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Volume : 25 Issue : 4 Year : 2021
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The Anatolian Journal of Cardiology - Anatol J Cardiol: 25 (4)
Volume: 25  Issue: 4 - April 2021
EDITORIAL
1.Studies and Reviews on Central Sleep Apnea, Endovascular Therapy, Robotic Surgery, and the associated Clinical and Genetic Characteristics in Cardiology
Çetin Erol
doi: 10.5152/AnatolJCardiol.2021.4  Page 215
Abstract | Full Text PDF

REVIEW
2.Heart failure and central sleep apnea in the era of implantable recorders
Irina Cabac-pogorevici, Valeriu Revenco
doi: 10.5152/AnatolJCardiol.2021.63668  Pages 216 - 224
Sleep-disordered breathing (SDB) is a complex syndrome with a high prevalence and a significant impact on the general well-being of the overall population. Heart failure (HF) is a major health issue with an increasing incidence, a high rate of hospitalizations, and high mortality in developing countries. Focusing on early recognition and management of HF comorbidities may have an important role in reducing the economic burden and public health impact of HF. The close interconnection between HF, heart rhythm disturbances, and sleep apnea is supported by the mutual risk factors such as age, smoking, obesity, and male sex. Central sleep apnea (CSA) may be considered a marker of advanced HF, often being associated with elevated pulmonary capillary wedge pressure, brain natriuretic peptide (BNP), and noradrenaline levels and with low left ventricular ejection fraction. In the same way, there is an important correlation between CSA and different types of arrhythmias. The large intraindividual rhythm variability reported in patients with SDB who underwent continuous monitoring by implantable loop recorder (ILR) demonstrated the incapacity of 24-hour and 48-hour Holter monitoring to accurately determine the incidence of cardiac arrhythmias. In patients with HF and CSA, the extended cardiac monitoring by ILR becomes compulsory because in-time interventions could be life saving, but with the absolute lack of solid evidence in this field, there is an acute need for extensive randomized trials to further highlight the potential beneficial effect of ILR monitoring in patients with CSA and HF.

