Değerli Meslektaşlarım,
On yıldır sürdürmekte olduğum Türk Kardiyoloji Derneği Arşivi editörlük görevim bu sayıda son buluyor, TKD Yönetim Kurulunun isteğine karşın görevimi daha fazla sürdürmeyi arzu etmedim. Gelecek sayıdan başlayarak editörlük görevini yayın kurulu üyelerimizden Prof. Dr. Dilek Ural üslenecek. Onun başkanlığındaki bir ekibin dergimizi yeni bir enerji, heyecan ve istekle çok daha iyi noktalara taşıyacağına eminim, bayrağı ona teslim etmenin mutluluğu içindeyim.

Objective: The aims of the present study were to examine, first, overall mortality in the Turkish Adult Risk Factor (TARF) 2015 survey, and second, distribution of cumulative mortality and temporal losses to follow-up in the 7 geographic regions of Turkey over 25 years.
Methods: Information on mode of death was obtained from first-degree relatives and/or primary health center personnel. Information regarding survivors was based on history, examination of the cardiovascular system, and Minnesota coding of electrocardiograms.
Results: Of the 1304 participants to be screened, 58 were lost to follow-up, 787 were examined, and 39 participants had died. In 420 subjects, verbal reporting alone was used to determine health status. Deaths were attributed to coronary heart disease in 16 subjects, and cerebrovascular event and cancer in 8 cases each. However, evidence suggested underlying autoimmune activation in 85% of cases. Cumulative 25-year assessment of the entire cohort, comprising 863 deaths over a mean follow-up of 20.5 years, corresponded to a rate of 11.4 per 1000 person-years. A significantly lower mortality rate was found in the Southeast. The 1992 participants lost to follow-up represented a rate of 22.5 per 1000 person-years.
Conclusion: The generally high overall mortality in Turkey is similar among geographic regions, with the exception of a lower rate in Southeastern Anatolia. One of every 45 surviving participants is lost to follow-up each year.

Objective: The aim of the present study was to assess cardiac autonomic function via indices of exercise heart rate recovery (HRR) in workers occupationally exposed to lead.
Methods: A total of 98 lead-exposed workers and 98 healthy controls were enrolled. All underwent exercise testing and transthoracic echocardiography. HRR indices were calculated by subtracting 1st - (HRR1), 2nd- (HRR2), and 3rd-minute (HRR3) heart rates from maximal heart rate (HR). Exercisetest parameters– HRR in particular– were compared betweengroups, and correlation analysis of blood, 24-hour urine lead levels, and test parameters was performed.
Results: Baseline demographic and clinical characteristics were found to be similar between groups. Mean HRR1 (26.2±3.6 vs 29.0±4.1 bpm, p<0.001), HRR2 (42.6±3.9 vs 46.9±3.7 bpm, p<0.001), and HRR3 (56.6±4.5 vs 61.8±4.3 bpm, p<0.001) values were significantly lower in the leadexposed group than in the healthy controls. HRR1 was found to be significantly correlated with blood (r: -0.415;p<0.001) and 24-hour urine lead levels (r: -0.446; p<0.001). HRR2 and HRR3 were significantly correlated with 24-hour urine lead level (r: -0.396; p<0.001 and r: -0.233; p=0.021, respectively).
Conclusion: Lead-exposed workers had lower HRR indices than normal subjects. Blood and 24-hour urine lead levels were significantly associated with HRR indices. Cardiac autonomic functions may be affected by exposure to lead, and those occupationally exposed should be closely followed for adverse cardiovascular outcome.

Objective: Myocardial perfusion scintigraphy (MPS) is a diagnostic tool commonly used to detect significant coronary lesion. However equivocal, false negative or positive results can be yielded. Controversial findings regarding the role of ischemia-modified albumin (IMA) in MPS evaluation persist. The aim of the present study was to examine the role of serum IMA in the assessment of MPS results.
Methods: MPS using technetium (99mTc) sestamibi and transthoracic echocardiography was performed on 62 consecutive subjects prospectively enrolled. Exercise treadmill test (ETT) with modified Bruce protocol was used to induce coronary ischemia. During MPS performance, blood samples for serum IMA were obtained at 3 times: at pre-exercise, at the peak of ETT, and 6 hours after ETT. Patients were classified into 3 groups according to MPS results (normal, equivocal, and ischemia).
Results: Sixty-two patients (23 normal, 20 equivocal, 19 with ischemia) were included. Pre- and peak-exercise IMA values were similar among the groups (p=0.706 and 0.904). Postexercise IMA values of the normal and equivocal groups were similar (p=0.733), while that of the ischemia group was significantly higher than the values of either the normal (p<0.001) or equivocal groups (p<0.001). ΔIMA (the difference between post-exercise and peak-exercise IMA) of the ischemia group was significantly higher than that of either the normal (p<0.001) or equivocal groups (p<0.001).
Conclusion: Serum IMA was found to be significantly increased in cases of ischemia on MPS. Subjects with normal and equivocal MPS had a similar pattern during the test. IMA may be used in differentiation of equivocal results from false positive results.

