In the current issue of Archives of Turkish Society of Cardiology Journal, Sigirci et al., have evaluated serum endocan and omentin-1 levels in patients diagnosed with stable angina pectoris who had coronary slow flow phenomenon on angiography. In this editorial comment, the comments on the article are provided.

Objective: The pathophysiology of the slow coronary flow (SCF) phenomenon is still unclear. The two most frequently cited mechanisms of SCF are endothelial dysfunction and subclinical diffuse atherosclerosis. The aim of this study was to investigate the relation of SCF to serum endocan levels which is associated with endothelial dysfunction and to serum omentin-I levels which is associated with atherosclerosis.
Methods: A total of 42 patients with SCF and 43 controls with normal coronary flow based on a coronary angiogram were enrolled. Serum endocan and omentin-I levels were measured and the presence of SCF was determined according to Thrombolysis in Myocardial Infarction frame count (TFC) calculations.
Results: The omentin-I level was significantly lower and the endocan level was significantly higher in patients with SCF than in the controls. Receiver operating characteristic curve analysis revealed that the sensitivity and specificity of endocan for SCF was 66% and 70%, respectively (area under the curve [AUC]: 0.760, 95% confidence interval [CI]: 0.65–0.86; p<0.001), and the comparable values for omentin were 66% and 61% (AUC: 0.630, 95% CI: 0.51–0.75; p=0.049). Multivariate logistic regression analysis revealed that a high endocan level (odds ratio [OR]: 6.8, 95% CI: 1.849–2.439, cutoff: 2.45 ng/mL; p=0.003) and a low omentin-I level (OR: 3.6, 95% CI: 1.057–12.893, cutoff: 4.63 ng/mL; p=0.041) were independently associated with the presence of SCF. In patients with SCF, the endocan level was positively correlated with the mean TFC, while the omentin-I level was negatively correlated (r=0.44; p<0.001 and r=-0.22; p=0.049, respectively).
Conclusion: These results revealed that endocan and omentin-I might be useful biomarkers for predicting the presence and severity of SCF.

Objective: The aim of this study was to evaluate the early effects of transcatheter closure of secundum atrial septal defect (ASD) on atrial and ventricular diameters and functions evaluated by transthoracic echocardiography, and to assess the relation of morphological changes to N-terminal pro-brain natriuretic peptide (NT-proBNP) levels.
Methods: Twenty-two patients with secundum-type ASD referred for percutaneous closure were included in the study as well as 22 healthy individuals who served as a control group. TTE and concurrent blood sampling were performed prior to and 24 hours and 30 days after the closure procedure.
Results: At follow-up 24 hours and 30 days after the closure, the right atrial (RA) area, right ventricular (RV) area, RV end-diastolic volume (EDV), and RV end-systolic volume (ESV) decreased, while left ventricle (LV) EDV (LVEDV), LVESV, and LV stroke volume (LVSV) increased. Global RV systolic and diastolic function indices, such as the tricuspid annular plane systolic excursion, the tricuspid E/A and E/e’ ratio decreased immediately after the closure. The NT-proBNP value increased in the 24 hours following closure, and after 30 days, it was still higher than the measurement recorded before the transcatheter closure. The LV structural and functional parameters were significantly correlated with the NT-proBNP value (LVEDV: r=0.37, p=0.02; LVESV: r=0.38, p=0.01; left atrium area: r=0.46, p=0.002; mitral E/e’: r=0.28, p=0.04).
Conclusion: Percutaneous ASD closure can lead to both early and sustained changes in cardiac anatomy and function involving both sides of the heart. The NT-proBNP level had increased at 24 hours post procedure, and was also notably increased 30 days after the percutaneous ASD closure, which is associated with increased LV diameter and volume.