ORIGINAL INVESTIGATION
3.Impact of coronary revascularization on outcomes of transcatheter aortic valve implantation
Bilge Duran Karaduman, Hüseyin Ayhan, Telat Keleş, Engin Bozkurt
doi: 10.14744/AnatolJCardiol.2020.42728  Pages 225 - 235
Arka plan ve Amaç: Koroner revaskülarizasyonun, transkateter kapak implantasyonu (TAVI) öncesi ve sonrası klinik sonuçlar üzerindeki etkisi tartışmalı olmakla beraber, en uygun revaskülarizasyon stratejisi için şu anda yeterli veri bulunmamaktadır. Bu çalışmada, TAVI hastalarında perkütan koroner girişimin (PKG) klinik sonuçlar ve mortalite üzerindeki etkisini sunmayı amaçladık.
Yöntem: Merkezimizde TAVI uygulanan ardışık 526 hastanın retrospektif analizini yaptık ve tıkayıcı koroner arter hastalığı olan 127 hasta çalışmamıza dahil edildi. Hastalar daha sonra iki gruba ayrıldı: revaskülarizasyon yapılan (grup 1) ve revaskülarizasyon yapılmayan grup (grup 2). Gruplar arasındaki prosedürel komplikasyonlar ve uzun dönem tüm nedenlere bağlı ölüm oranları karşılaştırıldı.
Bulgular: Beş yüz yirmi altı hastanın 65’i (%12.3) PKG yapılan grup 1’de ve 62’si (%11.7) revaskülarize edilmeyen grup 2 de idi. VARC-2 kriterlerine göre perikardiyal efüzyon, inme, majör vasküler komplikasyon, majör kanama ve yeni ortaya çıkan aritmileri içeren işlem sonrası komplikasyonlar benzerdi. Kaplan-Meier analizinde sağ kalım eğrileri her iki grupta benzerdi (40.0±2.8 ay; 34.4-45.6,% 95 CI; p=0.959). Bazal syntax skoru, kronik böbrek hastalığı evresi, önceki miyokard enfarktüsü ve başlangıçtaki troponin seviyeleri eşleştirildikten sonra grup 1 için uzun vadeli sağ kalım grup 2'den anlamlı olarak daha iyiydi (p=0.036). Vakaların% 75.4'ünde PKG aşamalı bir işlem olarak TAVI'den 11.0±14.7 gün önce veya sonra gerçekleştirildi. Vakaların %13.8'inde ise PKG, TAVI ile eş zamanlı olarak gerçekleştirildi. Eşzamanlı ve aşamalı PKG grupları arasında hastane içi, 6. ay ve 1. yıl mortalite açısından fark saptanmazken 30. gün mortalitede istatistiksel fark vardı (sırasıyla %11.1, %0, p=0.016).
Sonuç: Bu çalışma revaskülarize edilen ve edilmeyen hastalarda periprosedürel, uzun dönem güvenlik sonuçları ve mortalitede anlamlı bir fark olmadığını göstermektedir. Bununla birlikte, TAVI uygulanan hastalarda ne aşamalı ne de eşzamanlı PKG, olumsuz sonuçlara sahip değildir.
Objective: Although the effect of coronary revascularization on clinical outcomes before and after transcatheter valve implantation (TAVI) is debatable, there is currently insufficient data to determine the most appropriate revascularization strategy. In this study, we present our single-center experience of percutaneous coronary intervention (PCI) and its effect on clinical outcomes and mortality in patients undergoing TAVI.
Methods: We performed a retrospective analysis of 526 consecutive patients at our center, and 127 patients with obstructive coronary artery disease were included in the study. Patients were divided into two groups: the revascularization group (group 1) and the non-revascularization group (group 2). Procedural complications and long-term all-cause mortality rates were compared between the two groups.
Results: Of the 526 patients, group 1 comprised 65 patients (12.3%) who underwent PCI, and group 2 comprised 62 patients (11.7%) who did not undergo revascularization. According to Valve Academic Research Consortium 2 criteria, post-procedural complications, including pericardial effusion, stroke, major vascular complications, major bleeding, and emerging arrhythmias, were similar between the groups. A Kaplan–Meier survival curve analysis showed no significant difference between the revascularization and non-revascularization groups (Overall: 40.0±2.8 month; 95% CI 34.4-45.6 month, p=0.959). After adjustment for basal SYNTAX score, chronic kidney disease stage, previous myocardial infarction, and baseline troponin levels, the long-term survival of group 1 was significantly longer when compared with group 2 (p=0.036). In 75.4% of cases, PCI was performed within 11.0±14.7 days before or after TAVI as a staged procedure. In 13.8% of cases, PCI was performed simultaneously with TAVI. While there was no significant difference in in-hospital, 6-month, and 1-year mortality rates between the simultaneous and staged PCI groups, there was a significant difference in 30-day mortality (11.1% vs. 0%, respectively; p=0.016).
Conclusion: Peri-procedural and long-term safety outcomes and mortality rates are not significantly different between revascularized and non-revascularized patients, and neither staged nor simultaneous PCI have adverse outcomes in patients undergoing TAVI.

4.Characteristics of organ cysts and their association with type A aortic dissection
Yao-Jun Dun, Hong-wei Guo, Yi Chang, Ke Wei, Shu-Ya Fan, Xiao-Gang Sun, Xiang-yang Qian, Cun-tao Yu
doi: 10.14744/AnatolJCardiol.2020.99537  Pages 236 - 242
Objective: We aimed to evaluate the incidence of organ cysts in patients with type A aortic dissection (TAAD) to assess the association between organ cysts and TAAD.
Methods: Between January 2018 and December 2018, all patients with TAAD undergoing aortic surgery at our center were enrolled into the study; patients undergoing isolated coronary artery bypass grafting at our center were selected as the control group. Baseline differences between the 2 groups were adjusted using propensity-score matching. The incidence of organ cysts was compared between the 2 groups in total and matched cohorts.
Results: We enrolled 290 patients with TAAD and 293 patients with coronary artery disease (control group). The incidence of all organ cysts, liver cysts, renal cysts, and other organ cysts, was significantly higher in the TAAD group than in the control group (50.0% vs. 35.5%, p<0.001; 24.5% vs. 10.2%, p<0.001; 33.4% vs. 24.9%, p=0.023; and 6.2% vs. 1.5%, p=0.005; respectively). Among the 191 propensity score–matched patient pairs, the incidence of organ cysts, liver cysts, renal cysts, and other organ cysts was also significantly higher in the TAAD group than in the control group (57.6% vs. 30.9%, p<0.001; 28.8% vs. 11.0%, p<0.001; 39.3% vs. 19.9%, p<0.001; and 8.4% vs. 1.0%, p=0.001; respectively). The incidence of cysts with single-organ and multiple-organ involvement was also significantly higher in the TAAD group than in the control group (34.0% vs. 20.4%, p=0.003; and 23.6% vs. 10.5%, p=0.001).
Conclusion: Our results show a higher incidence of organ cysts in patients with TAAD which is indicative of a common pathogenetic pathway between organ cysts and aortic dissection.

