Bu derlemede Avrupa Kardiyoloji Derneði tarafýndan 2010 yýlýnda yayýnlanan yeni atrial fibrilasyon kýlavuzununda yer alan yenilikler kýsaca tartýþýlmýþtýr.

Herewith, new atrial fibrillation guideline which is published in 2010 by European Society of Cardiology has been briefly discussed.

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Amaç: Doku Doppler Görüntüleme ile deðerlendirilen izovolumik akselerasyon, sol ventrikül kontraktilitesinin önyükten baðýmsýz bir göstergesi olarak önerilmektedir. Çalýþmamýzda, hipertansif obez kiþilerde, sað ve sol ventrikül sistolik disfonksiyonunun erken döneminin öngörülmesinde izovolumik akselerasyonun kullanýmýný araþtýrdýk.
Metod: Yetmiþ sekiz obez (beden-kitle indeksi > 30 kg/m2) gönüllü, prospektif olarak çalýþmaya dahil edildi. Tüm hastalara konvansiyonel ve doku Doppler ekokardiyografi uygulandý. Sol ventrikül septal ve lateral annulus ile lateral triküspid anulusuna ait miyokardiyal velositeler elde edildi. Ýzovolumik kontraksiyon, EKG’deki R dalgasý pikinden önce baþlayan, miyokardiyal sistolik dalganýn öncesinde gelen dalga olarak tanýmlandý. IVA, pik velositenin, isovolumik kontraksiyon süresince görülen dalganýn baþlangýcýndan (sýfýr noktasýndan) bu dalganýn pik velositesine kadar süren zaman dilimine bölünmesiyle hesaplandý.
Bulgular: Bel çevresi ile sol ventrikül end-sistolik (r=0.22 p=0.047) ve end-diyastolik çap (r=0.384, r=0.001) arasýnda pozitif korelasyon; bel çevresi ile triküspit anulusu pik sistolik velositesi (r= -0.311, p=0.006) arasýnda negatif korelasyon saptandý. Her ne kadar hipertansif ve normotansif obez hastalar benzer doku Doppler temelli miyokardiyal velositelere sahip olsalar da, hipertansif obez hastalarda normotansif hastalardan anlamlý olarak daha düþük triküspid lateral anulus izovolumik akselerasyon (p=0.027), septal izovolumik akselerasyon deðerleri (p=0.026) ve septal izovolumik kontraksiyon miyokardiyal velositeleri (p=0.018) saptandý.
Sonuç: Ýsovolumik akselerasyon ve izovolumik kontraksiyon miyokardiyal velosite analizi, hipertansif obez bireylerde subklinik sol ve sað ventrikül disfonksiyonunun tanýsýnda faydalý olabilir.

Aims: Isovolumic acceleration assessed with tissue Doppler imaging has been proposed as a preload-independent indicator of left ventricular contractility. We investigated the utility of isovolumic acceleration in the prediction of preclinical right and left ventricular systolic dysfunction in hypertensive and obese subjects.
Methods: Seventy eight obese (body mass index>30 kg/m2) volunteers were prospectively enrolled. Conventional and tissue Doppler echocardiography was performed on all patients. Myocardial velocities of the left ventricular septal and lateral mitral annulus and lateral tricuspid annulus were obtained. The isovolumic contraction wave was determined as the preceding wave to the systolic wave that begins before the peak of the R wave on ECG. IVA was measured by dividing peak velocity by the time interval from onset of the wave (zero-crossing) during isovolumic contraction to the time at peak velocity of this wave.
Results: There was a positive correlation between waist circumference and left ventricular end systolic (r=0.22 p=0.047) and end-diastolic diameter (r=0.384, r=0.001) and a negative correlation between waist circumference and tricuspid annulus TDI peak systolic velocity (r= -0.311, p=0.006). Although hypertensive and normotensive obese patients had similiar TDI based myocardial velocities, hypertensive obese patients had significantly lower tricuspid annulus isovolumic acceleration (p=0.027), septal isovolumic acceleration (p=0.026), and septal isovolumic contraction myocardial velocity (p=0.018) than normotensive obese subjects.
Conclusion: Isovolumic acceleration and isovolumic contraction myocardial velocity analysis may be useful in the diagnosis of subclinical left and right ventricular dysfunction in hypertensive and obese patients.

