Objectives: In this study, we aimed to investigate the association between the presence and severity of metabolic syndrome (MetS) with intra- and inter-atrial electromechanical delay (AEMD) and P-wave dispersion (PWD).
Study design: A total of 144 patients (72 MetS patients and 72 age- and sex-matched control subjects) were included in the study. Patients with MetS were classified into three groups based on the number of MetS criteria as follows: Group 1 (patients with three MetS criteria), Group 2 (patients with four MetS criteria) and Group 3 (patients with five MetS criteria). Intra- and inter-AEMD were measured from parameters of tissue Doppler imaging. PWD was calculated from the 12-lead electrocardiogram.
Results: Both inter-AEMD (22.9±15 vs. 11.5±14, p<0.001) and intra-AEMD (23.6±12 vs. 8.3±19, p<0.001) were found to be significantly longer in patients with MetS than the control group. Similarly, PWD (49±25 vs. 36±24, p=0.001) were found to be significantly longer in the MetS patients than the controls. However, both inter-AEMD and intra-AEMD and P wave measurements were not found to be associated with the severity of MetS. While inter and intra-AEMD were better correlated with LV mass index and LA volume index, PWD correlated better with mitral inflow Doppler parameters. According to multivariate analyses, inter-AEMD, HDL-C, and systolic and diastolic blood pressure were found to be independent predictors, whereas E/A and LDL-C had borderline significance. For the intra-AEMD, systolic and diastolic blood pressure, body mass index and E/A were found to be independent predictors.
Conclusion: In patients with MetS, inter- and intra-AEMD, and P dispersion were found to be lengthened when compared with the controls. However, these parameters were not associated with the severity of MetS.

Objectives: Calcium accumulation in the coronary arteries is a known indicator of atherosclerosis. The purpose of this study was to demonstrate both the correlation between patients’ demographic characteristics and segmental calcium scores and also dominant topographic accumulation of calcium in the coronary arteries.
Study design: Two-hundred ninety-nine patients were included in the study (192 male, 107 female; mean age 59.08±10.7; range 19 to 84 years). All patients with total calcium scores of 1 Hounsfield unit or more underwent 16-slice multi-detector computed tomography with calcium scoring evaluation. Their coronary trees were divided into 14 different segments, and the number of lesions, and calcium score of each segment were calculated separately.
Results: When the coronary arteries were examined as for segmental calcium accumulation by segment, the proximal segment of the LAD (left anterior descending coronary artery) had the highest calcium accumulation. Total calcium scores were higher in the patients with high total and LDL cholesterol values than in normolipidemic patients. Total calcium scores were higher in patients with hypertension relative to the than for patients without hypertension. Calcium scores of smokers and non-smokers were not significantly different. Diabetic patients had higher calcium scores than patients without diabetes. No significant difference was identified between patients with and without a positive family history of coronary artery disease. Total calcium scores were higher in the advanced age group, and in patients with hyperlipidemia.
Conclusion: Segmental analysis of calcium scoring demonstrates that calcium accumulation is mostly seen in the proximal LAD. Coronary artery calcification is observedly increased in the presence of coronary artery risk factors as hypertension, advanced age, and hyperlipidemia.

Objectives: We aimed to assess arterial stiffness parameters and to investigate the relationship between these parameters and aortic calcification in patients with aortic arch calcification and without symptomatic atherosclerotic disease.
Study design: The population of this study consisted of 41 patients with aortic arch calcification verified by chest X-ray (group I, 17 males, mean age 70±5 years) and individuals without aortic arch calcification (group II, 17 males, mean age 68±6 years). Subjects with symptomatic or known vascular disease were excluded from the study. The arterial stiffness parameters of all subjects were measured non-invasively with a SphygmoCor device. Aortic pulse wave velocity (PWV), augmentation pressure (AP), augmentation index (AIx) and heart rate normalized augmentation index (AIx@75) were used as parameters of arterial stiffness.
Results: The two groups were compared according to demographic characteristics, medications currently being taken, and levels of serum lipids. There was no significant difference between the groups. AP in group I was significantly higher than that of group II (p=0.002). AIx and AIx@75 were similar in both groups. Aortic PWV of group I was significantly higher than that of group II (p<0.0001).
Conclusion: According to the results of this study, the presence of aortic calcification, verified by chest radiography, was associated with increased aortic PWV.