5.DNA and chromosomal damage in peripheral blood lymphocytes in patients with acute coronary syndrome undergoing a coronary angiography
Jovana Tubic Vukajlovic, Ivan Simic, Olivera Milosevic-djordjevic
doi: 10.14744/AnatolJCardiol.2020.39479  Pages 243 - 249
Objective: The aim of the study was to evaluate the DNA and chromosomal damage in peripheral blood lymphocytes (PBLs) of patients with acute coronary syndrome (ACS) and to explore the effect of coronary angiographies in these patients.
Methods: The study included ACS patients who underwent a coronary angiography (CAG) and healthy controls. The ACS sample was divided into two groups: patients with unstable angina pectoris (UAP) and acute myocardial infarction (AMI). The frequency of DNA damage [expressed as genetic damage index (GDI)] was analyzed using the comet assay pre- and post-CAG. Chromosomal aberrations were measured as micronuclei (MNs) frequency using the cytokinesis-block MN (CBMN) assay. Additionally, detailed anamnestic data were taken from the each patient.
Results: Increased levels of DNA and chromosomal damage have been revealed in ACS patients compared to the healthy controls. GDI values were also significantly higher in AMI patients than in UAP patients. A highly significant increase of DNA damage was also observed in all patients post-CAG. There was significantly higher MN frequency and significantly lower nuclear division index (NDI) in AMI patients than in UAP patients’ pre-CAG. After CAG, there was no significant difference in MN frequencies and NDI values between UAP and AMI patients.
Conclusion: Correlated with disease severity, our results showed that AMI patients have higher levels of both DNA and chromosomal damage in PBLs compared to UAP patients. The increased level of genome instability was especially evident post-CAG compared to the observed damage pre-CAG.

