Objective: The incidence of patent ductus arteriosus (PDA) is greater among patients living at high altitude. In this po-pulation, the ductal diameter is often larger and pulmonary hypertension is more frequent. The aim of this study was to evaluate the hemodynamic and morphological features of PDA and transcatheter closure procedures performed with various devices in a group of patients living at high altitude in Turkey.
Methods: The data of 327 patients who lived at an altitude of at least 1600 m above sea level and who had undergone cardiac catheterization for isolated PDA between May 2010 and July 2018 were retrospectively analyzed.
Results: The mean age was 7.33±7.67 years, and 62.4% of the patients were female. The mean ductal diameter was 3.74±2.14 mm. Pulmonary hypertension was present in 57.8%. Transcatheter closure was performed in 322 patients, with a 97.3% success rate. The Amplatzer duct occluder I (ADO I) was used most often, as well as off-label use of the Amplatzer vascular plug II (AVP) and the Amplatzer muscular ventricular septal defect occluder (AMVSDO). Pulmonary artery pressure decreased immediately in the vast majority after percutaneous closure. Transient left ventricular systolic dysfunction after ductal closure was seen only rarely. Follow-up was uneventful.
Conclusion: Transcatheter PDA closure can be performed with high success rate in highlanders. Off-label devices may be required for these procedures. Pulmonary hypertension is frequent but regresses after ductal closure. Transient left ventricular dysfunction after transcatheter closure is rarely seen in these patients and resolves without any medication.

Objective: The aim of this research was to investigate the relationship between atrial fibrillation (AF) recurrence and second generation cryoballoon ablation (CBA) procedural parameters in patients with non-valvular paroxysmal AF (PAF).
Methods: A total of 131 patients with a PAF diagnosis who underwent second-generation CBA (59 male; mean age: 55.2±10.6 years) were enrolled. Recurrence was defined as the detection of AF on a 12-lead electrocardiography (ECG) recording, or an attack lasting at least 30 seconds observed on Holter ECG records. CBA procedural data and echocardiographic findings were recorded and compared.
Results: After 1 year of follow-up, AF recurrence was detected in 27 patients. Patients with recurrence were older and had higher rates of hypertension and diabetes (p<0.05 for both). Left atrial diameter, left atrial volume (LaV), left atrial volume index, and the averaged warming angle (calculated by combining lowest temperature point and balloon temperature at 20°C point) were significantly higher in the recurrence group. Balloon warming time was significantly longer in the non-recurrence group (p<0.001). In binary logistic regression analysis, the averaged warming angle (odds ratio [OR]: 1.559, 95% confidence interval [CI]: 1.342–1.811; p<0.001) and LaV (OR: 1.063, 95% CI: 1.028–1.100; p<0.001) were found to be independent parameters for predicting recurrence. The cutoff value of the warming angle obtained with ROC curve analysis was 50° for the prediction of recurrence (sensitivity: 94.3%, specificity: 88.5%, area under the curve: 0.909; p<0.001). The cutoff value of LaV obtained by ROC curve analysis was 53.5 for prediction of recurrence (sensitivity: 77.8%, specificity: 74.5%; p<0.001).
Conclusion: Measurement of balloon warming angle during CBA and increased LaV may predict the AF recurrence.

Objective: Primary prevention of sudden cardiac death in ST-elevation myocardial infarction (STEMI) is a complicated issue due to the highly heterogeneous population. The effect of T-wave alternans (TWA) on cardiac mortality has been examined in various populations, most often in patients with a high risk of fatal arrhythmia, such as patients with a low left ventricular ejection fraction (LVEF). The aim of the present study was to investigate the prevalence of TWA and its relationship to cardiac mortality in young STEMI patients with preserved LVEF.
Methods: A total of 108 STEMI patients with preserved cardiac function who were under the age of 45 and underwent single-vessel primary percutaneous coronary intervention were enrolled in this prospective study. Preserved cardiac function was defined as an LVEF of ≥50% as detected with echocardiography 24 to 72 hours after the procedure. The TWA test was performed approximately 1 year after the STEMI occurrence. TWA positivity was defined with a maximal voltage of >64 μV and a heart rate of 125 beats per minute, as in previous studies. The patients were followed up for 5 years and overall cardiac mortality was measured.
Results: There was a positive TWA finding in 24 patients (22.2%). There was no significant difference in the use of medications, traditional risk factors, or LVEF in those with TWA positivity. During a follow-up period of 5 years, 7 patients (6.5%) reached the endpoint. Patients with TWA positivity had 10.7 times greater odds for 5-year cardiac mortality, independent of other risk factors.
Conclusion: Clinicians should consider using the TWA test in young STEMI patients, as TWA positivity may be associated with increased cardiac mortality in this population.