Objectives: Epicardial fat tissue is a type of visceral adipose tissue that functions as a metabolically active endocrine organ. Most components of metabolic syndrome (MetS), especially visceral obesity, are associated with a low-grade systemic inflammatory state. In this study, we aimed to assess the relationship between echocardiographic epicardial fat thickness (EFT), MetS, the components of MetS, and high sensitivity C-reactive protein (hs-CRP) levels in patients with MetS.
Study design: Forty-six patients (25 males, mean age 47.3±6.5 years) with the diagnosis of MetS (according to the Adult Treatment Panel III update criteria) but without clinical coronary artery disease, and 44 age and gender matched healthy volunteers (18 males, mean age 46.0±6.1 years) were included in the study. EFT, which was measured by transthoracic echocardiography, as well as clinical and biochemical parameters were compared between the two groups.
Results: Waist circumference, total and LDL-cholesterol, fasting glucose, triglycerides, systolic and diastolic blood pressure levels, hs-CRP, and uric acid levels were significantly higher in patients with MetS. EFT was also significantly increased in patients with MetS (8.7±0.2 mm vs. 4.8±0.1 mm, p<0.001). Multiple regression analysis determined that MetS itself (β=0.929, p<0.001) and hs-CRP (r=-0.181, p=0.007) are independent predictors of increased EFT.
Conclusion: This study demonstrates that EFT is higher in patients with MetS, and that MetS and hsCRP are independent predictors of this increased EFT. Increased EFT, which is associated with low-grade systemic inflammation, may play a role in the pathogenesis of atherosclerosis in MetS patients.

Objectives: Heart failure (HF) is a major public health problem responsible for high morbidity and mortality rates. Thus, the importance of survival predictors in directing the treatment of HF is gradually increasing. In some recently published studies, plasma homocysteine has been reported as a newly recognized risk factor for the development of HF. In the present study, we investigated the value of serum homocysteine levels in predicting the survival of patients with HF.
Study design: Seventy HF patients (44 males, 26 females; mean age 60±12; range 28 to 83 years) with left ventricle ejection fractions of <35% were included in our study. Clinical, echocardiographic, and biochemical parameters were measured at baseline, and all patients were followed. Cardiac death was established as the end point of the study.
Results: At the end of the 12 month follow-up period, 14 patients (20%) had died. Serum homocysteine levels were significantly higher in the deceased patients compared to the patients who survived (20.8±5.8 vs. 16.9±5.1 µmol/l, p=0.029). A serum homocysteine level of >17.45 µmol/l predicted death at the end of the first year with 71.4% specificity and 67.9% sensitivity (ROC area under curve: 0.855, CI 95% 0.792-0.965, p<0.001). Multivariate Cox regression analysis showed that the serum homocysteine level was the only parameter predicting survival.
Conclusion: Serum homocysteine level may be an important predictor of mid-term mortality in patients with HF.