6.Clinical and genetic characteristics and course of congenital long QT syndrome in children: A nine-year single-center experience
Yakup Ergül, Gülhan Tunca Şahin, Hasan Candaş Kafalı, Erkut Öztürk, Senem Özgür, Sertaç Haydin, Alper Güzeltaş
doi: 10.14744/AnatolJCardiol.2020.08791  Pages 250 - 257
Giriş: Uzun QT sendromu (LQTS), yaşamı tehdit eden ventriküler aritmiler ve ani ölümle ilişkili kalıtsal aritmi sendromudur. Bu çalışma, Türkiye'deki üçüncü basamak pediatrik kardiyoloji merkezinde LQTS tanısı ile takip edilen çocukların klinik ve genetik özelliklerini ve sonuçlarını bildirmeyi amaçlamaktadır.
Method: Ocak 2011 ile Nisan 2020 tarihlerinde LQTS tanısıyla takip edilen hastalar çalışmaya dahil edildi.
Bulgular: Çalışmaya ortalama yaşı 9,2 ± 4,5 yıl ve ortalama ağırlığı 35,72 ± 18,45 kg olan 145 hasta (76 erkek) dahil edildi. Otuz sekiz hastaya (% 26,2) aile taraması sırasında tanı konuldu. Hastaların önemli bir kısmı başvuru sırasında asemptomatik iken, 15 hasta (% 10.3) kardiak arrest sonrası, 26 hasta da (% 18) senkop nedeniyle araştırılırken tanı aldı. Ortalama Schwartz skoru 4.5 idi. Yüz onyedi hastada patojenik gen mutasyonu tespit edildi. Tüm hastalara beta bloker önerildi. Otuz dört (% 23,4) hastaya intrakardiyak defibrilatör (ICD) implante edildi. Dokuz hastaya (% 6.2) sol veya bilateral kardiyak sempatik denervasyon yapıldı. Ortalama 35.6±25.8 ay takip süresi içinde 5 hasta kaybedildi. Major kardiyak olayla karşılaşmada QTc> 500 ms, T dalga alternansı varlığı, yüksek Schwartz skoru ve Jervell Lange Nielson (JLN) sendromunun önemli bir risk faktörü olduğu gösterilmiştir.
Sonuç: LQTS'nin çeşitli klinik belirtileri vardır. Hastaların semptomları asemptomatik ile ani kardiyak ölüm arasında değişebilmektedir. Klinisyenlerin LQTS tanımadaki farkındalığının artması ile ani kardiyak ölümlerin önüne geçilebilir.
Objective: Long QT syndrome (LQTS) is an inherited primary arrhythmia syndrome associated with life-threatening ventricular arrhythmias and sudden death. This study aimed to report the clinical and genetic characteristics and outcomes of children diagnosed as having LQTS in a tertiary pediatric cardiology center in Turkey.
Methods: This was a retrospective review of pediatric patients diagnosed as having LQTS at our center from January 2011 to April 2020.
Results: A total of 145 patients (76 males) were included, with a mean age of 9.2±4.5 years and a mean weight of 35.7±18.5 kg; 38 (26.2%) were identified as having LQTS during family screening, whereas a significant proportion of patients were asymptomatic at presentation, 15 patients (10.3%) were diagnosed after previous cardiac arrest, and 26 patients (18%) had syncope. The mean Schwartz score was 4.5 points (range, 3–7.5 points). Furthermore, 107 patients (82%) were confirmed to have a pathogenic mutation for LQTS genes. All patients received beta-blockers. Implantable cardioverter-defibrillator insertion was performed in 34 patients (23.4%). Left or bilateral cardiac sympathetic denervation was performed in 9 patients (6.2%). Median follow-up time was 35.6±25.8 months. Five (3.4%) patients died during the follow-up. Statistical analyses of risk factors for major cardiac events revealed that the QTc was >500 ms and that T wave alternans, high Schwartz score, and Jervell and Lange-Nielsen syndrome were strong and significant predictors of cardiac events.
Conclusion: LQTS has a variety of clinical manifestations. Patients’ symptoms ranged between asymptomatic and sudden cardiac death (SCD). By raising the awareness of physicians regarding the disease, SCD might be prevented in the early period.

7.Primary patency and amputation free survival after endovascular management of infrarenal aorta total occlusions
Ender Özgün Çakmak, Münevver Sarı, Zeki Şimşek, Şeyhmus Külahçıoğlu, Ali Karagöz, Çetin Geçmen, Çağrı Kafkas, İbrahim Akın İzgi, Cevat Kırma
doi: 10.14744/AnatolJCardiol.2020.77550  Pages 258 - 265
Amaç: Endovasküler tedavi (EVT), yeni teknik ve teknolojilerin geliştirilmesinden sonra giderek daha fazla kullanılmaktadır. EVT, infrarenal aort tıkanıklıkları için kalıcı erken ve orta vadeli sonuçlar göstermiştir. (IAO). Bununla birlikte, uzun dönem sonuçları ve restenoz prediktörleri hakkında çok az şey bilinmektedir.
Metodlar: We retrospectively analyzed a singlecenter database of 55 consecutive patients (age, 58.8 ± 6.97 years; 67.2% male; 42% critical limb ischemia) undergoing EVT for IAO disease between January 2011 and March 2019. The outcome measures were primary patency rate and amputation free survival calculated by the Kaplan–Meier method. Independent predictors of restenosis were assessed by Cox proportional hazard regression model.
Sonuçlar: 49 hastada (89.1%) teknik başarı elde edildi. Toplamda, 97 stent (65 self-expandable stent, 60 balloon-expandable stent) implante edildi. Takip sırasında (34.5 ± 28 ay), 7 hastada restenoz saptandı. Primer açık kalma oranları 1, 3 ve 5 yıllarında sırasıyla %96, %82 ve %75 idi. Amputasyondan bağımsız sağkalım oranları sırasıyla 1, 3 ve 5 yılda %100, %90 ve %82 idi.
Sonuç: Bu çalışmada, infrarenal aort total oklüzif lezyonların EVT'si için primer açıklık ve amputasyondan bağımsız sağkalımının beş yıllık sonuçları olumlu idi. Demografik, lezyon ve işlem faktörlerinin hiçbiri bağımsız olarak primer açıklık kaybı ile ilişkili bulunmadı.
Objective: Endovascular therapy (EVT) has increasingly been used even after the development of new techniques and technologies. EVT has displayed durable early and mid-term outcomes for infrarenal aorta occlusions (IAO). Nonetheless, little is known regarding their long-term outcomes and predictors of restenosis.
Methods: A total of 55 consecutive patients (age, 58.8±6.97 years; 67.2% male; 42% critical limb ischemia) from a single-center database, undergoing EVT for IAO disease between January 2011 and March 2019 were retrospectively analyzed. The outcome measures were primary patency rate and amputation free survival calculated by the Kaplan–Meier method. Independent predictors of restenosis were assessed by Cox proportional hazard regression model.
Results: In 49 patients (89.1%), technical success was achieved. In total, 190 stents (65 self-expandable stents, 60 balloon-expandable stents) were implanted. During the follow up of 34.5±28 months, 7 patients experienced loss of patency. Primary patency rates were 96%, 82%, and 75% at 1, 3, and 5 years, respectively, and amputation free survival rates were 100%, 90%, and 82% at 1, 3, and 5 years, respectively.
Conclusion: In this study, five-year outcomes of primary patency and amputation free survival for EVT of infrarenal aorta total occlusive lesions were favorable. None of the demographic, lesion, and device factors were independently associated with loss of primary patency.

