Objectives: Obesity has been linked to a spectrum of minor cardiovascular changes. The aim of this study was to determine the effect of obesity on cardiac functions and its relations with subclinical hypothyroidism in healthy women.
Study design: Eighty-eight consecutive “healthy” females (mean age: 31.2±6.6 years) were included in the study. Thyroid function tests and echocardiography studies were performed in all patients. Height, weight, and waist and hip circumference were also measured. A body mass index (BMI) above 30 kg/m2 was considered obese.
Results: Left ventricular mass (LVM) was higher in obese subjects (p<0.001). Doppler-derived indices of LV diastolic filling showed clear abnormalities of myocardial relaxation in obese subjects with higher E/e’ (p=0.001) and larger left atrial volume (LAV) (p<0.001). LV myocardial performance index was also significantly higher in obese subjects (p=0.033). Thyroid-stimulating hormone (TSH) levels were significantly higher in obese subjects (p=0.011) and were positively correlated with BMI, waist circumference, LAV, and LVM. The prevalence of abnormal systolic and diastolic functions showed stepwise increases with higher TSH levels in obese subjects. Multiple regression analysis was used to evaluate the association of E/e’ with anthromorphometric and biochemical parameters, and waist circumference was found to be the strongest independent variable correlated with the E/e’ ratio.
Conclusion: Cardiac structural and functional deteriorations may be related with subclinical hypothyroidism in obese subjects.

Objectives: After coronary angiography and percutaneous coronary intervention (PCI), the classic sand bag method and compression devices are widely used for control of bleeding and prevention of vascular complications. The purpose of our study was to assess the major peripheral vascular complications and to compare the sand bag and a pneumatic compression device (“Close Pad”) in terms of major peripheral vascular complications after coronary interventions.
Study design: Between June 2011 and November 2011, a total of 434 patients who admitted to the Department of Cardiology of Uludag University Faculty of Medicine were included in the study. 396 patients underwent coronary angiography and 38 patients underwent PCI. Sand bag was applied in 209 patients. Bleeding requiring transfusion, hematoma larger than 10 cm², pseudoaneurysm, and arteriovenous (AV) fistula were defined as the major local complications. Logistic regression analysis were used to evaluate the datas.
Results: Major vascular complications occurred in 2% of diagnostic angiography and in 13.2% of PCI patients (p=0.003). The major vascular complications were significantly higher with the Close Pad device compared with sand bag (5.3% vs. 0.5%, p=0.007). Smoking, PCI, Close Pad, clopidogrel, and anticoagulants were observed to have increased risk of major local complications. In the logistic regression analysis, only smoking and Close Pad usage were evaluated as independent variables that increased the risk of major vascular complications (p<0.05).
Conclusion: Close Pad usage demonstrated increased risk of vascular complications when compared with the sand bag in patients undergoing cardiac catheterizations. After the PCI, patients should be selected carefully for application of the Close Pad.

Objectives: We aimed to identify the predictors of angiographically visible distal embolization (AVDE) during primary percutaneous coronary intervention (p-PCI) as well as to assess its impact on short- and long-term clinical outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI).
Study design: We retrospectively enrolled 2007 patients with STEMI who underwent p-PCI. We assessed the clinical and angiographic characteristics of patients in order to identify the predictors of AVDE and compared the outcomes of patients with and without AVDE during p-PCI.
Results: Distal embolization developed in 135 (6.7%) patients. Age (for each 10- year increase, Odds Ratio (OR) 1.34, 95% Confidence Interval (CI) 1.16-1.52, p<0.001), treatment of right coronary artery (OR 2.52, 95% CI 1.30-4.87, p=0.034), repeated balloon dilatation (OR 1.84, 95% CI 1.16- 2.94, p=0.009), cut-off occlusion pattern (OR 2.17, 95% CI 1.38-3.42, p=0.001), lesion length >15 mm (OR 1.67, 95% CI 1.09-2.58, p=0.019), and reference vessel diameter >3.5 mm (OR 5.08, 95% CI 3.32-7.65, p<0.001) were independent predictors of AVDE. In-hospital (8.1% vs. 3.8%, p=0.014) and one-month (10.8% vs. 4.9%, p=0.004) all-cause mortality rates were higher in patients with AVDE. At the long-term follow-up (median: 42 months), both all-cause (21.5% vs. 10.4%, p<0.001) and cardiac mortality rates (18.4% vs. 8.0%, p<0.001) were higher in patients with AVDE.
Conclusion: AVDE is associated with worse clinical outcome at both the short- and long-term follow-up of STEMI patients treated early with p-PCI.

