Objectives: We investigated correlations between the New York Heart Association (NYHA) functional classification system, which is commonly used to asses functional capacity, and conventional echocardiographic and tissue Doppler echocardiographic (TDE) parameters in patients with heart failure (HF).
Study design: The study included 122 patients (31 females, 91 males; mean age 59±11 years) with HF, whose left ventricular (LV) ejection fraction (EF) was less than 50%. The patients were evaluated in two groups based on the NYHA class I-II (n=79; mean age 58 years) and class III-IV (n=43; mean age 61 years). Correlations were sought between the functional status and standard two-dimensional echocardiographic and TDE parameters.
Results: The NYHA class showed significant inverse correlations with LV EF, LV stroke volume, mitral deceleration time of early filling, and flow propagation velocity (Vp), and significant positive correlations with end-systolic and end-diastolic diameters and volumes, pulmonary artery pressure (PAP), and the E/Vp ratio. Mitral early (E) and late (A) diastolic peak velocities and the E/A ratio were not correlated. Concerning TDE parameters, the NYHA class was in significant inverse correlation with systolic (Sm), early (Em) and late (Am) diastolic myocardial velocities, and in positive correlation with the E/Em ratio, whereas no correlation was found with the Em/Am ratio. Linear regression analysis showed that Sm, EF, and PAP were independent variables of functional capacity (=-0.33, p<0.005; =-0.26, p<0.05; =0.23, p<0.05, respectively).
Conclusion: There is significant relationship between myocardial velocities and functional capacity, and Sm, in particular, has the strongest association compared to conventional echocardiographic and other TDE parameters.

Objectives: It has been shown that asymmetric dimethylarginine (ADMA), an endogenous competitive antagonist of nitric oxide (NO) synthase, inhibits angiogenesis by reducing the production and bioavailability of NO. We investigated the effect of plasma ADMA level and L-arginine/ADMA ratio on the development of coronary collateral arteries.
Study design: The study consisted of 94 patients (66 males, 28 females; mean age 59±11 years) who underwent coronary angiography for suspected coronary artery disease and were found to have severe stenosis (>95%) in at least one major coronary artery. The patients were evaluated in two groups with poor (Rentrop score 0-1, n=44) and good (score 2-3, n=50) coronary collateral circulation according to the Rentrop collateral scoring system. Plasma levels of ADMA and L-arginine were measured by high-performance liquid chromatography.
Results: The two groups were similar with regard to basal characteristics and cardiovascular risk factors (p>0.05) except for stable angina, which was more common in patients with Rentrop score 2-3 collateral circulation (p<0.001). Despite similar L-arginine levels (p>0.05), patients with Rentrop score 0-1 had a significantly higher ADMA level (p=0.003) and lower L-arginine/ADMA ratio (p=0.019). Multivariate logistic regression analysis showed that plasma ADMA concentration was an independent predictor of coronary collateral development (odds ratio=0.674; 95% confidence interval=0.508-0.894; p=0.006).
Conclusion: Elevated plasma ADMA concentrations are associated with a poorly developed coronary collateral circulation, suggesting that dysregulation of the NO synthase pathway may result in impaired collateral development.

Objectives: We investigated factors associated with prolonged prehospital delay in patients with acute myocardial infarction (AMI).
Study design: A total of 439 patients (351 males, 88 females; mean age 57±12 years) with ST-elevation AMI were interviewed within 48 hours of hospitalization. Patients were pain-free and hemodynamically stable at the time of interview. Data were collected on the time from the onset of chest pain to hospital admission and on sociodemographic and clinical characteristics. The patients were evaluated in two groups according to the place to which the first presentation was made, i.e., a local clinic/ small hospital (clinic group: n=209, 47.6%) or our tertiary fully equipped cardiovascular center (hospital group: n=230, 52.4%).
Results: The median and mean delay times were 70 min and 185.2±334.8 min, respectively. Of the study group, 136 patients (31%) arrived within 60 minutes after the onset of symptoms. The median delay time was significantly longer in the clinic group (120 min vs 60 min; p<0.001). Female sex, age ≥55 years, and total education time <9 years were associated with a longer prehospital delay, whereas a history of coronary artery disease (CAD), smoking, and the absence of diabetes were associated with a shorter prehospital delay. In multivariate regression analysis, total education time <9 years, female sex, age ≥55 years, and the absence of previous CAD were independent predictors of prolonged prehospital delay. The incidence of direct hospital presentation significantly increased with older age, smoking, aspirin use, and previous CAD. In multivariate analysis, only previous CAD was an independent predictor of direct hospital presentation.
Conclusion: The median delay time of 70 min in this Turkish cohort is in accordance with the data from western populations. Public education campaigns to shorten prehospital delay should place more emphasis on the factors and patient subgroups associated with prolonged prehospital delay.