8.Early- and mid-term results of cryoablation of atrial fibrillation concomitant with robotic mitral valve surgery
Murat Kadan, Emre Kubat, Gökhan Erol, Kubilay Karabacak, Furkan Burak Akyol, Vedat Yıldırım, Cengiz Bolcal, Ufuk Demirkılıç
doi: 10.14744/AnatolJCardiol.2020.81669  Pages 266 - 272
Giriş: Atriyal fibrilasyon (AF) en sık görülen aritmilerden birisi olup, sıklıkla mitral kapak hastalığı ile ilişkilidir. Özellikle mitral kapak cerrahisi esnasında uygulanan cerrahi ablasyon, sinüzal ritmin yeniden tesis edilmesinde önemli bir prosedür olarak bilinmektedir. Bu çalışmada robotik mitral kapak cerrahisi esnasında, kriyoablazyon uygulanan hastalarımızın erken ve orta dönem sonuçlarını sunmayı amaçladık.

Methot: Kasım 2014 ve Ocak 2020 yılları arasında, merkezimizde robotik mitral kapak cerrahisine ek olarak AF kriyoablazyonu uygulanan 34 hastanın verileri retrospektif olarak incelendi. 10 hastada 1 yıldan daha kısa süreli, 14 hastada 1-5 yıl arası, 10 hastada ise 5 yıldan daha uzun süredir AF öyküsü mevcuttu. Çalışmamızın primer sonlanım noktası, postoperatif dönemde AF rekürrensi idi.

Sonuçlar: 32 hastaya mitral kapak replasmanı, 2 hastaya mitral kapak tamiri uygulandı. Ortalama kros klemp süresi 141.8±32.1 dakika, ortalama kardiyopulmoner baypas zamanı 196±25.6 dakika idi. 29 hastada (%85,3) kros klempin kaldırılmasının ardından sinüzal ritm restore edilirken 5 hastada junctional ritm izlendi (%14,7). Hastanede yatış süresi içerisinde bir hasta düşük kalp debisi ve bir hasta hepatorenal sendrom nedeniyle kaybedildi. 24 hasta (%75) sinüzal ritm, 6 hasta (%18,75) AF ve 2 hasta (%6,25) pace ritmi ile taburcu edildiler.