Primary percutaneous coronary intervention (p-PCI) significantly improves myocardial perfusion and survival after acute ST segment elevation myocardial infarction (STEMI). However, during procedure angiographically detectable distal embolization may occur of patients with poor outcome. In this issue of Archives of the Turkish Society of Cardiology, Oduncu et al. presented predictors and long term prognostic significance of angiographically visible distal embolization during primary percutaneous coronary intervention.

Objectives: Catheter ablation of premature ventricular complexes (PVC) improves clinical status and systolic performance of left ventricle (LV) in certain subset of patients, however whether PVC ablation is equally effective in younger (≤65 years old) and older (>65 years) patients remain unclear. We aimed to assess clinical benefits of catheter ablation of PVCs in elderly patients.
Methods: Fifty-one consecutive patients (66±10 years, 49 male) who underwent catheter ablation for symptomatic PVCs were included into the study. Twenty-seven patients were aged>65 years and 24 patients ≤65 years old. Frequency of PVCs per total heart beats by 24-hour Holter monitoring, LV ejection fraction (LVEF) and end-systolic diameters (LVEDD) were evaluated before and 6±3 months after ablation.
Results: The pre-ablation 24 hour PVC burden and PVC number was significantly higher in patients aged >65 years old compared aged ≤65 years (31±15.3 vs. 21.9±12.6; p = 0.04 and 34493±21226 vs. 23554±13792; p = 0.026, respectively). At follow up after catheter ablation, the mean PVC burden decreased to 9.1±10.3% (p<0.001) in patients >65 years while to 3.8±7.1 (p<0.001) in patients ≤65 years of age. Mean LVEF showed significant increase in both groups after ablation (43.4±10.4 vs. 51.5±8.2; p = 0.005 for age>65 years and 40.8±13.2 vs. 49.5±11.8; p = 0.003 for age ≤65 years). The improvement in LVEF was accompanied by significant decrease in LV end-diastolic diameter (p = 0.032 for age>65 and p = 0.047 for ≤65 years).
Conclusion: Catheter ablation is effective for treatment of frequent PVCs in all age groups.

Objectives: Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) is associated with lower rates of procedural success and higher complication rates compared with PCIs in non-CTO lesions. The purpose of this study was to analyze the relationship between lesion characteristics and procedural success rates and in-hospital outcomes after PCI for CTO with novel equipment.
Study design: We evaluated the prospectively entered data of 63 consecutive patients undergoing PCI for CTO at our institute between August 2009 and June 2012.
Results: A total of 63 patients (mean age: 64±11, 71% male) with one CTO lesion each underwent PCI. There were 46 patients (mean age: 63±10, 70% male) in the CTO success group and 17 patients (mean age: 65±13, 76.5% male) in the CTO failure group. Successful revascularization was achieved in 73% of patients. We used antegrade approach in 61 cases and retrograde approach in 2 cases. Our predominant strategy was single-wire technique, which was used in 54 cases (85.7%), followed by parallel-wire technique in 7 cases (11.1%). Moderate-to-severe tortuosity (odds ratio [OR]: 9.732, 95% confidence interval [CI]: 1.783- 53.115, p=0.009) and occlusion duration (OR: 1.536, 95% CI: 1.178-2.001, p=0.002) were independent predictors of procedural failure in the multivariate analysis. No in-hospital major cardiac events occurred.
Conclusion: We have reported a study with a relatively high success rate of PCI with very low procedural and in-hospital complications. Moderate-to-severe tortuosity was observed as the most challenging problem despite the utilisation of novel equipment and techniques for CTO recanalization.

