Invited Editorial

Objective: There are various cardiovascular abnormalities in end-stage liver disease (ESLD). In these patients, left ventricular (LV) systolic function is normal at rest but deteriorates during stress. This deterioration may be due to subclinical myocardial dysfunction. This study evaluated global LV and right ventricular (RV) functions using 2-dimensional (2D) speckle tracking in patients with ESLD.
Methods: Forty liver transplant candidates with ESLD and 26 healthy individuals were included in the study. All of the patients underwent conventional echocardiographic measurement. Longitudinal, circumferential, and radial strain measurements, as well as apical and parasternal short-axis image recordings were obtained. All 2D strain measurements were measured with offline analysis using velocity vector imaging (VVI) software.
Results: In the apical 4- and 2-chamber measurements, the LV mean longitudinal strain was significantly lower in the patient group compared with that of the control group (-16.0±3.2% versus -17.6±2.2%, -16.7±3.3% versus -18.7 ±2.1 ± 2.1 %; p=0.002, respectively). The LV mean circumfe-rential strain did not differ between groups. The LV mean radial strain and RV longitudinal strain were significantly lower in the patient group (45.4±10.7 vs. 52.7±10.8%; p=0.01 and -19.2±3.5% versus -21.5±3.6%; p=0.03, respectively).
Conclusion: Subclinical impairment of global LV and RV systolic functions was determined in liver transplantation candidates using VVI. This deterioration was detected in longitudinal and radial deformation rather than circumferential deformation mechanics, which is consistent with early-stage LV myocardial dysfunction.

Objective: This study was a comparison of the Systematic Coronary Risk Estimation for high-risk countries (SCORE-HRC), developed by the European Society of Cardiology (ESC) using data from 12 European cohort studies, and SCORE-Turkey, aimed at assessing the statin therapy protocol for primary prevention.
Methods: A total of 323 patients who experienced their first episode of acute coronary syndrome were included in the study. The SCORE risk calculations were determined using age, sex, smoking status, blood pressure, total cholesterol, and high-density lipoprotein (HDL-C) level data. Statin treatment indications were evaluated according to the ESC guidelines (2016).
Results: There was a significant difference in the statin indication ratio calculated using the SCORE-HRC and SCORE-Turkey formulae (42.7% and 39.0%, respectively; p=0.012). However, the recommendation to begin statin therapy was insufficient with both algorithms, according to the protocol of the ESC guidelines. There was also a significant difference between the 2 systems in the 10-year cardiovascular risk estimation (SCORE-HRC: 5.09±4.67, SCORE-Turkey: 4.8±4.67; p<0.001). The primary difference between the methods was related to HDL-C. The SCORE-HRC chart was more successful if the patient’s HDL-C level was low. As the HDL-C level increased, the SCORE-Turkey formula performed better (p<0.001). According to the SCORE-HRC, 7.8% of the patients aged 50-59 years were in a “very high-risk” group, while there were no patients aged <50 years in this group.
Conclusion: The SCORE-HRC was superior to the SCORE-Turkey in patients with acute coronary syndrome. It is only appropriate to use the SCORE-Turkey algorithm for patients with a high HDL-C level. Nonetheless, the ESC SCORE classification is inadequate to determine the “very high-risk” group based on this, ESC recommendations on initiation of statin therapy is insuffiecient particularly in those <60 years of age. The ESC risk classifications should be re-evaluated and a new algorithm should be developed for the Turkish community.

Objective: The pathophysiology of coronary slow flow phenomenon (CSFP) is poorly understood. Evidence suggesting endothelial dysfunction in patients with slow coronary flow (SCF) led to this evaluation of a possible correlation between microalbuminuria (MAU), as an indicator of endothelial dysfunction, and CSFP in order to investigate a mutual pathophysiology.
Methods: In this case-control study, 15786 patients who presented between September 2016 and April 2018 were screened. All patients with CSFP had chest pain and coronary angiography was indicated due to a positive noninvasive test. All cases had a Thrombosis in Myocardial Infarction (TIMI) flow grade of 2 or a corrected TIMI frame count of >27 without any evidence of obstructive coronary artery disease. The patients used as controls had completely normal coronary angiograms. Fasting mid-stream urine samples were analyzed using an immunoturbidimetric assay to determine the albumin-creatinine ratio (ACR) as a surrogate of microalbuminuria (MAU) (ACR: 30–300 mg/g). The prevalence of MAU in the case and control groups was analyzed.
Results: A total of 154 individuals with a normal coronary angiogram and 46 patients with SCF were enrolled in the study. The prevalence of MAU was greater in patients with SCF than in the control group (8.7% vs 1.9%, respectively; p=0.048). Even after adjustment for major risk factors, the association between MAU and CSPF remained significant.
Conclusion: The results of this study indicated that there was a relationship between MAU and CSFP and confirmed that endothelial dysfunction is a contributing factor to CSFP. These findings are of utmost importance due to the prognostic value of MAU for both all-cause and cardiovascular mortality rates.

