Objective: To evaluate the outcome and the systolic blood pressure changes after surgical treatment of aortic coarctation in adults. Methods: Between February 1995 and January 2001, 12 adult patients with a mean age of 29±10 years, underwent repair of aortic coarctation in our clinic. The diagnostic and operative data of these patients were retrospectively analyzed. Follow-up was complete in all hospital survivors. Results: The mean systolic blood pressure of 8 hypertensive patients decreased from 155±7 mmHg to 115±9 mmHg after surgical intervention. One patient with a dilated cardiomyopathy died one day after the operation due to an intractable ventricular fibrillation (mortality 8.3%). Four patients had been operated for coexisting cardiovascular pathologies during a mean follow-up period of 32±26 months. Conclusion: Surgical treatment of aortic coarctation in adults can be safely performed with an acceptable mortality and morbidity, both resulting from coexisting cardiovascular disorders in our patient group. The systolic blood pressure may decrease significantly after the operation.

Objective: Insulin resistance is a risk predictor for many cardiovascular diseases, but its effect on etiology and prognosis of diseases has not been clearly identified. In this study, we aimed to investigate whether admission index of insulin resistance (aIRI), recently and practically presented for determination of insulin resistance, could be a new risk predictor of early prognosis in nondiabetic acute coronary syndromes. Methods: One hundred and sixty nondiabetic patients admitted to the intensive coronary care unit and underwent coronary angiography with the diagnosis of acute myocardial infarction (AMI) (Group I; 72 patients; mean age - 58 ± 12 years) or unstable angina pectoris (UAP) (Group II; 88 patients; mean age 58 ± 10 years) were included in the study. In all patients blood glucose and insulin levels were measured on admission and AIRI was calculated by the formula of “admission glucose level X insulin level / normal blood glucose level (5mmol/L) X normal insulin level (5 mU/L)” for each patient. After determining the left ventricular ejection fraction (LVEF) and wall motion score index (LVWMSI) echocardiographically and calculating the Gensini score index from coronary angiography, the patients were followed up for major cardiac events (heart failure, atrial fibrillation, reinfarction, life–threatening ventricular arrhythmias, atrio-ventricular block, need for revascularisation and mortality) for 30 days. Results: AIRI was found higher in Group I (7.2± 5.3 versus 5.2±4.4, p< 0.01) than in Group II. AIRI was positively correlated with Gensini score and LVWMSI (r=0.41, p<0.01 and r=0.48, p<0.001, respectively) and negatively correlated with LVEF (r=-0.37, p=0.001) in Group I. In addition, it was seen that positive correlation of AIRI with Gensini score (r=0.23, p=0.01) and LVWMSI (r=0.43, p=0.0001) in Group I persisted on multivariate regression analysis. Again, AIRI was significantly correlated with heart failure (r=0.42, p<0.0001), atrial fibrillation (r=0.35, p=0.002) and reinfarction (r=0.23, p=0.04) in Group I. Along with this, in multivariate regression analysis, it was correlated with heart failure (r=0.21, p<0.007), atrial fibrillation (r=0.18, p=0.01) and reinfarction (r=0.18, p=0.01). On the other hand, there was no significant correlation between AIRI and these parameters in Group II. Conclusion: AIRI can be used in early stage as a risk predictor to determine high-risk subgroups of nondiabetic patients presenting with AMI. Also AIRI, a parameter, which is practically calculated and easily used, is an independent risk factor detecting the extent of coronary artery disease and left ventricular dysfunction in patients with AMI.