Objectives: The effects of obesity on atrial conduction and ventricular repolarization have been studied in detail, but these parameters have not been well documented in overweight children. The aim of our study was to investigate the effects of overweight on atrial conduction and ventricular repolarization in children by using P-wave dispersion (Pw-d) and QT dispersion (QT-d) analyses.
Study design: Sixty-seven overweight children and 70 children within normal limits were included in this cross-sectional prospective controlled study. All subjects underwent electrocardiographic and anthropometric evaluation, and blood samples were obtained. Pw-d and QT-d were investigated between two groups.
Results: Homeostatic model assessment of insulin resistance levels were higher in the overweight group (2.9±1.2 vs. 1.1±0.8, p=0.001). No statistically significant differences were found in Pw-d and QT-d when the groups were compared. The following findings were recorded for the overweight and control groups, respectively: mean RR interval (635±42 msec vs. 645±45 msec, p=0.867), Pw-d [30 (10- 55) msec vs. 27.5 (15-50) msec, p=0.441] and QT-d (30 (15-55) msec vs. 22.5 (10-60) msec, p=0.476). In addition, Pw-d and QT-d were not correlated with the levels of insulin or body mass index.
Conclusion: There was no significant difference in atrial conduction or ventricular repolarization features between overweight children and normal-weight children.

We present the case of a 72-year-old male who underwent a permanent transvenous DDD pacemaker implantation for symptomatic complete heart block. The postoperative surface electrocardiogram (ECG) revealed a right bundle branch block (RBBB) pacing pattern with transition in lead V3 and left bundle branch block (LBBB) in D1, suggesting a malpositioned ventricular lead in the left heart. Malposition of a lead was ruled out by chest X-ray and echocardiogram confirming apical right ventricular pacing. After a literature review, a surface ECG maneuver, by placing leads V1 and V2 one intercostal space lower, restored the usual patterns of paced LBBB pattern. We discuss the literature concerning safe-paced RBBB.

Angiosarcoma, the most common primary malignant neoplasm of the heart in adults, usually presents as pericardial effusion or right-sided heart failure. Rupture of an angiosarcoma-infiltrated cardiac chamber as a cause of hemothorax is very rare in the literature. In this report, we describe a 34-year-old male patient, who presented to emergency service with sudden chest pain and dyspnea. The diagnostic work-up revealed spontaneous right-sided hemothorax and a large right atrial (RA) mass with suspicious atrial perforation. An urgent surgery showed a vascularized irregular RA mass invading the parietal pericardium and pleura and a perforation of the RA free wall. Histopathologic examination confirmed the diagnosis of angiosarcoma, and the patient was subsequently referred for radiotherapy and chemotherapy.

A 41-year-old female was admitted to our hospital with an unidentified source of fever, dyspnea and dizziness. Transthoracic echocardiography demonstrated severe mitral valve regurgitation, and further examination with transesophageal echocardiography (TEE) revealed a 7 mm vegetation on the anterior mitral leaflet. Blood cultures were negative, and after 45 days of empiric 12 g/day ampicillin-sulbactam therapy, the vegetation was shown to have disappeared. However, due to ongoing severe mitral regurgitation and valve deformity, a prosthetic metallic mitral valve replacement was performed. After the operation, TEE was performed again due to subfebrile fever; however, the valve was normal and blood cultures were negative. Because of the probable relapse risk of infective endocarditis, the preoperative intravenous antibiotherapy was continued for 21 days and then orally for one week. Then, she was placed on follow-up by our outpatient clinic. As her INR was highly unstable during this period and she developed newonset subfebrile fever, she was hospitalized again, and the TEE demonstrated vegetation. Blood cultures were still negative, and a combination of vancomycin-rifampicin-gentamicin was started. While under that therapy, first stroke and after a few days recurrent trans-ischemic attack developed, and the vegetation was seen to have enlarged. Urgent valve operation was performed with a bioprosthetic mitral valve, and ampicillinsulbactam therapy was added to her previous antibiotherapy at the suggestion of the Microbiology Department. Oral anticoagulant therapy was planned for three months; however, during the postoperative period, her INR levels were highly unstable and could not be maintained in therapeutic ranges for even two consecutive days. Adjusted dosage of dabigatran to 110 mg/bid according to renal clearance in combination with 150 mg/day aspirin was started. However, valve thrombosis and a massive stroke developed under this therapy. The thrombosis disappeared after continuous heparin infusion, and she was discharged with neurological sequelae on 150 mg/day aspirin 55 days after her last operation. During the follow-up period of four months, no other clinical events occurred.