Objective: Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is a new term to define the syndrome of clinical evidence of MI occurring in the absence obstructive coronary artery disease. Given that there is believed to be a large number of MINOCA cases, effective diagnostic and therapeutic strategies are needed. Documentation of the demographic parameters and diagnostic methods used in existing cases is a first step. The purpose of this study is documentation of the prevalence, demographic details, and possible etiological causes, as well as inpatient and 1-year prognosis data of MINOCA patients in the Turkish population.
Methods: The MINOCA-TR Study is a national, multi-center, prospective, observational study. A sample of 1028 conse-cutive MI patients who undergo diagnostic angiography will be enrolled. This is a cohort study that will include patients from 32 different centers. After an initial screening/enrollment visit, follow-up will be performed at the time of hospital discharge for the overall MI study population. Patients diagnosed as MINOCA will be followed up with 3 prospective office or telephone visits as part of the Prospective MINOCA Registry.
Conclusion: Demographic information, clinical characteristics, management strategies, and inpatient prognostic indicators will be documented in the cross-sectional portion of the registry. Additional diagnostic data, therapeutic strategies, and prognostic relevance will be recorded in the 12 months of the prospective research. The results are expected to inform future diagnostic and therapeutic strategies and enhance understanding of the condition by highlighting the national burden of the disease from a medical and a public health perspective, as well as stimulate future research focusing on the MINOCA population.

Objective: This study explored a unique form of atrioventricular nodal reentrant tachycardia (AVNRT) in which certain acutely ill patients have a first episode of supraventricular tachycardia (SVT) with a short RP interval.
Methods: A retrospective chart review was conducted of patients at a single institution who developed SVT with short RP and yielded 19 patients.
Results: None of the 19 patients had a prior history of AVNRT or any other arrhythmia. The mean age was 58 years, the majority of patients were male (13/19), and there was a presence of hypertension (10/19), diabetes mellitus (5/19), hyperlipidemia (7/19), congestive heart failure (2/19), coronary artery disease (3/19), obstructive sleep apnea (2/19), and active cancer (8/19). The reasons for admission were planned surgery (8/19), sepsis (8/19), drug abuse (2/19), and neurological disorder (2/19). The AVNRT either terminated spontaneously or following the administration of adenosine. The patients were treated with amiodarone (12/19), metoprolol (6/19), or diltiazem (1/19). Follow-up (mean: 370 days) details revealed that patients were on amiodarone (3/19), metoprolol (6/19), were not taking any cardiac medication (5/19), or had passed away (5/19). Only 1 patient had a recurrence of AVNRT, and none of the patients required ablation therapy.
Conclusion: “AVNRT of the sick” has not been previously described in the medical literature, to our knowledge. It can be successfully treated with medications and the chance of recurrence after resolution of the acute illness is small.

Objective: Optimal management in asymptomatic children and adolescents with the Wolff-Parkinson-White (WPW) electrocardiographic pattern is still debatable. The aim of this retrospective study was to evaluate the electrophysiological properties of asymptomatic children and adolescents with WPW.
Methods: The medical records and procedural data of asymptomatic children and adolescents with the WPW electrocardiographic pattern who underwent invasive electrophysiological study (EPS) and catheter ablation between April 2012 and April 2018 were evaluated.
Results: In all, 149 consecutive, asymptomatic children and adolescents with WPW who underwent EPS were retrospectively investigated. In 39 (26.2%) of the patients, a shortest pre-excited R–R interval of ≤250 ms during atrial fibrillation or an accessory pathway effective refractory period of ≤270 ms was found. A total of 39 patients with high-risk antegrade conduction and 45 patients with inducible orthodromic atrioventricular re-entrant tachycardia underwent catheter ablation. In addition, 14 patients underwent catheter ablation due to family preference.
Conclusion: High-risk antegrade conduction properties are exhibited by more than one-quarter of asymptomatic children and adolescents with WPW. Ablation should be considered as a first-line therapy in asymptomatic children and adolescents with high-risk WPW.