Objective: Inflammation is thought to play a role in the pathogenesis of atrial fibrillation. The relationship between CD40 ligand (CD40L), a prothrombotic and proinflammatory molecule, and lone atrial fibrillation was presently investigated for the first time. Levels of serum CD40L were also tested, regarding potential to distinguish patients with lone atrial fibrillation from healthy individuals.
Methods: Presently included were 35 patients with lone persistent atrial fibrillation and a control group of 30 healthy individuals. Serum levels of CD40L and high-sensitive C-reactive protein (hs-CRP) were measured, and transthoracic echocardiography was performed.
Results: Mean serum CD40L, hs-CRP, left ventricular end-diastolic diameter, and left atrial diameter values were significantly higher in the group with lone persistent atrial fibrillation than in the control group (7.4±3.5 ng/mL vs 4.3±1.2 ng/mL, p<0.0001; 3.7±1.6 mg/L vs 1.7±0.8 mg/L, p<0.0001; 53.0±4.2 mm vs 46.0±3.8, p<0.0001; 43.5±3.5 mm vs 33.7±3.5, p<0.0001, respectively). Serum CD40L levels were positively correlated with left atrial diameter (r=0.81, p<0.0001) and hs-CRP (r=0.72, p<0.0001). Receiver operating characteristic curve analysis revealed that serum CD40L at the optimal cut-off level of >4.5 ng/mL successfully discriminated patients with lone atrial fibrillation from controls (area under the curve: 0.847; 95% confidence interval: 0.759–0.934; p<0.0001).
Conclusion: The present findings suggest that CD40L levels play a crucial role in the development of lone atrial fibrillation. In addition, results support that regular clinical follow-up of these patients is necessary, due to increased cardiovascular disease risk, determined by elevated CD40L levels.

Objective: Association of ABO blood type with occurrence of pulmonary embolism (PE) has been demonstrated, and association of blood type with disease mortality and morbidity has recently been reported. Presently described was a retrospective study of mortality and morbidity according to blood group.
Methods: Blood type and medical data of 230 patients with confirmed PE was abstracted from medical records. Two control groups were used for data analysis; the 1st included blood donors (Control 1), the 2nd included hospital staff born in the same region (Control 2).
Results: In PE patients, blood group A was the most common phenotype (46.1%), followed by blood groups O (25.2%), B (20.4%), and AB (8.2%). Among the control groups, no significant difference was found in distribution of A vs non-A (36.4% vs 36.6%, respectively) or O vs non-O (66.6% vs 66.4%, respectively) blood groups. Blood group A was significantly more prevalent than non-A in patients with PE, compared to both control groups (p=0.002 and 0.03, respectively), and blood group O was significantly less prevalent than non-O in patients with PE, compared with both control groups (p=0.009 and 0.04, respectively). No significant difference was found in PE patients regarding in-hospital and midterm (6–36 months follow-up) mortality (p=0.36 and 0.15, respectively) based on blood groups.
Conclusion: Blood group A was significantly more common, and blood group 0 significantly less common, in patients with PE. No association was found regarding blood type and in-hospital outcome or midterm mortality.