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Amaç: Kalp boþluklarýnýn delinmesi, elektrofizyolojik çalýþma ve geçici kalp pili takýlmasýnýn nadir rastlanan bir komplikasyonudur. Bu çalýþmada, kateterle iliþkili sað kalp delinmesi geliþen hastalar geriye dönük olarak incelenerek bu komplikasyonun sýklýðý ve klinik seyri araþtýrýldý.
Çalýþma planý: Haziran 2002 ile Kasým 2007 tarihleri arasýnda kurumumuzda kateterle iliþkili kalp delinmesi tanýsý konan hastalar çalýþmaya alýndý.
Bulgular: Çalýþma dönemi içinde toplam 2385 uygulama gerçekleþtirildi (1287 elektrofizyolojik çalýþma, 1098 balonsuz geçici kalp pili uygulamasý). Sekiz olguda kalp delinmesi tanýsý kondu. Bu komplikasyonun sýklýðý iþlem sayýsý açýsýndan %0.34 (8/2385), kullanýlan kateter sayýsý açýsýndan %0.14 (8/5603) bulundu. Kalp delinmesi üç olguda elektrofizyolojik çalýþma sýrasýnda, diðer olgularda geçici (1 olguda kalýcý) kalp pili elektrodunun yerleþtirilmesi sýrasýnda meydana geldi. Etkilenen boþluklar yedi olguda sað ventrikül, bir olguda sað atriyum idi. Kalp pili yerleþtirilmesinden sonra sað ventrikül delinmesinin geç evrede saptandýðý üç hastada ani ölüm geliþti. Sað atriyum delinmesi saptanan bir hastaya cerrahi eksplorasyon yapýldý. Ýki hastaya koroner baypass ameliyatý uygulandý, bunlarýn birinde delinme ameliyat sýrasýnda görüldü. Ýki hasta ise konservatif olarak izlendi.
Sonuç: Erken saptanan sað ventrikül delinmelerinde prognoz nispeten daha iyi olsa da, geç saptanan delinmeler ve sað atriyum delinmeleri acil giriþim gerektiren durumlardýr ve sonuçlarý çok kötü olabilir.

Objectives: Perforation of heart chambers is one of the rare complications observed during electrophysiological studies and placement of pacemaker leads. In this study, we performed a retrospective evaluation of patients with catheter-related right heart perforation, aiming to determine its incidence and clinical course.
Study design: We reviewed cases with catheter-relater cardiac perforations observed at our institution from June 2002 to November 2007.
Results: During the study period, a total of 2,385 procedures were performed (1,287 electrophysiologic studies, 1,098 temporary nonballoon-floating pacing lead placements). Eight cardiac perforations were diagnosed, with the overall procedure-based and catheter-based incidences of 0.34% (8/2,385) and 0.14% (8/5,603), respectively. Three of these perforations were related to diagnostic electrophysiology catheters, and five were related to temporary (1 permanent) transvenous pacemaker leads. Seven perforations involved the right ventricle and one involved the right atrium. Three patients in whom right ventricular perforation was detected at a late stage died suddenly after pacemaker lead implantation. One patient underwent surgical exploration because of right atrial perforation. Two patients underwent coronary bypass operation and, in one of these patients, perforation was detected during surgery. Two patients were managed conservatively.
Conclusion: Although right ventricular perforations detected early have a relatively benign course, those detected late and right atrial perforations require emergent surgical exploration and may have catastrophic consequences.

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Amaç: Kronik kararlý koroner arter hastalýðý olan kiþilerde koroner kolateral dolaþým (KKD) ile yüksek duyarlýklý C-reaktif protein (hs-CRP) düzeyleri arasýndaki iliþki araþtýrýldý.
Çalýþma planý: Çalýþmada, akut koroner olaydan en erken bir ay sonra yapýlan koroner anjiyografide en az bir ana koroner arteri tam týkalý olan 104 hasta geriye dönük olarak incelendi. Son bir ay içinde akut koroner sendrom tanýsý konan, ciddi kapak hastalýðý, herhangi bir sistemik hastalýk veya sistemik enflamatuvar hastalýðý olan, koroner arter cerrahisi veya perkütan koroner giriþim uygulanan hastalar çalýþmaya alýnmadý. Kolateral sýnýflamasýnda Rentrop ölçütleri kullanýldý. Rentrop 0 ve 1 yetersiz KKD, Rentrop 2 ve 3 yeterli KKD olarak tanýmlandý. Hastalarýn hs-CRP düzeyleri koroner anjiyografiden 1-7 gün önce ölçüldü.
Bulgular: Rentrop sýnýflamasýna göre kolateral akým 10 hastada derece 0, 26 hastada derece 1, 29 hastada derece 2, 39 hastada derece 3 bulundu. Yeterli KKD grubunda 68 hasta (%65.4), yetersiz KKD grubunda 36 hasta (%34.6) vardý. Yaþ, cinsiyet, risk faktörleri, kullanýlan ilaç, týkalý olan damarýn yeri ve anlamlý lezyonu olan damar sayýsý açýsýndan iki grup benzer bulundu. Yetersiz KKD grubunda hs-CRP düzeyleri (ortanca 5.42 mgr/dl; daðýlým 2.3-9.8 mgr/dl) yeterli KKD grubundan (ortanca 3.36 mgr/dl; daðýlým 2.2-9.7 mgr/dl) anlamlý derecede yüksek bulundu (p=0.003). Lojistik regresyon analizinde, hs-CRP düzeyinin kolateral geliþimini olumsuz etkileyen bir öngördürücü olduðu görüldü (β=-320; odds oraný= 0.725; %95 güven aralýðý 0.587-0.894; p=0.003).
Sonuç: Bulgularýmýz, kararlý koroner arter hastalýðý olan kiþilerde yüksek hs-CRP düzeyinin kolateral geliþimini olumsuz etkileyen öngördürücü olduðunu göstermektedir.

