patient was discharged on the 10th day. Renal arteriography during elective LAD intervention 18 days after discharge showed complete revascularization, stent patency, and improved blood flow. This is the first case of renal infarction that developed in the early hours of primary PCI, despite effective anticoagulant and antiplatelet treatment. Intensive coronary artery and left ventricular thrombi may be explained by the use of anabolic steroids.

A 52-year-old man with left atrial tachycardia underwent radiofrequency catheter ablation. A steerable 4-mm-tip ablation catheter was advanced into the left atrium through a patent foramen ovale without transseptal puncture. However, the tip of the catheter was stuck in a structure. A pull-back maneuver rendered the catheter free and the procedure was cancelled. Transthoracic and transesophageal echocardiograms obtained immediately after the procedure showed intimal layer dissection in the interatrial septum and intramural hematoma formation throughout the anterior left atrial wall. The patient was in stable condition. Therefore, he was followed-up conservatively with serial echocardiographic examinations. The dissected intimal layer disappeared in 10 days and the hematoma underwent near-complete resolution in three months. This case highlights a rare complication of catheter ablation procedure that all interventionists should be familiar with.

Stent endothelization is complete after one month in the absence of radiation therapy. The incidence of late stent thrombosis associated with bare metal stents is low beyond this one month period. In this paper, we report on a case of very late acute stent thrombosis that occurred after 118 months of first bare metal stent implantation. A 55-year-old male patient was admitted with chest pain and was diagnosed to have acute anterior myocardial infarction. He had a history of bare metal stent implantation for a critical stenosis in the left anterior descending coronary artery. Immediate coronary angiography demonstrated occlusion of the stent in the left coronary artery. Thromboaspiration was not an available option, so a new bare metal stent was implanted and TIMI III flow was established after balloon angioplasty.

We present a 30-year-old male with complex and predominantly cardiovascular autonomic dysfunction. He had frequent syncopal attacks and paroxysmal atrial fibrillation (PAF). Physical, electrocardiographic, and echocardiographic findings were unremarkable. Syncopal attacks were precipitated by emotional stress, upright position, and micturition. Electrocardiograms obtained immediately after syncopal events revealed PAF with a low ventricular rate, which spontaneously returned to sinus rhythm without any medication. Syncopal events were suggestive of postural orthostatic tachycardia syndrome (POTS), were induced during upright position, and were associated with a sudden increase in heart rate to approximately 140 beats per minute and a sudden drop in blood pressure. Syncope was also induced during carotid sinus massage (CSM) in the upright position. It was thought that cardiac autonomic dysfunction, with POTS as the main component, was responsible for this clinical condition. Syncopal episodes increased in frequency during treatment with metoprolol. Treatment with ivabradine (5 mg twice a day) resulted in disappearance of syncopal episodes both during upright position and CSM. During six months of follow-up, the patient remained asymptomatic without syncope or atrial fibrillation.

Aortic stenosis has emerged as a global pandemic with the ageing population and has become the third leading cause of structural heart disease after hypertension and coronary artery disease in industrialized countries. Older age and presence of serious comorbid conditions make surgery prohibitively risky in a large group of patients. The long-term results of balloon aortic valvuloplasty have been unsatisfactory, limiting the use of this procedure to only palliation or as a bridge to surgery. Percutaneous aortic prosthetic valve implantation has emerged as a new treatment modality for patients who are not eligible for surgery. After the first successful human application in 2002, transcatheter aortic valve implantation has undergone dramatic technologic improvements, yielding highly promising results. This review presents an outline on the ongoing evolution of transcatheter aortic valve implantation in an attempt to provide insight into its future use in the clinical management of severe aortic stenosis.