Sonuç: Robotik mitral cerrahisi esnasında uygulanan AF kriyoablazyonu,kabul edilebilir erken ve orta dönem sonuçları ile uygun bir tedavi olarak değerlendirilebilir.
Objective: Atrial fibrillation (AF) is the most common arrhythmia, which is also associated with mitral valve disease. Surgical ablation is still known to be an important procedure in restoring sinus rhythm (SR) concomitant with mitral valve surgery (MVS). In this study, we aimed to pres-ent our early- and mid-term result of AF cryoablation during robotic MVS.
Methods: Between November 2014 and January 2020, total 34 patients who underwent robotic MVS with concomitant AF ablation were ret-rospectively analyzed. Ten patients had a <1 year AF history, 14 had 1–5 years, and 10 had >5 years. The primary end point of the study was postoperative AF recurrence.
Results: Total 32 and 2 patients underwent mitral valve replacement and mitral valve repair, respectively. Mean aortic cross-clamp and cardio-pulmonary bypass times were 141.8±32.1 min and 196±25.6 min, respectively. The SR was restored with the removal of cross-clamp and cardiac junctional rhythm was observed in 29 (85.3%) and 5 (14.7%) patients, respectively. Two in-hospital deaths secondary to low cardiac output and hepatorenal failure were recorded. Among the rest, 24 (75%) patients were in SR, 6 (18.75%) in AF, and 2 (6.25%) in paced rhythm at discharge.
Conclusion: Robotic cryoablation of AF during MVS is a feasible method with favorable early- and mid-term results.

EDITORIAL COMMENT
9.Robotic surgical ablation of atrial fibrillation in mitral valve surgery
Ahmet Rüçhan Akar
doi: 10.14744/AnatolJCardiol.2020.92744  Page 273
Abstract | Full Text PDF

DIAGNOSTIC PUZZLE
10.What is your diagnosis?
Uğur Nadir Karakulak, Sinem Kılıç, Banu Evranos, Ahmet Aydın, Mustafa Yılmaz
doi: 10.5152/AnatolJCardiol.2021.05571  Page 274
Abstract | Full Text PDF

CASE REPORT
11.Stridor serving as a harbinger of the mirror-image right aortic arch carrying three anatomic dispositions contributing to a noosing vascular ring
Meng-Luen Lee, Ming-Sheng Lee, Albert D Yang, Ming-Che Chang, Ying-Cheng Chen
doi: 10.14744/AnatolJCardiol.2020.53327  Pages 275 - 277
Abstract | Full Text PDF | Video

12.Implantation of a leadless pacemaker in a patient after Senning procedure – a case report
Wiktoria Kowalska, Ewa Jedrzejczyk Patej, Marta Jagosz, Zbigniew Kalarus, Beata Sredniawa
doi: 10.14744/AnatolJCardiol.2020.36453  Pages 278 - 279
Abstract | Full Text PDF

13.Severe left ventricular outflow tract obstruction with mitral regurgitation caused by accessory mitral valve tissue in an adult: A case report
Sejla Sehovic, Djani Behram, Merjema Karavdic, Sanko Pandur, Mirsad Kacila
doi: 10.5152/AnatolJCardiol.2021.40088  Pages 280 - 281
Abstract | Full Text PDF

DIAGNOSTIC PUZZLE - ANSWER
14.A stranger in the heart
Uğur Nadir Karakulak, Sinem Kılıç, Banu Evranos, Ahmet Aydın, Mustafa Yılmaz
doi: 10.5152/AnatolJCardiol.2021.05571  Page 282
Abstract | Full Text PDF

E-PAGE ORIGINAL IMAGES
15.Black-pooling sign: A novel intravascular ultrasound imaging marker that predicts stent edge hematoma growth
Yusuke Oba, Hiroshi Funayama, Hayato Shimizu, Masao Takahashi, Kazuomi Kario
doi: 10.14744/AnatolJCardiol.2020.49921  Page E15
Abstract | Full Text PDF | Video

16.A giant pericardial lipoma and left ventricular aneurysm: A rare combination
Yu Zhang, Yuman Li, Qing Lv, Jing Wang, Shenglei Shu, He Li, Li Zhang, Mingxing Xie
doi: 10.14744/AnatolJCardiol.2020.06529  Page E16
Abstract | Full Text PDF | Video

17.Decompression of the left heart chambers via atrial flow regulator: A new insight into heart failure treatment
Uğur Nadir Karakulak, Ergün Barış Kaya, Mehmet Levent Şahiner, Kudret Aytemir
doi: 10.14744/AnatolJCardiol.2020.05949  Pages E17 - E18
Abstract | Full Text PDF