Objectives: We evaluated the relationship between coronary collateral circulation (CCC) and blood high-sensitivity C-reactive protein (hs-CRP) levels in patients with chronic stable coronary artery disease.
Study design: The study included 104 patients who underwent coronary angiography at least one month after acute coronary event and were found to have total coronary occlusion in at least one major coronary artery. Patients with the diagnosis of acute coronary syndrome within the past month, severe valve disease, systemic disease, systemic inflammatory disease, or a history of coronary surgery or percutaneous coronary intervention were excluded. Collateral circulation was graded according to the Rentrop classification. Grades 0 and 1 were defined as poor, grades 2 and 3 were defined as good CCC. Blood hs-CRP levels were measured 1 to 7 days before coronary angiography.
Results: According to the Rentrop classification, CCC was graded as 0 in 10 patients, 1 in 26 patients, 2 in 29 patients, and 3 in 39 patients. Sixty-eight patients (65.4%) had a good CCC, and 36 patients (34.6%) had a poor CCC. The two groups were similar with respect to age, sex, risk factors, medications, localization of the occluded coronary artery, and the number of occluded arteries. However, hs-CRP levels were significantly higher in patients with a poor CCC (median 5.42 mg/dl; range 2.3-9.8 mg/dl) compared to those with a good CCC (median 3.36 mg/dl; range 2.2-9.7 mg/dl, p=0.003). Logistic regression analysis showed that hs-CRP level was a significant predictor exerting an adverse effect on collateral development (β=-320; odds ratio= 0.725; 95% confidence interval 0.587-0.894; p=0.003).
Conclusion: Our findings suggest that high hs-CRP level is a significant predictor of poor collateral development in patients with chronic stable coronary artery disease.

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Amaç: Doku deformasyon süresi bölgesel miyokart fonksiyonlarý için önemlidir. Bu çalýþmada koroner yavaþ akým (KYA) fenomeninin zirve sistolik gerilim (strain) süresi ile iliþkisi deðerlendirildi.
Çalýþma planý: Çalýþmaya koroner anjiyografide KYA saptanan 25 hasta (23 erkek, 2 kadýn; ort. yaþ 48.4±11.9) ve koroner anjiyografisi normal bulunan 20 saðlýklý kiþi (16 erkek, 4 kadýn; ort. yaþ 51±11.3) alýndý. Koroner yavaþ akýmýn belirlenmesinde TIMI kare sayýsý yöntemi (TKS) kullanýldý. Ekokardiyografik kayýtlar standart apikal ve parasternal görüntülerden elde edildi. Renkli Doppler miyokart görüntüleri 160-200/sn kare hýzýnda elde edildi. Zirve sistolik gerilim süresi, sol ventrikülün tüm duvarlarýnýn bazal, orta ve apikal segmentlerinden ölçüldü.
Bulgular: Hasta ve kontrol grubu arasýnda sol ventrikül sistolik fonksiyonlarý açýsýndan anlamlý fark görülmedi (ejeksiyon fraksiyonu %67±5 ve %66±4). Hasta grubunda TKS deðerleri kontrol grubundan anlamlý derecede yüksek bulundu (sol ön inen arterde 42.8±7.7 ve 17.9±3.5; sirkumfleks arterde 37.7±6.5 ve 16.6±2.9; sað koroner arterde 41.2±6.4 ve 17.3±2.7; p<0.001). Renkli doku Doppler miyokart görüntülerinden sol ventrikülün 18 segmentinden ölçülen zirve sistolik gerilim sürelerinin tümü hasta grubunda kontrol grubuna göre anlamlý yükseklik gösterdi (p<0.001). Hasta ve kontrol gruplarýnda ayný duvarlar için bazal segmentlerle karþýlaþtýrýldýðýnda, orta segmentlerde ölçülen gerilim süreleri daha kýsa bulunurken (p<0.05), orta ve apikal segmentlerden ölçülen gerilim süreleri arasýnda anlamlý fark saptanmadý (p>0.05).
Sonuç: Çalýþmamýz KYA’da zirve sistolik gerilim sürelerinin uzadýðýný gösteren ilk çalýþmadýr. Bu uzama, KYA olan hastalarda miyokardýn bölgesel kasýlma fonksiyonlarýndaki bozulmaya iþaret eden bir belirteç olabilir.

Objective: Time of tissue deformation is an important role in regional myocardial contractile function. The aim of this study was to evaluate the effect of coronary slow flow (CSF) on time to peak systolic strain (Ts).
Study Design: The study included 25 patients who had CSF pattern in coronary angiogram and 20 controls who had normal coronary angiogram. ‘TIMI frame count (TFC)’ methods were used for the detection of CSF. Echocardiographic recordings were obtained from standard apical/parasternal views. Color Doopler myocardial imaging (CDMI) data were acquired at 160-200 s-1 frame rates. Ejection fraction (EF) was measured by Simpson’s rule. Ts were measured from basal, mid and apical segments of all left ventricular walls.
Results: There was no difference between patients and controls for left ventricular systolic functions (EF; 67±5 vs. 66±4, respectively). TFC values were greater in the patients than in the controls (LAD: 42.80±7.65 vs. 17.90±3.46; Cx: 37.68±6.49 vs. 16.60±2.90; RCA: 41.20±6.37 vs. 17.30±2.69; respectively, p<0.001 for all). There were significant differences between patients and controls for Ts, in 18 segments to left ventricle (p<0.001). Mean Ts were shorter in most of the mid segments compared with basal segments (p<0.05) in same walls of patients and controls. There were no differences in mean Ts between the mid and apical segments in all subjects.
Conclusion: Our study is the first to demonstrate the coronary slow flow induced prolongation of the time to peak systolic strain. This condition might be an additional factor to deterioration of regional myocardial contractile function in CSF patients.