Objective: Carotid ultrasonography is a reliable and non-invasive method to evaluate atherosclerosis disease and its complications. B-mode cineloops are widely used to assess the severity of atherosclerosis and its progression; ho-
wever, tracking rapid wall motions of the carotid artery is still a challenging issue due the low frame rate. The aim of this paper was to present a new hybrid frame rate up-conversion (FRUC) method that accounts for motion based on manifold learning and optical flow.
Methods: In the last decade, manifold learning technique has been used to pseudo-increase the frame rate of carotid ultrasound images, but due to the dependence of this method to the number of recorded cardiac cycles and frames, a new hybrid method based on manifold learning and optical flow was proposed in this paper.
Results: Locally linear embedding (LLE) algorithm was first applied to find the relation between the frames of consecutive cardiac cycles in a low dimensional manifold. Then by applying the optical flow motion estimation algorithm, a motion compensated frame was reconstructed.
Conclusion: Consequently, a cycle with more frames was created to provide a more accurate consideration of carotid wall motion compared to the typical B-mode ultrasound ima-ges. The results revealed that our new hybrid method outperforms the pseudo-increasing frame rate scheme based on manifold learning.

Antiphospholipid syndrome (APS) is a clinical disorder that creates an increased risk of arterial or venous thrombotic events or pregnancy-associated complications and includes the presence of autoantibodies against negatively charged phospholipids. This syndrome is often associated with systemic autoimmune diseases, such as systemic lupus erythematosus (SLE). Libman-Sacks endocarditis is a form of non-bacterial thrombotic endocarditis and is infrequently seen in APS. There are few data documenting the echocardiographic response of APS valve disease to medical treatment. This is an unusual case of a young female patient with SLE and APS who had chorea and non-bacterial thrombotic aortic valve endocarditis. Echocardiography revealed that the vegetation had receded after a combination of warfarin and immunosuppressive therapy.

Permanent His bundle pacing (HBP) activates the ventricles through the normal conduction system and has become a useful technique for patients with a high ventricular pacing rate. Presently described is a case of drug-refractory atrial fibrillation (AF) with a high ventricular rate that was treated with atrioventricular (AV) node ablation and permanent HBP. A 62-year-old woman with persistent AF and a drug-refractory high ventricular response was referred for exercise intolerance and palpitation. She had a history of failed catheter ablation attempts and amiodarone toxicity. Permanent HBP and AV node ablation was planned to achieve rate control with a stepwise approach. Initially, implantation of a permanent pacemaker was performed. The His lead and right ventricular back-up leads were implanted successfully, in the manner described previously. The His lead was connected to the atrial channel of the pacemaker battery and programmed to AAI pacing mode. The AV node was ablated successfully 3 weeks later without any threshold changes in the His lead. No His lead threshold changes were observed during or after AV node ablation and the patient was subsequently asymptomatic with twice daily apixaban 5 mg. Permanent HBP after AV node ablation can be a beneficial treatment option to prevent pacing-induced ventricular dyssynchrony and heart failure in patients who are not eligible for cardiac resynchronization therapy.

A calcified amorphous tumor (CAT) of the heart is a non-neoplastic mass, characterized by nodules of calcium on a background of amorphous fibrinous material. Mitral annular calcification (MAC) is one of the conditions most frequently associated with CAT. Most MAC-related CAT cases are reported in end-stage renal disease (ESRD) patients. This report is a description of a patient with normal renal function who was incidentally diagnosed with a CAT arising from MAC. An asymptomatic 43-year-old man with normal renal function underwent echocardiography. The echocardiography results revealed a highly mobile hyperechoic mass attached to the atrial side of the mitral annulus superimposed on a heavily calcified mitral annulus. Cardiac surgery and histopathological evaluation confirmed a diagnosis of MAC-related CAT. While MAC-related CAT is usually associated with ESRD patients, the precise etiology and management strategy of this benign tumor remain unclear. The rare incidence of this tumor in patients with normal renal function highlights the importance of further research of the pathology of this uncommon condition.

Femoral artery is the most common vascular access site used for angiographic interventions. Various complications such as hematoma, bleeding, dissection, arteriovenous fistula and pseudoaneurysm have been described following iatrogenic puncture. However, angiosarcoma formation at the access site is very uncommon and it poses a diagnostic dilemma due to its resemblance to organized hematoma. A 75-year-old patient who had undergone coronary angiography has suffered from an angiosarcoma and its vascular complications due to local invasion at the puncture site. Although the tumor was completely excised and flow was re-established, he was lost 17 months later because of multiple metastases and their complications. Presence of a persistent mass with vascular complaints should raise suspicion for this rare and aggressive type of tumor.

Labile hypertension is a common problem in daily clinical practice. It is defined as a rapid, temporary rise in blood pressure to above 140/90 mm Hg, most often due to emotional stress, followed by a return to normal values. In the clinical setting, it may be due to white coat hypertension, masked hypertension, pseudopheochromocytoma, orthostatic hypertension, or supine hypertension. Labile hypertension can lead to increased cardiovascular risk. Ambulatory blood pressure monitoring is often used for the diagnosis. Alpha blockers+beta blockers and antidepressants are frequently used for treatment.