Objectives: Multi-vessel coronary artery disease (MVCAD) has long been recognized as an important predictor of adverse outcomes in patients with chronic stable angina. The aim of this study is to investigate the relationship between hematologic parameters and impairment of left ventricular systolic functions in patients with stable MVCAD.
Study design: Patients (n=202) with stable angina and MVCAD were included in this study. According to the left ventricle ejection fraction (LVEF) determined by echocardiography, patients were divided into two groups as the preserved group (LVEF >50%) and the impaired group (LVEF <50%). The preserved group consisted of 106 patients and the impaired group consisted of 96 patients.
Results: The frequency of diabetes mellitus was significantly higher in the impaired group compared to the preserved group (respectively, 50% vs. 33%, p=0.01). High sensitivity C-reactive protein (hs-CRP) levels and, neutrophil/lymphocyte ratio (N/L ratio) were significantly higher in the impaired group than in the preserved group (3.9±2.4 vs. 7.9±3.8, p<0.001; 2.7±0.7 vs. 3.9±1.2, p<0.001, respectively). There was a significant correlation between LVEF, N/L ratio and hs-CRP; hs-CRP and N/L ratio were positively correlated (r=0.584; p<0.001), and LVEF was negatively correlated with both hs-CRP and N/L ratio (r=-0.48, p<0.001 and r=-0.43, p<0.001, respectively). A N/L ratio >3.0 had 77% sensitivity and 68% specificity in predicting left ventricular dysfunction in patients with stable MVCAD. In multivariate analysis, N/L ratio (OR: 2.456, <95% Cl 2.056–4.166; p<0.001) was an independent predictor of left ventricular dysfunction in stable patients with MVCAD.
Conclusion: N/L ratio and hs-CRP, which is inexpensive and easily measurable in the laboratory, is independently associated with impaired LV systolic functions in patients with stable MVCAD.

Implantable cardioverter-defibrillators (ICD) have been increasingly used to treat life-threatening ventricular tachyarrhythmias. Although they have life-saving capabilities, they are very sensitive to electromagnetic energy sources. It has been reported that many problems associated with the mechanism of the detection and termination of tachyarrhythmias of the ICDs occur due to electromagnetic interference (EMI). In spite of the fact that EMI has been decreasingly observed with the latest generation ICDs, problems may still occur during radiotherapy. The CyberKnife is the latest stereotactic radio-surgery technology in the field of radiotherapy, and is currently being used for the treatment of malign neoplasm in the body. It is especially preferred for the treatment of advanced stage and metastatic tumors. Five ICD shocks were detected in a patient during routine ICD controls. When the patient was evaluated, it was determined that he had undergone radiotherapy with CyberKnife® technology because of lung metastasis and rectal adenocarcinoma. It was learnt that he had received the ICD shocks while he had been on radiotherapy. When the stored intracardiac electrograms stored in the memory of the ICD were investigated, it was established that the shocks were inappropriate shocks due to oversensing because of the exposure to EMI.

Exercise electrocardiography (ECG) is one of the most commonly utilized tests in cardiology. Despite the drawbacks, exercise ECG is widely preferred due to low cost, standardization, and strong prognostic information. A prolonged PR interval during recovery has recently been proposed as an indicator of mortality. Herein, we report an interesting case of a patient who presented with the complaint of exertional dyspnea and exhibited PR lengthening during the recovery period on the exercise ECG. The patient had a PR interval of 240 ms before exercise, which decreased to 160 ms at peak stress. However, during recovery, the PR interval prolonged gradually, reaching 320 ms at the second minute and persisting at that length until the end of the recovery period. The patient achieved 87% of the age predicted maximum heart rate, and experienced non-disabling shortness of breath and a pressure sensation in the chest, with no apparent ST segment depression. Recovery parameters, including heart rate recovery and systolic blood pressure recovery, were also within normal limits. The patient underwent coronary angiography with the suspicion of CAD which revealed severe multi-vessel disease. This rare case emphasizes the importance of PR lengthening in the recovery period as a sign of severe ischemia, in addition to other signs, such as prominent ST-segment changes, chronotropic incompetence, impaired hemodynamic response, and poor exercise capacity during stress ECG evaluation.