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Amaç: Sekundum tip atriyal septal defektlerin (ASD) perkütan yolla kapatýlmasý cerrahi tedaviye önemli bir seçenek haline gelmiþtir. Bu çalýþmada, eriþkin hastalarda sekundum tip ASD’lerin Amplatzer týkayýcý cihaz ile kapatýlmasýna ait klinik deneyimimiz ve erken dönem sonuçlar deðerlendirildi.
Çalýþma planý: Çalýþmaya sekundum ASD nedeniyle Amplatzer septal týkayýcý cihaz kullanýlarak transkateter yolla ASD kapama iþlemi uygulan 52 hasta (36 kadýn, 16 erkek; ort. yaþ 33±14; daðýlým 14-69) alýndý. Transözofageal ekokardiyografide ölçülen ortalama atriyal septum çapý 19.5±5.7 mm, kullanýlan Amplatzer cihaz çapý ortalama 24.5±5.7 mm idi. Klinik ve ekokardiyografik olarak tüm hastalar birinci ayda deðerlendirildi.
Bulgular: Kýrk sekiz hastada (%92.3) ASD kapama iþlemi baþarýyla tamamlanýrken, dört hastada (%7.7) iþlem baþarýsýz olarak kabul edildi. Ekokardiyografik kontrollerde triküspit yetersizliði, sað ventrikül geniþliði ve sistolik pulmoner arter basýncýnda anlamlý gerileme izlendi (sýrasýyla p=0.003, p=0.026, p=0.0001). Tüm hastalarýn fonksiyonel kapasitelerinde anlamlý iyileþme görüldü (p=0.0001). Dört hastada iþlem sonrasý ilk günde þant izlendi, ancak bir ay sonra þant tamamen kayboldu. Ýki hastada önemli komplikasyon görüldü. Bir hastada iþlemden hemen sonra cihaz embolizasyonu nedeniyle ventrikül fibrilasyonu geliþti. Sol ventrikül sistolik disfonksiyonu olan bir hastada ise, iþlem sonrasýnda ikili antitrombosit tedavinin kesilmesine baðlý olarak Amplatzer cihaz trombüsü izlendi. Bu durum antikoagülasyon ile baþarýlý þekilde tedavi edildi. Tüm hasta grubunda herhangi bir ritim bozukluðu izlenmedi.
Sonuç: Sekundum ASD’lerin Amplatzer týkayýcý cihaz ile perkütan kapatýlmasý güvenli, etkin ve baþarý oraný yüksek bir tedavi þeklidir.

Objectives: Percutaneous closure of secundum atrial septal defects (ASD) has become an important alternative treatment to surgery. We evaluated our clinical experience with, and short-term results of transcatheter closure of ASDs with the Amplatzer septal occluder in adult patients.
Study design: The study included 52 patients (36 women, 16 men; mean age 33±14 years; range 14 to 69 years) who underwent transcatheter ASD closure with the Amplatzer occluder device. The mean ASD diameter measured by transesophageal echocardiography was 19.5±5.7 mm and the mean device diameter was 24.5±5.7 mm. All the patients were assessed clinically and echocardiographically one month after the procedure.
Results: Transcatheter ASD closure was successfully performed in 48 patients (92.3%) and failed in four patients (7.7%). Echocardiographic controls showed significant decreases in tricuspid regurgitation, right ventricular dilatation, and pulmonary artery pressure (p=0.003, p=0.026, and p=0.0001, respectively). Functional capacity of the patients also showed significant improvements (p=0.0001). After implantation, residual shunts were detected in four patients, all of which disappeared one month after the procedure. Major complications were seen in two patients. One patient developed ventricular fibrillation immediately after the procedure due to device embolization. One patient with left ventricular dysfunction developed device thrombosis due to cessation of dual antiplatelet therapy, which was successfully treated by anticoagulation therapy. Arrhythmia was not observed in any patient.
Conclusion: Percutaneous closure of secundum ASDs with the Amplatzer occluder device is a safe and effective procedure with a high success rate.