Objectives: Transradial approach (TRA) for coronary angiography has only become popular in our country in recent years. In this study, we evaluated radial and femoral angiographies performed at our center.
Study design: A total of 487 patients (351 males, 136 females) were scheduled for coronary angiography using TRA in 2007. Data regarding the procedure were compared with those of 500 patients (369 males, 131 females) who underwent coronary angiography via the transfemoral approach (TFA). All the procedures were performed by the same experienced cardiologist. Coronary angiography from the radial artery was performed after a positive Allen test and a careful physical examination of the access site. A 100-cm Optitorque radial catheter was mostly used to cannulate both right and left coronary arteries. Transfemoral catheterization was performed using 6 Fr diagnostic catheters, usually Judkins curve catheters.
Results: Procedural success rates were 96.5% (n=470) and 98.4% (n=492) in the TRA and TFA groups, respectively (p>0.05). The two groups were similar with respect to the procedural variables, except for the access time which was slightly higher in the TRA group (p<0.01). A higher incidence of coronary slow flow was detected in the TRA group (p<0.01). In 423 patients (90.0%), a single catheter was used for both selective right and left coronary angiography in the TRA group, resulting in a significantly lower number of catheter use (2.1±0.2 vs 3.2± 03; p<0.001). Only minor complications were seen during TRA, most commonly being pain and ecchymoses. In the TFA group, 27 patients (5.4%) developed hematoma at the access site, of more than 5 cm in diameter. Hospital stay was significantly shorter in the TRA group (2.1±0.4 hr vs 6.7±1.0 hr; p<0.001).
Conclusion: Transradial coronary angiography is a good alternative to TFA and can be performed safely and effectively in eligible patients.

Objectives: We evaluated patients who underwent complete or partial surgical correction for atrioventricular septal defect (AVSD) with regard to surgical techniques and early and midterm results.
Study design: Forty-six patients were treated for complete (n=28) or partial (n=18) AVSD between 2000 and 2007. There were nine boys and 19 girls (mean age 5.5 months; range 1.5 to 11 months) with complete AVSD. Of these, 17 patients underwent total repair, while 11 patients underwent palliative procedures. Five males and 13 females (mean age 11 years; range 1 to 50 years) with partial AVSD were treated with total repair. Down syndrome was seen in nine patients (32.1%) and one patient (5.6%) in complete and partial AVSD groups, respectively. Twenty-one patients (75%) and 14 patients (77.8%) could be followed-up for a mean of 26.3 months (range 1-72) and 21.8 months (range 2 to 71) in the two groups, respectively.
Results: Total repair of partial AVSD resulted in no mortality or significant morbidity. Early postoperative mortality occurred in three cases (10.7%) after repair of complete AVSD, one of which had Down syndrome. Six patients required prolonged mechanical ventilation beyond one week. Two patients without Down syndrome underwent reoperation due to severe atrioventricular (AV) valve insufficiency in the early postoperative period. None of the patients required permanent pacemaker implantation. Clinical and echocardiographic monitoring showed moderate left AV valve insufficiency in three patients in each group, while the remaining patients had no or minimal insufficiency.
Conclusion: Total repair of complete AVSD should be the procedure of choice in early infancy. Left AV valve insufficiency continues to be the most important cause of postoperative morbidity in these cases.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, generally treated with total correction within the first two years of life. Occasionally, some unoperated cases can reach older ages. A 68-year-old woman with diabetes mellitus presented with swelling in legs and abdomen, weakness, exertional dyspnea, and orthopnea. On physical examination, she had mild cyanosis with clubbing. Her blood pressure was 110/60 mmHg and pulse rate was 79 beat/min. She had a systolic ejection murmur and bilateral rales on basal lung areas. Massive edema was noted in both lower limbs. Electrocardiography showed atrial fibrillation with normal ventricular response. Chest radiography showed an increased cardiothoracic ratio and bilateral minimal pleural effusion. Echocardiography showed biatrial dilatation (right atrium 62 mm, left atrium 49 mm) and thickening of left ventricular walls. There was right ventricular hypertrophy with decreased systolic function. A very large ventricular septal defect and severe pulmonary stenosis were noted. The patient did not accept any interventional procedure. To our knowledge, this is the oldest unoperated TOF case reported from our country.