Objective: Although many articles have been published about transcatheter coil occlusion, few studies have been conducted on the long-term outcomes of patent ductus arteriosus closure with a coil. This study is an examination of the follow-up data of patients who underwent transcatheter patent ductus arteriosus closure with a coil.
Methods: Between May 1996 and May 2018, 243 patients underwent transcatheter patent ductus arteriosus closure with a coil. The patients were divided into 2 groups based on the timing of the use of ductal occluders at the facility. Until the end of 2005, every ductus was closed with a coil. Since initiating the use of ductal occluders in 2006, coils are mostly used to close small, elongated ducts, and occasionally, some complex ducts.
Results: The median age of the patient was 4.33 years, the median weight was 15 kg, and the median duct diameter was 2 mm. In this study group, 98 (40%) patients were male and 145 were female (60%). The angiographic features of the ductus were classified as type A in 126 patients, type B in 15, type C in 6, type D in 9, type E in 74, and 13 were recorded as other types. In 238 of the patients, the patent ductus arteriosus was successfully closed with a coil. In 5 (2.2%) cases, the procedure was unsuccessful. Echocardiography follow-up continued for an average of 4.1±4.1 years (1 day-19 years). A residual shunt was observed in 42 patients, and spontaneous occlusion was seen in 29 of the 42 patients.
Conclusion: The results of this study indicated that closure of the patent ductus arteriosus with a coil was a safe and effective method.

Objective: Although hemodynamic instability has been identified as the most established mortality predictor in acute pulmonary embolism (PE), the debate is still open about the prognostic significance of saddle pulmonary embolism (SPE). This study determined the in-hospital mortality rate of SPE patients diagnosed via computed tomographic pulmonary angiography (CTPA) and compared these cases with non-SPE patients.
Methods: The presence of SPE observed on CTPA was used to classify 492 consecutive patients into SPE and non-SPE groups. Different features were compared between the 2 groups, and independent predictors of in-hospital mortality in acute PE were identified.
Results: A total of 70 patients (14.2%) had SPE. In univariate analysis, the SPE group was seen to have a higher in-hospital mortality rate, as well as a lower oxygen saturation level and systolic and diastolic blood pressure in comparison with the non-SPE group (all p values <0.005). Multivariate analysis revealed that SPE was an independent predictor of in-hospital mortality in acute PE patients (Odds ratio: 9.21, 95% confidence interval: 3.40-24.89; p value <0.001).
Conclusion: The results of this study indicated that SPE had a statistically significant importance in predicting in-hospital mortality and adverse events in PE patients. These findings were not consistent with many prior studies.

Objective: Liver stiffness (LS) values are known to be associated with increased right ventricle (RV) pressure in patients with heart failure (HF). The aim of this study was to determine the changes in LS in patients of different New York Heart Association (NYHA) classes and the parameters related to increased LS in HF patients with reduced ejection fraction (HFrEF).
Methods: A total of 181 patients with HFrEF were included in the study. Routine anamnesis, physical examination, laboratory examinations and echocardiography were performed. The LS measurement was performed using the ElastPQ technique. The patients were grouped by NYHA class I-IV.
Results: The LS values were significantly different between NYHA class groups, increasing significantly from NYHA class I to IV. The number of patients with LS >7 kPa or >10.6 kPa was significantly greater among the class III-IV patients. The RV myocardial performance index, tricuspid regurgitation pressure gradient, N-terminal pro b-type natriuretic peptide, and aspartate aminotransferase levels were found to be independently associated with LS. It was also observed that LS independently determined III-IV classification and that an increase of 1 kPa increased the risk of being class III-IV by 94.4%. Receiver operating characteristic analysis with a cut-off value of 7 kPa for LS identified patients with class III-IV disease with 82.8% sensitivity and 81.8% specificity.
Conclusion: In HFrEF, the LS value increased with NYHA class and independently determined patients with class III-IV disease. A higher LS value independently determined increased RV pressure and systolic functions.

Objective: This study was designed to evaluate variations in popliteal artery (PA) distal branching observed in lower extremity magnetic resonance angiography (MRA) images.
Methods: A total of 576 lower extremity MRA examinations that were performed consecutively between 2008 and 2012 in a single hospital were retrospectively evaluated. In all, 767 lower extremity images of 425 patients were included in the study and 151 examinations that were inappropriate were excluded. A bilateral evaluation was conducted of 342 lower extremities, and 83 lower extremities were evaluated unilaterally. The anatomical variations in the PA branching patterns were classified and assessed, and the results were evaluated with other studies that have examined PA distal branching variations with digital subtraction angiography and computed tomography angiography.
Results: The most frequently seen pattern was type IA (normal pattern), detected in 613 (80%) extremities. Variations in PA branching were depicted in 154 (20%) extremities and 733 (95.6%) limbs had a normal level of PA branching. Type II variations, with a high division of the PA (at or above the level of the tibial plateau), were seen in 34 (4.4%) extremities. Type III variations were observed in 87 (11.4%) extremities. Of the 342 bilaterally evaluated patients, 251 (73%) had a bilaterally symmetrical pattern. Type IA was the most frequently encountered bilaterally symmetrical pattern.
Conclusion: MRA examination can be used as an alternative to digital subtraction angiography for the evaluation of PA branching patterns.