Thromboembolic obstruction of the renal artery is a serious clinical problem, but rarely diagnosed. The diagnosis is not usually established until irreversible renal parenchymal damage occurs. Here, we present a case of renal artery thromboembolism in a patient who had atrial fibrillation and was treated by selective intra-arterial infusion of tissue plasminogen activator (TPA). A 69-year-old male was admitted to our hospital with a one-hour history of palpitation and epigastric pain. He had inferior myocardial infarction and percutaneous coronary intervention to the right coronary artery two weeks before. Coronary angiogram was performed, and no significant stenosis was detected. One hour later, epigastric pain spread to the left flank region. Spiral computerized tomography showed occlusion of the left renal artery. Emergency abdominal angiography was performed, and selective intra-arterial infusion of TPA was started promptly. The abdominal pain disappeared, and urine output remained adequate. Forty-eight hours later, angiographic follow-up confirmed the complete lysis of the thrombus in the left renal artery. No renal or hemorrhagic complications were observed, and the patient was discharged four days later with normalized renal function on oral anticoagulation.

A 44-year-old male patient admitted with palpitations was diagnosed with tachycardia with wide QRS, but recovered after being treated with amiodarone. The patient’s coronary angiography was normal. As the patient’s resting ECG was compatible with Brugada type 2, an ajmaline challenge test was scheduled. The infusion procedure was suspended following an observation of type 1 ECG findings in the 4th minute of infusion. Approximately 10-15 seconds later, a monomorphic ventricular tachycardia with a rate of 150 beats/minute developed. In the follow-up, the patient’s heartbeat returned spontaneously to the sinus rhythm within 3-4 minutes. Polymorphic ventricular tachycardia or ventricular fibrillation tachyarrhythmias usually result in syncope or sudden cardiac death in cases of Brugada syndrome, while monomorphic tachycardia, as in our case, is rare. Here, we present a rare case of monomorphic ventricular tachycardia, which was observed during the ajmaline challenge test.

A 24-year-old female underwent implantation of a right-sided dual chamber permanent pacemaker for cardioinhibitory syncope with active fixation atrial lead. Five days after the procedure, the patient developed pleuritic chest pain and difficulty in breathing. Minimal pericardial effusion and right hemopneumothorax were found. The atrial active screw-in lead was visualized just above the right atrial appendage with its helix perforating the right atrial wall, pericardium and pleura, reaching the right mid-lobe. Lead extraction was performed, and a passive bipolar atrial lead was implanted during the same session without any problems.

Despite advances in treatment, heart failure (HF) remains a highly prevalent, worldwide problem with a high morbidity and mortality. Cardiac resynchronization therapy (CRT) has become an essential therapeutic tool in HF patients with significant dyssynchrony due to intrinsic conduction disease. Although the prevalence of atrial fibrillation (AF) in patients with advanced HF is high, those patients are excluded or underrepresented in most of the CRT trails. In randomized studies supporting the benefits and indications for CRT, only 2% of patients had AF. Observational studies, a randomized trial and several meta-analyses showed that HF patients with AF may experience benefits similar to patients with a sinus rhythm in terms of functional capacity and reverse remodeling, quality of life, and even survival. With this review, it was aimed to discuss the clinical issues related to CRT, efficacy, heart rate control strategies, and their effects on the therapy.