Primary cardiac tumors of the ventricles are very uncommon. Cardiac hemangiomas are extremely rare primary benign cardiac tumors that are often asymptomatic and are typically diagnosed incidentally during an echocardiographic examination. We report the case of a 27-year-old male who was referred to our hospital complaining of atypical chest pain over the last three months. The pain was unrelated to exercise, and consisted of 1-2 minutes of ongoing, stinging chest pain followed by 2-3 seconds of ongoing palpitations. His physical examination was unremarkable, his blood pressure was 130/80 mmHg, his ECG was sinus rhythm, and his heart rate was 82 beats/min. A transthoracic echocardiogram revealed a mobile 1.20x1.28 cm mass in the left ventricular cavity at the antero-lateral wall. Subsequent coronary angiography was performed to determine the vascular supply for the mass, and showed late opacification of a well-vascularized left ventricle mass from the second diagonal artery. Surgery was performed and the mass was complete resected. The pathological and histological examination of the resected mass showed that it was a hemangioma. The patient was discharged 5 days after surgery without symptoms

An alternative to the surgical repair of secundum type atrial septal defects (ASD) and of patent ductus arteriosus (PDA) is transcatheter closure. However, there is limited information about the efficacy of using percutaneous devices to close multiple ASDs. An 8-year-old female patient was admitted to our hospital with a cardiac murmur. A large secundum multi-fenestrated ASD (17 mm, 4.5 mm, 3 mm) and PDA (3 mm) were diagnosed upon echocardiographic examination. During cardiac catheterization, the PDA was closed with an Amplatzer Duct Occluder (6x4 mm) followed by the closure of the ASD with an Amplatzer septal occluder (22 mm) with no residual shunting. The percutaneous closure of multi-fenestrated ASD with PDA in pediatric patients may be considered as a first-choice treatment with minimal complications.

Spontaneous left main coronary artery (LMCA) dissection is an unusual cause of myocardial ischemia and sudden death. It is defined as an intramural hematoma of the media of the vessel wall. A 56-year-old male who underwent a two-vessel bypass ten years previous presented with chest pain for two hours. His blood pressure and heart rate were 60/35 mmHg and 120 beats per minute, respectively. The ECG showed inferior ST-segment elevation. Coronary angiography revealed total LMCA occlusion with dissection flap. A dissection flap was collapsing the true lumen of the LMCA. A bare metal stent was implanted after the flap was perforated and fenestrated by a stiff guide wire. Good TIMI 3 flow was achieved in the circumflex artery. Three months after the index procedure, coronary computed tomography angiography disclosed thrombosis of the false lumen beneath the patent left main stent. In conclusion, primer stenting can be successfully performed in the presence of spontaneous LMCA dissection.

Allergic symptoms accompanied by myocardial ischemic symptoms are defined as Kounis syndrome. Etofenamate is a safe and effective non-steroidal antiinflammatory drug that has widespread utilization. We hereby present a 71-year-old man with Kounis syndrome. Following intramuscular 1 g etofenamate injection, the clinical presentation when admitted to the emergency department (ED) was erythematous rash, pruritus, nausea and vomiting, dizziness, diaphoresis, and chest pain resulting in cardiopulmonary arrest. After 10 minutes of successful cardiopulmonary resuscitation, the electrocardiogram revealed acute inferior myocardial infarction. In patients who are admitted to the ED with allergic symptoms accompanied by chest pain Kounis syndrome should be consider for prompt management. Electrocardiographic examination should be an essential part of the initial evaluation in such patients.

Coronary bypass graft surgery provides symptomatic relief and a long life expectancy for most patients with coronary artery disease who have suitable vessels. Although arterial conduits are becoming more popular, saphenous vein grafts (SVG) are still frequently used in coronary artery bypass surgery since they are readily available, especially in emergency situations. However, SVG tend to degenerate over time, as nearly half of them develop significant stenosis and nearly 40% of them become completely occluded within a decade. Treatment options for SVG failure include redo-surgery, percutaneous intervention, and/or medical therapy. However, challenges in maintaining graft patency (as a predictor of long-term survival) and interventional complications (e.g., distal embolization, ‘’no-reflow,’’ and higher rates of periprocedural myocardial infarction) are still ongoing problems for cardiologists and cardiovascular surgeons. This review discusses the possible causes of graft failure and the contemporary approaches for improving outcomes in patients undergoing coronary artery bypass graft surgery with at least one SVG.