Objective: World Health Organization and other international guide committees defined different obesity categories according to the body mass index (BMI) and waist circumferences. The purpose of our study was (i) to compare the dispersion of other coronary risk factors in patients with coronary artery disease (CAD) with different obesity categories that were defined according to the body mass index (BMI) and the waist circumference, (ii) to determine to which extent these cut-off values effect the dispersion of other coronary risk factors. Methods: The study group included 617 consecutive subjects (516 male, mean age - 57.2±10.8 years) who underwent their first angiography between January 2000 and May 2000 and in whom significant coronary lesions were detected. The distribution of risk factors such as, age, smoking, hypertension, diabetes mellitus, high LDL-C, low HDL-C, total cholesterol/HDL-C ratio, triglycerides, family history of premature CAD was compared between overweight and obese cases defined according to BMI values. The same risk factors were compared among the cases grouped as action level 1 and action level 2 defined by the waist circumference. Results: In male patients; smoking was found to be higher in overweight individuals than in obese cases (71% vs. 56%) (p<0.05). In female patients; the only difference was the ratio of total-C/HDL-C as being greater in obese group than overweight group (p<0.05). In male and female patients there was no significant difference between obese and overweight cases regarding the number of total risk factors. According to the waist circumference, in male patients, smoking was more prevalent in action level 1 group than in action level 2 group. In female patients risk factors prevalence was similar in both groups. Conclusion: In patients with CAD, the amount of total risk factors doesn't differ between overweight and obese cases and between patients with action level 1 and action level 2 of the waist circumference. These findings indicate the necessity of using the same secondary prevention approaches in patients with CAD and different levels of obesity

Objective: To identify characteristics associated with complications during pregnancy in patients with mitral stenosis. Methods: Thirty-seven pregnant women with mitral stenosis, followed-up from 1998 to 2001 were evaluated. Predictor variables were the mitral valve area (MVA) measured by echocardiogram and functional class (FC) before pregnancy according to NYHA criteria. Progression of functional class, thromboembolism, death, need in medical abortion, cardiac surgery or balloon mitral valvulotomy were accepted as maternal events. Fetal/neonatal events were determined as abortion, fetal or neonatal death, prematurity or low birth weight (<2.500g), and extended stay in the nursery or hospitalization in newborn intensive care unit. Results: The mean ± SD of age of the patients was 24.7±5.8 years. The eventful and uneventful patients were similar in age and percentage of first pregnancies. Of patients with an events occuring during gestational period, 37. 5% had class I functional capacity whereas 62.5% had class II/III (p=0.001). A clinical event was noted in 34 % of the patients with sinus rhythm and in all of patients with atrial fibrillation (p=0.007). The mean mitral valve area was 1.11±0.23 cm2 in the group with clinical event and 1.6±0.27 cm2 in the group without an event (p<0.001). The most frequently observed maternal complication was the worsening of the functional capacity and the most frequent fetal/neonatal complications were prematurity and low birth weight. Mitral valve area and functional capacity were found to be significantly related with maternal complications but not with the fetal/neonatal complications. Conclusion: In pregnant women with mitral stenosis, the MVA and the FC are strongly associated with maternal complications but not related to fetal/neonatal events.

Objective: Dobutamine is a sympathomimetic drug, which can be used in patients with dilated cardiomyopathy (DCM). We investigated the effects of intermittent dobutamine use on cardiac parameters and quality of life in patients with DCM. Methods: Twelve patients with ischemic and idiopathic DCM, refractory to conventional therapy, have been included in the study. In addition to traditional treatment, dobutamine (1-2 mg/kg/min infusion increasing up to 10mg/kg/min for 3 days) was administered, and repeated at the 1st, 2nd and 3rd months. The patients were evaluated 3 times, before and immediately after the first treatment and after the treatment on the third month, using echocardiography, exercise stress testing, ambulatory ECG, right ventricular catheterization, cardiac enzymes (creatine kinase MB isoenzyme – CK-MB, troponin-T) and the Minnesota Living with Heart Failure Questionnaire for quality of life. Results: After the first treatment, left ventricular ejection fraction (LVEF), cardiac output, cardiac index (CI), pulmonary wedge pressure and life quality improved significantly (p<0.05); but, after the treatment on the third month, these parameters except PCWP returned to nearly baseline values. Additionally, a significant increase in the number of patients with ventricular premature beats and with troponin-T positivity was detected after the third month of treatment. Conclusion: The use of dobutamine in addition to conventional therapy in patients with DCM provided improvements in some systolic parameters and quality of life particularly after the first treatment. In the late period of the treatment, however, it was determined that these beneficial effects tended to disappear and harmful effects became more evident.