Sinus of Valsalva aneurysms (SVA) are relatively rare lesions with a variable clinical presentation. We presented two patients, one of whom (male, aged 96 years) had an unruptured asymptomatic right SVA without a left-to-right shunt to the right ventricle, and the other (male, aged 33 years) a fistula from the right sinus of Valsalva to the right atrium due to nonpenetrating thoracic trauma. The diagnosis was made by echocardiography in both cases. The elderly patient was followed-up with medical therapy for a year without any complications. The younger patient had complaints of progressive exertional dyspnea and fatigue following blunt substernal and thoracic trauma. He underwent successful surgical repair of the SVA.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly that is often referred to as Bland-White-Garland syndrome. Isolated anomalous origin of the left anterior descending (LAD) or circumflex arteries is even rarer. A 38-year-old woman presented with typical angina of about two-year history. Physical examination findings were normal other than a grade 3/6 systolic murmur. Electrocardiography showed anterolateral ST-segment depression and T wave inversion, indicating anterior ischemia. Color flow transthoracic Doppler echocardiography showed dilated coronary arteries. Parasternal short axis views demonstrated an abnormal flow originating from the common pulmonary artery. Upon suspicion of a coronary anomaly, coronary angiography was performed. Both the left circumflex (Cx) and right coronary arteries (RCA) were found dilated, giving extensive collaterals to the LAD artery, which drained into the main pulmonary artery. Computed tomographic angiography confirmed that the LAD artery originated from the main pulmonary artery. Surgical correction was performed and the LAD artery was re-anastomosed to the aorta. Control coronary angiography performed one week after surgery showed patent LAD artery and diminished collateral supply from the RCA and Cx arteries.

Left main coronary artery originating from the right coronary artery (RCA) is a rare anomaly. A 52-year-old male patient was submitted to catheterization laboratory for primary percutaneous coronary angioplasty with a diagnosis of acute anterior myocardial infarction. He had several risk factors including smoking, hypertension, and type 2 diabetes mellitus. Selective right coronary angiography showed an eccentric 85% stenosis at the mid-segment of the RCA, and the left main coronary artery originating from the right aortic sinus. The proximal segment of the left main coronary artery was completely occluded with thrombus and there was severe stenosis (95%) at the bifurcation of the left anterior descending artery with the circumflex artery. A metal stent was implanted in the stenotic segment of the left main coronary artery. The patient was discharged on the seventh day of stent implantation without any complications. Coronary artery bypass grafting was planned for stenotic lesions in the RCA and at the bifurcation of the left anterior descending artery with the circumflex artery.

Dual left anterior descending (LAD) artery is a very rare congenital coronary artery anomaly. A 51-year-old woman presented with atypical chest pain and palpitation. Electrocardiography showed nonspecific ST-segment depression in inferior and lateral leads. Coronary angiography showed a rudimentary LAD artery terminating in the midportion of the anterior interventricular sulcus, after giving the first septal branch. In right coronary angiography, there was another LAD artery originating from the proximal right coronary artery and coursing to the anterior interventricular sulcus. This anomaly was consistent with type IV dual LAD.

Although prosthetic valve endocarditis has a relatively low incidence, it is associated with a high risk for mortality and morbidity. Periannular complications such as abscess formation, pseudoaneurysm, and fistulas are common in prosthetic valve endocarditis, indicating a poor prognosis. Echocardiography is a very important diagnostic tool in cases of suspected prosthetic valve endocarditis and transthoracic and transesophageal echocardiography should be performed without delay. If the initial echocardiographic examination is inconclusive and the clinical suspicion of infective endocarditis remains high, repeat echocardiography is necessary with an interspersion of 7 to 10 days.