Objective: Panic disorder (PD) is now recognized as a common and important problem in children, and particularly adolescents, and one that can negatively affect daily well-being and educational performance. The aim of this study was to investigate the relationship between heart rate variability (HRV) and the severity of symptoms before and after treatment with psychotherapy and fluoxetine.
Methods: The PD study group consisted of 23 children diagnosed with PD and the healthy control (HC) group comprised 27 healthy children. Panic-anxiety symptoms were measured using 2 assessments performed before and after treatment. HRV was evaluated with a 24-hour Holter examination.
Results: According to the analysis of the 24-hour, all-day Holter device recordings, the high frequency (HF) and parasympathetic (%) scores in the PD group were lower than those of the HC group (p<0.05). The low frequency (LF)/HF ratio and sympathetic (%) scores in the PD group were higher than those of the HC group (p<0.05). The analysis of daytime readings indicated that the HF values of the PD group were lower than those of the HC group (p<0.05), while the very LF/HF ratio and LF/HF ratio were higher than those of the HC group (p<0.05). Analysis of nighttime Holter results revealed that the rMSSD, pNN50, and HF readings of the PD group were lower than those of the HC group (p<0.05), while the LF/HF ratio in PD patients was higher than that seen in the HC group (p<0.05).
Conclusion: In children and adolescents with PD, increased sympathetic activity can cause changes in some HRV parameters. Some of these changes may return to normal with treatment.

Objective: The aim of this study was to determine the usefulness of the Tei Index, an echocardiographic parameter, in the early determination of pulmonary artery pressure (PAP) in congenital heart disease (CHD) with a left-to-right shunt.
Methods: Right and left ventricular functions were evaluated using Tei Index values determined with tissue Doppler echocardiography. Cardiac catheterization was performed in all cases. The presence of pulmonary arterial hypertension (PAH) was defined as a mean PAP of ≥25 mm Hg and a pulmonary vascular resistance index of >3 WU/m2. Patients with a pulmonary/systemic blood flow ratio of ≥2 were considered candidates for surgery.
Results: The Tei Index values measured from the left ventricular posterior wall and the right ventricular anterior wall were found to be significantly higher in the patients with PAH (0.68±0.18, 0.67±0.16, respectively) compared with the patients without PAH (0.56±0.16, p=0.027; 0.51±0.12 p=0.001). A significant correlation was detected between the Tei Index value measured from the left ventricular posterior wall and the mean PAP (correlation coefficient: 0.491).
Conclusion: The right ventricular Tei Index values in children with CHD and a left-to-right shunt can be used as a parameter to follow up on the potential development of PAH, to make a diagnosis in the early period, and to make a timely decision about surgery.

Objective: The aim of this retrospective study based on real-life data was to evaluate the lipid profile and demographic, clinical, and laboratory features of patients with acute coronary syndrome (ACS) at a tertiary center and to examine the mortality rate.
Methods: Information including endpoint data for at least 2 years following the index ACS event was retrieved from hospital records. Patients without sufficient follow-up data were called by phone. Modified Dutch Lipid Clinic Network criteria were used to identify the presence of familial hypercholesterolemia (FH). Factors affecting mortality in the 2-year follow-up period were evaluated using Cox regression analysis.
Results: A total of 985 ACS patients (215 females) between 21 and 93 years of age were included. The females were older and had a lower smoking rate than the males. In females, the history of obesity and hypertension, the diabetes rate, and the thyroid-stimulating hormone level were higher than those of the males. In 95.6% of the patients, lipid parameters were measured upon hospital admission. No significant difference in dyslipidemia frequency was observed between genders. The frequency of FH was 7.6%. The rate of lipid-lowering drug use was <20% at admission, >90% at discharge, and decreased to 50% in the follow-up period. The mortality rate was 3.8% in the in-hospital period and 8.1% during the 2 years of follow-up.
Conclusion: The mortality rate in ACS patients was 3.8% in the in-hospital period and 8.1% in the 2-year follow-up period. The frequency of hypercholesterolemia was 89.5% and the rate of lipid-lowering drug use was insufficient. Secondary prevention after ACS was not adequately employed even at a tertiary center. The FH frequency was 7.6% and those with FH were observed to have ACS at a younger age than those without.

