Objectives: The effect of acute exacerbation of chronic obstructive pulmonary disease (COPD) on brachial artery flow-mediated dilation (FMD) has not been examined. The aim of this study was to assess the endothelial function of COPD patients during acute exacerbations.
Study design: The study included 30 consecutive patients (8 women, 22 men; mean age 64.2±10.9 years) who experienced acute exacerbation of COPD, defined according to the Anthonisen criteria (increased dyspnea, sputum, and sputum purulence). All patients received the same antibiotic and bronchodilator treatment. Endothelial function was assessed by brachial artery ultrasonography within the first 48 hours and after complete resolution of exacerbation symptoms. Flow-mediated dilation was defined as both the maximum absolute and maximum percentage changes in the vessel diameter during reactive hyperemia. The results were compared with those of 20 age-and sex-matched controls without COPD.
Results: The patient and control groups were similar in terms of age, gender, hypertension, diabetes, hyperlipidemia, coronary artery disease, heart rate, and blood pressure. Parameters of FMD during acute exacerbation were significantly lower than those obtained after recovery (absolute change: 0.23±0.12 mm vs. 0.38±0.17 mm, p<0.001; percentage change: 6.44±3.99% vs. 10.42±4.86%, p<0.001) and than those of the control group (absolute change: 0.36±0.13 mm, p=0.001; percentage change: 9.77±3.83%, p=0.003). Flow-mediated dilation increased significantly after recovery, yielding similar values to those of the controls. Improvements in FMD were significant in both sexes.
Conclusion: Acute COPD exacerbation is associated with worsening endothelial function, increasing the risk for cardiovascular morbidity.

Objectives: The aim of this study was to determine the prevalence of atrial fibrillation in long-term hemodialysis patients and to identify clinical and echocardiographic risk factors.
Study design: The study included 183 patients (93 males, 90 females; mean age 52±17 years) who had been on long-term hemodialysis treatment (mean 41.6±39.8 months) and had preserved systolic function. Atrial fibrillation was determined electrocardiographically and the patients were divided into two groups depending on the presence or absence of atrial fibrillation. Conventional and tissue Doppler echocardiographic examinations were performed on interdialytic days. Clinical, laboratory, and echocardiographic parameters were compared.
Results: Twenty-four patients (13.1%) had atrial fibrillation. Patients with atrial fibrillation significantly differed in terms of higher age (64.9±9.8 vs. 49.9±16.6 years; p<0.001), higher frequency of coronary artery disease (37.5% vs. 10.7%; p=0.008), and lower serum albumin level (3.6±0.4 vs. 3.9±0.5 mg/dl; p=0.015). Echocardiographic examination showed significantly increased left and right atrial diameters (p<0.05), higher incidence of mitral and/or aortic calcification (p=0.033), increased systolic pulmonary artery pressure (38.1±6.1 vs. 28.5±5.5 mmHg, p<0.001) and E/E’ ratio (11.8±3.8 vs. 8.8±4.7, p=0.008) in patients with atrial fibrillation. In multivariate logistic regression analysis, age (OR 1.09; 95% CI 1.00-1.17; p=0.036) and right atrial diameter (OR 1.19; 95% CI 1.05-1.35; p=0.008) were independent risk factors for the development of atrial fibrillation.
Conclusion: Our findings highlight age and right atrial diameter as independent predictors of atrial fibrillation in hemodialysis patients. In addition, the E/E’ ratio and pulmonary artery pressure may be considered new risk factors of atrial fibrillation in this population.

Objectives: Metabolic syndrome (MetS) is associated with increased risk for cardiovascular disease. We evaluated aortic stiffness and factors affecting aortic stiffness by echocardiography in patients with MetS.
Study design: The study included 27 patients (18 men, 9 women; mean age 56±7.5 years) and 33 patients (20 men, 13 women; mean age 54.3±5.5 years) with and without MetS, respectively, according to the ATP-III criteria. Blood pressure, pulse pressure, waist circumference, and levels of total cholesterol, HDL and LDL cholesterol, triglyceride, and high-sensitivity C-reactive protein (hs-CRP) were measured. Systolic and diastolic diameters of the ascending aorta were measured by M-mode echocardiography from the parasternal long-axis views, and parameters of aortic stiffness (aortic strain and distensibility) were calculated.
Results: Compared to the control group, patients with MetS had significantly higher values of blood pressure, pulse pressure, waist circumference, and higher triglyceride, glucose, and hs-CRP levels and lower HDL cholesterol level (p<0.05). In the MetS group, aortic strain (9.0±3.5% vs. 6.3±3.8%; p=0.007) was significantly increased and aortic distensibility (2.7±1.9 cm2/dyn/103 vs. 4.8±1.9 cm2/dyn/103; p=0.001) was significantly decreased. Aortic distensibility was negatively correlated with age (r=-0.269, p=0.03), hs-CRP (r=-0.287, p=0.002), systolic blood pressure (r=-0.533, p<0.001), and diastolic blood pressure (r=-0.275, p=0.03). In age-adjusted multiple regression analysis, systolic blood pressure (β=0.8, p<0.001), waist circumference (β=0.5, p=0.02), and hs-CRP (β=0.6, p=0.002) were independent predictors of aortic distensibility.
Conclusion: Aortic stiffness is increased in patients with MetS. Using a noninvasive and readily available tool, transthoracic echocardiography, arterial stiffness can easily be assessed, so that the incidence of cardiovascular diseases and associated mortality can be decreased through appropriate treatment for risk factors.