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Amaç: Doppler ekokardiyografinin akut romatizmal ateþ (ARA) tanýsýndaki kullanýmý hastalýðýn erken tanýnmasýný ve böylelikle romatizmal yinelemelerden korunmayý saðlayabilir. Bu çalýþmada, ARA’lý hastalarda ekokardiyografi ile subklinik kardit tanýsýnýn sýklýðý araþtýrýldý.
Çalýþma planý: Çalýþmada 1992 yýlýnda deðiþtirilmiþ Jones ölçütleri ile ARA tanýsý konan ve Doppler ekokardiyografi ile incelenen 80 hasta (64 gezici poliartrit, 16 romatizmal kore) deðerlendirildi. Romatizmal kardit, Doppler ekokardiyografide mitral ve aort kapak yetersizlik jetlerinin en az iki farklý kesitte görülmesi, jet uzunluklarýnýn 1 cm’den fazla olmasý, mitral için sistol ve aort kapaðý için diyastol boyunca süren tepe akým hýzýnýn 2.5 m/sn’nin üzerinde olmasý olarak tanýmlandý. Subklinik kardit tanýsý konan olgular 1, 3, 6 ve 12. aylarda tekrar deðerlendirildi.
Bulgular: Çalýþma grubunda ARA’lý 25 hastada (%31.3; 13 kýz, 12 erkek; ort. yaþ 11.4±2.5) ekokardiyografik deðerlendirmede subklinik kardit saptandý. Gezici poliartritli 64 olgunun 34’ünde (%53.1) klinik kardit, 17’sinde (%26.6) subklinik kardit; romatizmal koreli 16 hastanýn beþinde (%31.3) klinik kardit, sekizinde (%50) subklinik kardit saptandý. Bir yýllýk izlemi yapýlabilen subklinik karditli 20 olgunun 11’inde (%55) karditin sürdüðü görüldü.
Sonuç: Klinisyenler ARA kuþkusu olan hastalarda kalp etkilenmeleri için uyanýk olmalýdýrlar. Subklinik kardit sýklýðýnýn yüksek olmasý nedeniyle, ekokardiyografi ile saptanan karditin bir taný ölçütü olarak kullanýlmasý gerekmektedir.

Objectives: Routine use of Doppler echocardiography for the initial diagnosis of acute rheumatic fever (ARF) might allow early detection and, hence, prevention of rheumatic recurrences. This study sought to determine the incidence of subclinical carditis in ARF patients.
Study design: The study included 80 patients (64 migratory polyarthritis, 16 rheumatic chorea) who were diagnosed with ARF according to the Jones criteria, 1992 update. Rheumatic carditis was defined as the presence of the following findings on Doppler echocardiography: mitral and aortic regurgitant jets in at least two planes, the length of the jets >1 cm, and peak flow velocities of >2.5 m/sec for both mitral and aortic regurgitations persisting throughout systole and diastole, respectively. The patients diagnosed with subclinical carditis were re-evaluated at 1, 3, 6, and 12 months.
Results: Echocardiography revealed subclinical carditis in 25 patients (31.3%; 13 girls, 12 boys; mean age 11.4±2.5 years) with ARF. Of 64 patients with migratory polyarthritis, 34 (53.1%) had clinical carditis and 17 (26.6%) had subclinical carditis. The incidences of clinical and subclinical carditis among 16 patients with rheumatic chorea were 31.3% (n=5) and 50% (n=8), respectively. Of 20 patients who completed one-year follow-up, persistence of subclinical carditis was observed in 11 cases (55%).
Conclusion: Clinicians should be attentive to the presence of cardiac involvement among patients with suspected ARF. Considering the high incidence of subclinical carditis, echocardiographic evidence of carditis should be used as a diagnostic criterion.

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Kist hidatik hastalýðýnda kardiyak tutulum yaygýn olmayan bir durumdur, tüm hidatidozis olgularýnýn yaklaþýk %0.5-2’sinde görülür ve esas olarak sistemik enfeksiyonun bir parçasýdýr. Bu yazýda, 57 yaþýndaki kadýn hastada rastlanan izole kardiyak kist hidatik sunuldu. Hasta 10 aydýr var olan sýkýþtýrýcý göðüs aðrýsý yakýnmasýyla baþvurdu. Transtorasik ekokardiyografide, sol ventrikül duvarýnda, primer kardiyak tümörü ya da sol ventrikülü sýkýþtýran kitle akla getiren, heterojen ekogenisitede kitle benzeri bir görüntü izlendi. Göðüs bilgisayarlý tomografi bulgularý, 50x65 mm boyutlarýnda kalsifiye sol ventrikül anevrizmasý ve hafif perikart sývýsý þeklinde bildirildi. Koroner anjiyografide epikardiyal koroner arterler normal bulunurken, kalsifiye sýnýrlarý olan apikal bir kitle görüldü. Serolojik test sonucu ekinokok hastalýðý için negatif bulundu. Kardiyak manyetik rezonans görüntülemede ise, sol ventrikül anterolateral duvarýnda, lümen içine taþan, 54x48 mm boyutlarýnda kistik lezyon görüldü. Dört haftalýk albendazol tedavisinden sonra kistin çýkarýlmasý için cerrahiye baþvuruldu. Ameliyatta kistin patlamýþ olduðu görüldü. Kardiyak kist hidatik tanýsý patolojik incelemeyle doðrulandý. Altý aylýk izlem sýrasýnda hastanýn yakýnmasý yoktu ve transtorasik ekokardiyografide kistik görünüm izlenmedi.