Objective: The current guidelines use a cut-off value of 0.9 mm to define abnormally increased carotid intima-media thickness (C-IMT), regardless of age or gender. This study was conducted to examine the effects of age and gender on C-IMT and cut-off values for C-IMT in different age groups.
Methods: A total of 644 patients with a recorded C-IMT measurement, at least 1 cardiovascular risk factor, and aged between 20 and 90 years were included in the study. Common and internal C-IMT (CC-IMT and IC-IMT) measurements were obtained using carotid ultrasonography (USG). The patients were divided into 5 groups based on age: Group I (20–40 years), Group II (41–50 years), Group III (51–60 years), Group IV (61–70 years), and Group V (>70 years).
Results: The CC-IMT and IC-IMT values were significantly greater as the age of the group increased. Group I to Group V had a median CC-IMT value of 0.70 mm, 0.70 mm, 0.75 mm, 0.75 mm, and 0.85 mm, respectively. The median IC-IMT value for each group was 0.60 mm, 0.65 mm, 0.70 mm, 0.70 mm, and 0.80 mm, respectively. The median CC-IMT value was 50 μm greater than the median IC-IMT value in all groups. Only the CC-IMT value was significantly different in males (0.80±0.20 mm vs. 0.76±0.19 mm; p=0.020). Age, hypertension (HT), smoking, hyperlipidemia, systolic-diastolic blood pressure, and body mass index measures were associated with increased C-IMT. Regression analysis revealed that increased C-IMT was independently associated with age and HT presence. Each decade of life and the presence of HT revealed an incidence of increased C-IMT by 44% and 53%, respectively.
Conclusion: C-IMT significantly increased with age. New, age-appropriate cut-off values are needed for C-IMT assessment. In addition, it was observed that the CC-IMT value was approximately 50 μm greater than the IC-IMT measurement in all age groups. CC-IMT measurements should be included in USG reports.

Presently described is a case in which the tip of the delivery catheter system (nose cone) has been broken during catheter removal after valve deployment in a femoral transcatheter aortic valve replacement procedure and the successful management of this rare complication.

An Osborn wave may be observed on an electrocardiogram (ECG) as a late delta wave at the end of the QRS complex in cases of hypothermia. An 18-year-old male known to be a synthetic cannabinoid user was found unconscious and hypothermic. The patient’s body temperature was 33ºC, and an Osborn wave and atrial fibrillation were detected in ECG readings. Following the application of heating and supportive therapy, consciousness returned and the ECG findings improved. Rewarming and supportive treatment can be life-saving in a hypothermic patient when initiated as soon as possible.

Trisomy 14 mosaicism is a rare chromosomal abnormality with distinct and recognizable clinical features. Congenital heart anomalies can accompany in this syndrome. To the best of our knowledge, this is the first case of mosaic trisomy 14 with an aortopulmonary window to be described in the literature.

Isotretinoin is widely used in the treatment of acne vulgaris and other dermatological diseases. Numerous side effects have been reported in the literature. A myocardial bridge occurs when segments of the coronary artery create an intramyocardial tunnel. Atherosclerotic plaque formation frequently occurs in the segment proximal to a myocardial bridge. Coronary thrombus formation, which is often the cause of myocardial infarction in young patients, can be triggered by many factors. Kounis syndrome is described as acute coronary syndromes associated with allergic or hypersensitivity reactions. This article is a description of the case of a patient predisposed to the development of a thrombus by a myocardial bridge who was successfully treated for coronary thrombosis and which may represent a case of Kounis syndrome associated with isotretinoin use presented in the context of the relevant literature.