Objective: Our study aimed to estimate the impact of addressing modifiable risk factors on the future burden of cardiovascular diseases (CVD) in the general population and in two high-risk populations (heterozygous familial hypercholesterolemia and secondary prevention) for Turkey.
Methods: One model investigated the impact of reaching the World Health Organization (WHO) voluntary targets for tobacco use, hypertension, type 2 diabetes, obesity and physical inactivity in the general population. Another model estimated the impact of reducing LDL-cholesterol in two high-risk populations through increased access to effective treatment. Inputs for the models include disease and risk factor prevalence rates, a population forecast, baseline CVD event rates, and treatment effectiveness, primarily derived from the published literature. Direct costs to the public health care system and indirect costs from lost production are included, although the cost of programs and pharmacological interventions to reduce risk factors were not considered.
Results: The value of reaching WHO risk factor reduction targets is estimated at US$9.3 billion over the next 20 years, while the value of reducing LDL-cholesterol is estimated at up to US$8.1 billion for high-risk secondary prevention patients and US$691 million for heterozygous familial hypercholesterolemia patients.
Conclusion: Efforts to achieve WHO risk factor targets and further lower LDL-cholesterol through increased access to treatment for high-risk patients are projected to greatly reduce the growing clinical and economic burden of CVD in Turkey.

Sinus of Valsalva aneurysms are rare congenital anomalies. Sinus of Valsalva aneurysm rupture, leads to biventricular failure due to systemic to pulmonary shunting. Surgical repair has been the traditional treatment for these aneurysms. Recently, percutaneous treatment has been successfully performed to selected patients. We present a 36-year-old man who had ruptured sinus of Valsalva aneurysm, that was successfully treated with using a catheter-based approach with the patent ductus arteriosus occluder device.

Shone’s complex is a rare congenital cardiac malformation characterized by serial obstructive lesions of the left heart at multiple levels. Presently described is an unusual case of an adult male patient who presented with palpitations and worsening dyspnea. An echocardiographic evaluation revealed Shone’s complex associated with left ventricular non-compaction cardiomyopathy (NCC). To our knowledge, an association between NCC and Shone’s complex has not been previously described.

A 77-year-old man with a past medical history of myelodysplastic syndrome, coronary artery disease, hypertension, and chronic atrial fibrillation presented at the hematology outpatient clinic with progressive shortness of breath, weakness, and chest and back pain. Echocardiography was performed and the patient was diagnosed with severe pericardial effusion near the right ventricle. Pericardial drainage was performed. Erysipelothrix rhusiopathiae was isolated from the pericardial fluid. Complications of respiratory and renal failure developed during follow-up. The clinical and laboratory findings of vegetation on the tricuspid valve, pericardial effusion, and atrial fibrillation with a low heart rate suggested possible pancarditis. A multidisciplinary treatment approach with the cardiology and infectious disease departments was critical to successful management of this case.

Massive pulmonary embolism is a well-known cause of sudden cardiac arrest in the adult population. Systemic fibrinolysis can be a life-saving option. Therapeutic hypothermia is highly recommended for nontraumatic sudden cardiac arrest victims to minimize neurological complications. However, there are limited data about the use of therapeutic hypothermia for sudden cardiac arrest victims also treated with systemic fibrinolysis. Concerns about hypothermia-related coagulopathy and a possible tendency to bleeding have limited the use of cooling therapy in such cases. Presently described is a case of sudden cardiac arrest due to a massive pulmonary embolism that was successfully treated with the concomitant usage of systemic fibrinolysis and therapeutic hypothermia.