Cardiac involvement is an uncommon presentation of hydatid cyst disease, accounting for approximately 0.5-2% of all hydatidosis cases, and mainly occurring as part of a systemic infection. Herein, we report on an isolated cardiac hydatid cyst in a 57-year-old woman. She presented with a complaint of squeezing chest pain of 10 month-history. On transthoracic echocardiography, a mass like appearance with heterogeneous echogenicity was noted in the left ventricular wall, suggesting a primary cardiac tumor or a mass compressing the left ventricle. Thoracic computed tomography findings were reported as a calcified left ventricular aneurysm 50x65 mm in size and minimal pericardial fluid. Coronary angiography showed normal epicardial coronary arteries and an apical mass with calcified contours. Serological test was negative for echinococcal disease. Cardiac magnetic resonance imaging showed a cystic lesion, 54x48 mm in size, in the left ventricular anterolateral wall, protruding into the lumen. After albendazole treatment for four weeks, surgery was performed for excision of the cyst. During the operation, rupture of the cyst was noted. The diagnosis of cardiac hydatid cyst was confirmed by pathological examination. During a six-month follow-up, the patient was asymptomatic, with no cystic appearance on transthoracic echocardiography.

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Kýrk dört yaþýnda kadýn hasta periferal arter embolisi tanýsýyla hastanemize yatýrýldý. Periferal anjiyografide popliteal arterde tam týkanýklýk saptandý. Týkanýklýk Fogarty arteryel embolektomi kateteri ile baþarýlý þekilde tedavi edildi. Transtorasik ve transözofageal ekokardiyografi incelemelerinde non-koroner Valsalva sinüsünde hareketli, yuvarlak trombüs görüldü. Cerrahi tedaviyi kabul etmeyen hastaya warfarin ile antikoagülan tedaviye baþlandý. Antikoagülan tedaviden bir ay sonra yapýlan transtorasik ekokardiyografide non-koroner Valsalva sinüsündeki trombüsün kaybolduðu gözlendi. Hastada sistemik emboli ataðý bir daha görülmedi. Non-koroner Valsava sinüsünde anevrizma olmaksýzýn oluþan trombüse baðlý periferal emboli nadir bir durumdur.

A 44-year-old woman was admitted with the diagnosis of peripheral arterial emboli. Peripheral angiography demonstrated total occlusion of the popliteal artery. The obstruction was successfully resolved with a Fogarty arterial embolectomy catheter. Both transthoracic and transesophageal echocardiography showed a mobile, round thrombus in the noncoronary sinus of Valsalva. The patient did not accept surgery, and anticoagulation with warfarin was initiated. One month after treatment, transthoracic echocardiography demonstrated disappearance of the thrombus in the noncoronary sinus of Valsalva. The patient did not experience any recurrent episode of systemic embolization. This is a rare case of peripheral embolism caused by a thrombus in the noncoronary sinus of Valsalva without aneurysm.

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Bu yazýda, ilginç bir “yalancý” atriyal fibrilasyon olgusu sunuldu; daha sonra yapýlan elektrofizyolojik çalýþma sayesinde hastaya atriyal duraklama ve düzensiz ektopik kavþak ritmi tanýsý kondu. Elli altý yaþýnda kadýn hasta bir saðlýk kuruluþuna çarpýntý, bayýlma hissi ve nefes darlýðý yakýnmalarýyla baþvurmuþ. Elektrokardiyogramýnda dar QRS kompleksinin eþlik ettiði düzensiz ritim izlenmesi ve P dalgalarýnýn görülmemesi üzerine, yeni geliþen atriyal fibrilasyon düþünülerek hastaya doðru akýmlý kardiyoversiyon uygulanmýþ ve bu sýrada kardiyopulmoner canlandýrma giriþimi gerektiren kardiyak asistol geliþmiþ. Hasta daha sonra kurumumuza yönlendirildi. Ekokardiyografik incelemede iki atriyumda da geniþleme, belirgin sol ventrikül hipertrofisi, ciddi aort darlýðý, orta derecede mitral ve ciddi triküspit yetersizlik izlenirken, sol ventrikül sistolik fonksiyonu normal bulundu. Elektrokardiyografide dar QRS kompleksinin eþlik ettiði düzensiz ritim ve fibrillatuvar f dalga yokluðu, 24 saatlik Holter izleminde ise 3.5 saniyeden uzun süren üç adet ventrikül asistol ataðý izlendi. Elektrofizyolojik çalýþmada, sað atriyum lateral serbest duvarýnýn ve septal duvarýnýn yukarý ve aþaðýsýnda elektriksel aktivite izlenmedi. Bu bulgularla taný atriyal duraklama ve düzensiz ektopik kavþak ritmi olarak kondu. Hasta aort kapaðý deðiþimini kabul etmedi ve kalýcý kalp pili yerleþtirildikten bir yýl sonra altta yatan hastalýðýnýn ilerlemesi nedeniyle kaybedildi.