Objectives: We investigated the incidence of unresponsiveness to intravenous gamma globulin (IVIG) treatment in Kawasaki disease (KD) and evaluated its relation with coronary artery involvement.
Study design: The study included 20 children (13 boys, 7 girls; mean age 4.2±3.4 years; range 9 months to 12 years) with KD. The mean disease duration on admission was 7.3±2.4 days (range 5 to 14 days). Initial treatment consisted of a single dose of IVIG and high-dose of aspirin. Unresponsiveness was defined as the persistence of fever and other symptoms within the first 48 hours of treatment. All the patients were evaluated by two-dimensional echocardiography before and after treatment. The mean follow-up period was 16.5±2.8 months (range 9 to 24 months).
Results: Unresponsiveness was seen in five patients (25%), who received a subsequent dose of IVIG, which improved fever in two patients. The remaining three patients received high-dose methylprednisolone. One patient who showed no response to either IVIG or methylprednisolone was treated with low-dose oral methotrexate. Six patients (30%) had coronary artery involvement (4 dilatations, 2 aneurysms), five patients on admission echocardiography, and one patient on control echocardiography seven days after treatment. Of five unresponsive patients, four (80%) had coronary artery involvement on admission. Patients with coronary involvement underwent coronary angiography after a mean of one year. Five patients had normal coronary arteries, whereas no angiographic regression was observed in one patient who had a giant coronary artery aneurysm on admission and was treated with oral methotrexate.
Conclusion: The incidence of unresponsiveness to treatment was markedly high in KD patients who had coronary artery involvement on admission.

Objectives: Data on adult congenital heart diseases (CHD) are limited in Turkey. We evaluated the types and clinical features of CHDs in adult patients followed-up in our center.
Study design: This study included 200 adult patients (age >16 years) who were diagnosed as having CHD in our clinic between April 2006 and January 2009. The patients were evaluated in three groups based on the complexity of adult CHD (simple, moderate, or great) according to the most recent ACC/AHA guidelines.
Results: There were 121 females (60.5%) and 79 males (39.5%). The mean age was 34.7±13.4 years (range 16 to 75 years) and female-to-male ratio was 1.53. The mean age was 32.8±14.0 years in males, and 36.0±12.9 in females. Nearly half of the patients were in the age groups of 20-29 years (n=46, 23%) and 30-39 years (n=49, 24.5%). According to the ACC/AHA criteria, 145 patients (72.5%) had simple CHD, 34 patients (17%) had moderate CHD, and 21 patients (10.5%) had severe-complex CHD. The mean age tended to decrease as the severity of CHD increased (35.7±13.7, 33.2±12.4, and 30.5±12.2 years, respectively). The most common adult CHD was atrial septal defect (n=105, 52.5%), followed by ventricular septal defect (n=34, 17%), Ebstein’s anomaly (n=7, 3.5%), and Eisenmenger’s syndrome (n=6, 3%). Aortic coarctation, transposition of the great vessels, patent foramen ovale, pulmonary stenosis, and aortic valve disease showed equal distribution with five patients (2.5%).
Conclusion: In our study, atrial and ventricular septal defects accounted for the majority of CHDs in adult patients (69.5%). Multicenter studies are required to determine the incidence of CHD among adult population in Turkey.

Pulmonary embolism (PE) is an important cause of morbidity and mortality during pregnancy. A 21-year-old pregnant woman presented with chest pain and progressive shortness of breath at 35 weeks of gestation. Her respiratory rate was 26 breaths/min. Electrocardiography showed sinus tachycardia and nonspecific ST-T changes. Her plasma D-dimer level was elevated (1,325 ng/ml). Transthoracic echocardiography revealed enlargement of the right ventricle and a large, highly mobile thrombus in the right atrium moving during diastole into the right ventricle. Doppler ultrasonography of the lower extremities showed bilateral acute deep femoral vein thrombosis. Following the diagnosis of right heart thrombosis with massive PE, low-dose and prolonged infusion of tissue-type plasminogen activator (25 mg in three hours) was administered. Echocardiography performed six hours after thrombolysis showed a significant decrease in the right ventricular size and complete lysis of the thrombus in the right heart. Thrombosis risk panel studies showed factor V Leiden homozygote mutation. A live newborn was delivered by cesarean section at 37 weeks of gestation. No complications were seen during a 6-month follow-up.