Objective: Several risk factors are established for prediction of sudden cardiac death caused by ventricular arrhythmias in patients with hypertrophic cardiomyopathy (HCM). QT dispersion (QTd) is thought to reflect the heterogeneity of ventricular repolarization. The relation of QTd with ventricular arrhythmias and sudden cardiac death has been shown by several studies. The aim of this study is to examine whether there is a relationship between QTd and established risk factors of sudden cardiac death in patients with HCM. Methods: In the present study 48 patients with HCM and 30 normal subjects were studied. The patients with electrocardiographic changes that could affect QT interval measurements and those in whom QTd was calculated in less than 9 leads were excluded from the study. A family history of sudden death due to HCM, a history of ventricular fibrillation, nonsustained ventricular tachycardia on Holter monitoring and a history of recurrent syncope were accepted as risk factors for sudden cardiac death. Results: QTd was significantly greater in patients with HCM than in normal controls (55±22 ms vs 34±13 ms, p<0.001). There was no significant difference in QTd between patients with and without risk factors (57±22 ms vs 53±20 ms, p>0.05). There was also no significant difference in QTd between patients with and without left ventricular outflow gradient >30 mmHg (57±23 ms vs 53±19 ms, p>0.05). Conclusion: Although QTd was significantly greater in patients with HCM than in normal controls, its relation to risk factors of sudden death could not be established.

rimary pulmonary hypertension is an uncommon disease. Its diagnosis is suspected after clinical examination however it can be made only after detailed evaluation of heart and lungs and exclusion of all etiologies for secondary pulmonary hypertension. Prognosis in general is poor but it ranges individually. In this article we aimed to examine this subject by interpreting a patient referred to our clinic for syncope and diagnosed as primary pulmonary hypertension.

Coronary stent implantation was firstly performed as only a bail-out procedure for poor angioplasty results, but nowadays it has become a primary modality of coronary revascularization. The deployment of intracoronary stents during percutaneous transluminal coronary angioplasty has been shown in a number of clinical trials to provide additional benefits regarding the rate of restenosis and clinical outcome over angioplasty alone. Direct stent implantation is the term applied to the technique of coronary stent implantation without firstly preparing the way with balloon predilation. In simple lesion subsets, both initial success rate and restenosis rate are superior to conventional balloon angioplasty. There is a considerable potential advantage of direct stenting over conventional stenting with respect to savings in procedural time, contrast load, and fluoroscopy time. Because predilation is not employed, there is an additional saving on angioplasty balloons, and a more efficient and less usage of stents is possible by minimizing the dissection rate. Lesion selection plays a major role in the high success rates. Long, heavily calcified lesions, small vessels or lesions with excessive proximal tortuosity are not considered suitable for direct stenting. With additional experience and continued improvement in stent technology it seems likely that more patients will be potential candidates for direct stenting

The electrophysiological mechanism of atrial fibrillation (AF) has been the subject of interest for almost a hundred years. The mechanism that leads to the induction of atrial fibrillation can be a single automatic focus firing impulses with high rate (e.g. pulmonary vein) as well as macro- or more frequently micro-re-entrant circuits. The focal mechanism has been recently shown to be responsible for at least a particular group of AF cases. Cellular and electrophysiological abnormalities such as partly depolarised cells, fibrosis, conduction abnormalities, shortening of the refractoriness and the increase in dispersion of refractoriness in the atrium can be the underlying factors for the genesis of atrial fibrillation. Factors such as the autonomic nervous system, aging, enlargement of the atria can modulate these electrophysiological features. AF can be maintained in the existence of particular conditions and AF itself leads to some changes in the atrium that are thought to be the base of perpetuation of fibrillation in the atria. These changes in the atrial electrophysiology and anatomy are called AF-induced atrial remodeling. Whatever it is the triggering mechanism for AF, “multiple wavelet re-entry” has been widely accepted to be the maintaining mechanism of AF. Finally, it can be considered that we are facing the different types of AF that can be induced with different mechanisms, that need special conditions to perpetuate and maintain, but present with similar findings in the electrocardiogram.