We present an interesting case of ‘‘pseudo’’ atrial fibrillation which was further diagnosed as atrial standstill with irregular junctional ectopic rhythm during electrophysiologic study. A 56-year-old woman presented to a health facility with symptoms of palpitation, lightheadedness, and shortness of breath. Upon detection of irregular rhythm with narrow QRS complexes and no visible P waves on the electrocardiogram, newly developed atrial fibrillation was considered and a direct current cardioversion was performed, during which cardiac asystole developed necessitating cardiopulmonary resuscitation. The patient was then transferred to our institution. Echocardiographic examination showed biatrial dilatation, normal left ventricular systolic function, marked left ventricular hypertrophy, severe aortic stenosis, moderate mitral regurgitation, and severe tricuspid regurgitation. The electrocardiogram showed an irregular rhythm with narrow QRS complexes without any fibrillatory f waves and 24-hour Holter monitoring revealed three episodes of ventricular asystole lasting for more than 3.5 seconds. During the electrophysiologic study, no electrical activity was observed at the high and low levels of the right atrial lateral free wall and septal wall. The final diagnosis was established as atrial standstill and irregular junctional ectopic rhythm. The patient refused aortic valve replacement and died due to progression of the underlying disease one year following permanent pacemaker implantation.

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Fulminan miyokardit, miyokardý tutan ve ani baþlangýçlý akut kalp yetersizliðine neden olan enflamatuvar bir hastalýktýr. Hastalar hýzlý ve agresif tedavi edilmezlerse prognoz kötüdür. Miyokardit geliþiminde otoimmün mekanizmalarýn rolü olduðu düþünülse de, miyokarditte immündüzenleyici tedaviler halen araþtýrma konusudur. Bu yazýda, standart medikal tedaviye raðmen klinik durumu hýzla bozulma gösteren, akut miyokarditli 30 yaþýnda bir kadýn hasta sunuldu. Hastaya yüksek doz intravenöz immünglobulin tedavisi (2 günde 70 gr/gün) uygulandý ve tedavinin ikinci gününde klinik tablosunda belirgin iyileþme görüldü. Sol ventrikül ejeksiyon fraksiyonu %32’den tedavinin 24. saatinde %40’a, 48. saatinde %50’ye yükseldi. Hasta 10. günde normal ejeksiyon fraksiyonu ile taburcu edildi ve iki yýllýk takip süresince yeni kardiyak olay geliþmedi. Yüksek doz intravenöz immünglobulin tedavisi seçilmiþ hastalarda, özellikle akut fulminan miyokarditin erken döneminde yararlý olabilir.

Fulminant myocarditis is an inflammatory process that occurs in the myocardium and causes acute-onset heart failure. Its prognosis is poor unless patients are promptly and aggressively supported. Although an autoimmune mechanism has been postulated for myocarditis, immunomodulatory treatment strategies are still under investigation. We report on a 30-year-old woman with acute myocarditis, whose condition rapidly deteriorated despite standard medical therapy. High-dose intravenous immunoglobulin therapy (70 g/day for 2 days) was given and the patient showed dramatic improvement on the second day. Left ventricular ejection fraction increased from 32% to 40% and to 50% at 24 and 48 hours of treatment, respectively. She was discharged on the tenth day with normal ejection fraction. She was free of cardiac events during a two-year follow-up. High-dose intravenous immunoglobulin may be potentially useful in selected patients, especially if given early in acute fulminant myocarditis.

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Methemoglobinemi, okside demir içeren hemoglobin miktarýndaki artýþa baðlý olarak, deðiþen derecelerde siyanozla kendini gösteren bir tablodur. Prilokain klinikte sýk kullanýlan bir lokal anesteziktir ve süt çocuklarýnda tedavi dozunda bile edinsel methemoglobinemiye neden olabilmektedir. Bu yazýda, transkateter pulmoner balon valvüloplasti iþlemi sonrasýnda ciddi siyanoz geliþen ve toksik methemoglobinemi tanýsý konan iki kýz bebek sunuldu. Yaþlarý 2 ayýn altýnda olan hastalara, balon valvüloplasti iþlemi öncesinde prilokain ile inguinal bölgeye lokal anestezi uygulanmýþtý. Kan methemoglobin düzeyleri %49.6 ve %37.7 ölçülen hastalar intravenöz metilen mavisi ve askorbik asit ile baþarýlý bir þekilde tedavi edildi.

Methemoglobinemia is characterized by varying degrees of cyanosis due to increased hemoglobin concentrations containing oxidized iron. Prilocaine is a widely used local anesthetic and can cause methemoglobinemia in infants even in therapeutic doses. We present two female infants (younger than 2 months) who developed severe cyanosis after transcatheter pulmonary balloon valvuloplasty and were diagnosed with toxic methemoglobinemia. Both infants were anesthetized with local prilocaine application before balloon valvuloplasty. Methemoglobin levels of the patients were measured as 49.6% and 37.7%, respectively. Both were successfully treated with intravenous methylene blue and ascorbic acid.