Brugada syndrome is a rare condition characterized by ST-segment elevation in the right precordial leads. Fever can induce Brugada-like electrocardiographic (ECG) changes. We reported on a 26-year-old male patient with fever and ST-segment elevation in the right precordial leads. Serial cardiac markers were normal and transthoracic echocardiography showed normal wall motion and no evidence for pericardial effusion. Brugada-like ECG changes disappeared after fever resolved. Since the patient had never experienced any arrhythmic symptom, syncope, or spontaneous type 1 ECG, electrophysiological study was not performed and he was not referred for defibrillator implantation. The patient was discharged with strong recommendations to avoid certain medications responsible for Brugada-like ECG changes and to receive urgent treatment for fever. He was asymptomatic during a year follow-up. Emphasis is placed on this particularly rare, but important condition, as it may easily be misdiagnosed and fever may even precipitate ventricular fibrillation.

Split right coronary artery (RCA) is a congenital anomaly of the coronary arteries where either two separate arteries arise from the aortic trunk or RCA bifurcates into two major arteries immediately after its origin from the right sinus of Valsalva. We present two cases (59-year-old male, 50-year-old female) who sought treatment for exercise-induced angina pectoris. Coronary angiography revealed a split RCA in both cases. In the first case, the RCA consisted of two well-developed arteries bifurcating immediately after its origin from the sinus of Valsalva. In the second case, the RCA split from adjacent ostia into two major arteries almost identical in size. In both cases, the split RCAs had a parallel course. Both patients were scheduled to receive medical treatment and had an uneventful follow-up of 15 and 11 months, respectively.

A 20-year-old male patient presented with dyspnea and palpitation. An atrial shunt was detected on transthoracic echocardiography. Transesophageal echocardiography (TEE) showed two secundum atrial septal defects (ASD), 13 mm and 15 mm in size, respectively. There was no other congenital heart disease. During right heart catheterization, pulmonary artery pressure was 40 mmHg and the Qp/Qs ratio was 1.9. His coronary arteries were normal. The patient underwent elective percutaneous ASD closure under general anesthesia and continuous TEE monitoring. The distance between the two defects was 16 mm. Two 25-mm PTS sizing balloon catheters were simultaneously inflated, yielding maximum defect diameters of 13 mm and 15 mm. First the smaller defect, then the larger defect were closed with 15 mm and 18 mm Occlutech Figulla ASD occluders, respectively. Total fluoroscopy time was 25 min, and total procedural time was 95 min. No residual shunt was observed. The patient was discharged the next day without any complication.

A 68-year-old man with a history of two coronary artery bypass operations was admitted with acute inferior myocardial infarction (AMI) and cardiogenic shock. The electrocardiogram showed ST-segment elevation in leads D2, D3, and aVF. Coronary angiography demonstrated a 75% thrombotic stenosis in the right coronary artery (RCA), 90-99% stenosis in the intermediate coronary artery, and plaques in the circumflex artery. While assessing the patency of bypass grafts, a 99% stenosis was noted in the distal subclavian artery. The culprit artery was deemed to be the RCA, and after direct stenting, TIMI III flow was achieved. Ten days later, stent implantation was performed for the intermediate coronary artery, at which time distal subclavian artery stenosis was not observed. Distal subclavian artery spasm was thought to occur during AMI.

Lutembacher syndrome is a rare combination of congenital atrial septal defect (ASD) and acquired mitral stenosis (MS). Although it is traditionally corrected by surgical treatment, both conditions are amenable to transcatheter treatment without the need for surgery. We present a 49-year-old woman with Lutembacher syndrome. On pretreatment transthoracic echocardiography, planimetric mitral valve area was 1.5 cm2, maximum diastolic gradient was 17 mmHg, and mean diastolic gradient was 9 mmHg. Combined percutaneous treatment was performed including balloon valvuloplasty for MS and closure of the ASD with the Amplatzer septal occluder. The patient was discharged uneventfully. Transthoracic echocardiography performed a week later showed planimetric mitral valve area as 2.1 cm2, maximum diastolic gradient as 9 mmHg, and mean diastolic gradient as 4 mmHg. Complete closure of the ASD was achieved. Transcatheter treatment may be an effective alternative to surgery in selected patients with Lutembacher syndrome.

Transradial access was first used in 1989 for diagnostic coronary angiography. With further improvements in the technique, it has gained wide popularity in percutaneous transluminal coronary angioplasty and percutaneous coronary interventions including stenting. When performed with appropriate indications, transradial approach is a preferable technique for coronary interventions due to lower rate of bleeding complications, increased patient comfort, shorter hospital stay and follow-up period, and decreased workload.

The output of publications in cardiovascular medicine during 2009 originating from Turkey’s institutions were evaluated based on data of the Web of Knowledge. Only original articles and reviews appearing full-text in source publications of Science Citation Index CD Edition were included. A weighted credit system was used for items published jointly by multiple departments or with a noncardiological Turkish institution. Turkey’s publications declined substantially to 167 articles and reviews, with a parallel decrease in her share of world publication from 10.8 to 8.2 per mille. Six-sevenths of the output originated from adult cardiology. The median impact factor of 2.18 was higher roughly by 17% than in the previous year; half of the publications appeared in periodicals with an impact factor of 1.27 to 3.12, reflecting a consistent qualitative improvement. University medical faculties persisted to lag behind in productivity, while the Gülhane Military Medical Academy led by far, runners-up being the Turkish Society of Cardiology, Kartal Koşuyolu Research Hospital, and medical faculties of Başkent University and İstanbul University.