Objective: Failure to decrease blood pressure (BP) during the night is associated with higher cardiovascular (CV) morbidity and mortality. There is strong evidence that fixed-dose combinations (FDCs) of antihypertensive agents are associated with significant improvement and non-significant adverse effects. The aim of the present study was to evaluate whether FDC affected nocturnal BP favorably in patients with uncontrolled, non-dipper hypertension (HT).
Methods: All non-dipper hypertensives were either newly diagnosed with stage 2–3 HT or had HT uncontrolled with monotherapy. Patients (n=195) were consecutively assigned to 4 treatment groups: FDC of valsartan/amlodipine (160/5 mg), free-drug combination of valsartan 160 mg and amlodipine 5 mg, amlodipine 10 mg, and valsartan 320 mg. Ambulatory blood pressure monitoring (ABPM) was repeated at 4th and 8th week.
Results: Average 24-h (24-hour) and nocturnal BP were similar among the groups at baseline evaluation, and had significantly decreased by the fourth week of treatment. However, BP continued to decrease only slightly between the 4th and 8th weeks in the valsartan and amlodipine monotherapy groups, but continued to decrease significantly in both combination groups. After 4 weeks, day-night BP difference and day-night BP % change were significantly elevated in the combination and valsartan groups. Between the 4th and 8th weeks, however, day-night BP difference and day-night BP % change continued to rise only in the FDC group, nearly reducing to baseline levels in the free-drug combination and valsartan groups. An additional 2.2 mmHg decrease was observed in the FDC group, compared to the free-drug combination group.
Conclusion: In non-dipper HT, FDC of valsartan and amlodipine improved diurnal-nocturnal ratio of BP and provided 24-h coverage.

Summary– Severe aortoiliac disease is traditionally treated with aortofemoral bypass (AFB). However, certain recurrent problems typically follow this type of treatment, problems which often require surgical intervention. Presently described is the endovascular recanalization of the native aortoiliac arteries in 2 patients who had undergone AFB. One patient with a history of aortounifemoral bypass graft had a newly emerged distal abdominal aorta and contralateral iliac artery occlusion as a result of progressive atherosclerosis. Another patient had thrombosis of the left limb of aortobifemoral bypass graft. In these patients, primary stenting was used as secondary treatment to recanalize aortoiliac occlusion. To our knowledge, the present are the first reported cases of such treatment.

Summary– Takotsubo cardiomyopathy (TTC), also known as left ventricular apical ballooning syndrome or stress cardiomyopathy, is characterized by transient left ventricular systolic dysfunction and the absence of obstructive lesion in the epicardial coronary arteries. The most common presentation is acute substernal chest pain, although occasionally dyspnea and syncope, and rarely shock with ST-segment elevation and elevated cardiac biomarkers have been observed. Inverted (reverse) TTC is a rare pattern characterized hypokinesis of the basal and midventricular segments. Presently described was case of a 27-year-old woman with ventricular fibrillation following endoscopic nasal sinus surgery.

Summary– The atriofascicular accessory pathway (AP), known as the Mahaim pathway, is a rare form of pre-excitation, comprising less than 3% of all APs. Mahaim AP is characterized by decremental, anterograde-only conduction, and antidromic tachycardia with left bundle branch morphology. Prevalence of Mahaim AP in Ebstein’s anomaly is significantly high. In addition, combination of Wolff–Parkinson–White (WPW) syndrome and Mahaim AP in patients with Ebstein’s anomaly has been reported. Presently described is the coexistence of Mahaim AP and manifest WPW syndrome in a patient with Ebstein’s anomaly, who was successfully ablated without fluoroscopy.

Summary– Cardiac resynchronization therapy has become a mainstay of treatment for advanced systolic heart failure refractory to medical management. However, several limitations may affect this therapy, including a non-response rate of nearly 30%, failure to implant the leads via conventional transvenous route in an optimal location, and inability to cannulate the coronary sinus branches due to difficult anatomy or presence of venous valves. Venous occlusion may also present as a potential obstacle in patients with prior implantation of cardioverter-defibrillator. Presently described are cases of 2 patients with venous occlusion.

Summary– Vascular complications increasing the rates of morbidity and mortality are among the most common complications observed during transcatheter aortic valve implantation (TAVI). Endovascular management is often life-saving. However, due to limitations of time in cases of iliac rupture and dissection, precautions taken prior to the procedure and the placement of safety guidewire in the contralateral femoral artery are crucial. Here, an 85-year-old woman and and 84-year-old man who had severe symptomatic aortic stenosis and underwent TAVI were presented. Although the valves were successfully implanted, the procedures were complicated by rupture and dissection of the right iliofemoral artery. With the use of safety guidewire, 2 self-expandable graft stents were inserted at the site of rupture and in the place of dissection in the iliofemoral artery, and the patients could be managed successfully.

Summary– Among electrophysiologic procedures, catheter ablation of atrial fibrillation (AF) is challenging, requiring the isolation of all pulmonary veins (PVs). AF is associated with serious complications including PV stenosis. Presently described was a technically challenging case of PV isolation in a patient with left-sided pneumonectomy due to lung cancer.

Letter to the Editor