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Bu yazýda, 19 yaþýnda asemptomatik bir kadýn hastada rastlantýsal olarak saptanan kapak seviyesi üzeri izole akciðer atardamar darlýðý ve akciðer atardamar anevrizmasý sunuldu. Kardiyolojik deðerlendirmede akciðer odaðýnda sistolik üfürüm, elektrokardiyografide sað eksen sapmasý ve akciðer grafisinde akciðer atardamarýnda belirginleþme saptandý. Transtorasik ekokardiyografide akciðer atardamarýnýn gövdesi normalden geniþ olarak izlendi; hafif pulmoner yetersizlik ve hafif triküspit yetersizliði gözlendi. Renkli Doppler ile akciðer atardamarý kapaðýnýn yaklaþýk 2 cm distalinde türbülans akým izlendi. Transözofageal ekokardiyografide kapak üzeri seviyede zarýmsý yapý ve darlýk sonrasý geliþmiþ yakýnsal (proksimal) anevrizma izlendi. Akciðer atardamarý gövdesi en geniþ olduðu yerde 40 mm ölçüldü. Toraks bilgisayarlý tomografisinde yakýnsal anevrizmanýn akciðer atardamarý gövdesi ile sýnýrlý olduðu görüldü ve boyutu 41 mm ölçüldü. Hastanýn semptomsuz olmasý, anevrizmanýn kitle basý bulgularýnýn bulunmamasý, darlýk düzeyindeki basýnç farkýnýn nispeten düþük olmasý (16 mmHg) ve soldan saða þant bulunmamasý nedeniyle düzenli olarak radyolojik takibine karar verildi.

We present a 19-year-old asymptomatic female patient in whom isolated pulmonary supravalvular stenosis and pulmonary artery aneurysm were incidentally detected. On cardiologic examination, a systolic murmur was heard over the lungs, right axis deviation was seen on the electrocardiogram, and marked appearance of the pulmonary artery was noted on the chest X-ray. On transthoracic echocardiography, the pulmonary artery trunk was found to be wider than normal, and there were mild pulmonary and tricuspid regurgitation. Color Doppler examination showed a turbulent flow 2 cm distal to the pulmonary valve. Transesophageal echocardiography showed a supravalvular membranous structure and a proximal pulmonary artery aneurysm. The pulmonary artery trunk was measured as 40 mm at the widest part. Thoracic computed tomography revealed that the proximal pulmonary artery aneurysm was localized to the pulmonary artery trunk and measured 41 mm. As the patient was asymptomatic and there were no signs of aneurysmatic compression or a left-to-right shunt, and due to the presence of a relatively low gradient (16 mmHg) across the stenotic area, she was scheduled to regular radiologic control.

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Ülkemiz kurumlarýnýn 2010 yýlýnda kardiyovasküler týp alanýnda yayýn üretimiyle ilgili performanslarý Web of Knowledge veritabaný kullanýlarak deðerlendirildi. Araþtýrmada Türkiye kaynaklý uluslararasý tam metinli makale ve derlemeler, Science Citation Index’in CD edisyonuna kaynak dergiler dikkate alýnarak belirlendi. Birden fazla kurumdan ya da bilim dalýndan çýkan ortak yayýnlar için kesirli puan sistemi uygulandý. Geçen yýl CD edisyonunda taranan dergilerde kardiyovasküler týp alanýnda, Türkiye’den köken alan tam metinli makale ve derleme sayýsý 121 ile dörtte birden fazla gerilerken, dünyadaki payýmýz da binde 8.2’den 6.1’e, yani 2001 öncesi düzeye indi. Yayýn üretiminde 95 yayýn eriþkin kardiyolojisinden kaynaklandý. Makalelerin yayýmlandýðý dergilerin ortanca etki deðeri de, geçen yýla kýyasla 1.60 ile (yarýsý 1.15-2.60 etki deðerli dergilerde) kabaca beþte bir oranýnda geriledi. Üretkenlikte önde giden týp kurumlarýmýz Gülhane Askeri Týp Akademisi, Siyami Ersek Kalp ve Damar Cerrahisi, Türkiye Yüksek Ýhtisas ve Kartal Koþuyolu Eðitim ve Araþtýrma hastaneleri ile Erciyes Üniversitesi ve Cerrahpaþa týp fakülteleri idi. Bilimde ve kardiyolojide bir çöküþ yolunda mesafe aldýðýmýzýn bilincine yetkililerce varýlýp yeni ciddi düzenlemeler yapýlmalý.

The performance of Turkey’s institutions was evaluated regarding publication output in cardiovascular medicine in 2010 based on data of the Web of Knowledge. Only articles in full-text and reviews that appeared in source publications covered by Science Citation Index CD Edition were included. A fractional count system was used for items published jointly with a foreign or noncardiological Turkish institution. Turkey’s publications numbered as low as 121, representing more than one-fourth decline, and her share of world publication decreased from 8.2 to 6.1 per mille, to a level below that of before 2001. Ninety-five articles originated from adult cardiology. The median impact factor also declined to 1.60, by one-fifth compared with the previous year; half of the publications appeared in periodicals with an impact factor of 1.15-2.60. Among medical institutions with highest productivity, Gülhane Military Medical Academy, Siyami Ersek Cardiovascular Surgery Center, Türkiye Yüksek Ýhtisas Hospital, and Kartal Koþuyolu Education and Research Hospital as well as Erciyes University and Cerrahpaþa medical faculties ranked in front. Authorities need to be aware that Turkey’s science and, in particular, cardiology are losing prestige and should take new serious measures.

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