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Yayın Acute myocardial infarction during thrombolysis of mechanical aortic valve thrombosis associated with heparin-induced thrombocytopenia(National Library of Medicine, 2011) Gündüz, Sabahattin; Özkan, Mehmet; Biteker, Murat; Ekşi Duran, Nilüfer; Güneysu, TahsinWe report a case of a 60-year-old man with obstructive aortic prosthetic valve thrombosis (APVT). He was treated with low-dose (25 mg) slow infusion (6 hours) of intravenous tissue plasminogen activator (t-PA), and he suffered acute anterior myocardial infarction (MI) at the fourth hour of t-PA infusion. Infusion was kept on, and coronary reperfusion and successful lysis of APVT were achieved. Intravenous unfractionated heparin (UFH) was then started, however, on the third day following heparin treatment, heparin-induced thrombocytopenia (HIT) was recognized by a drop in the platelet count and rethrombosis of the prosthetic valve. Although no nonheparin anticoagulant was available, intravenous continuous infusion of streptokinase (SKZ) 250,000 U per day was administered for 5 days followed by transition to warfarin therapy. Successful lysis of the APVT was again achieved with this regimen and the patient was discharged after uneventful recovery. The patient remained well at 6 months and 1 year follow-up.Yayın Allergic myocardial infarction in childhood: Kounis syndrome(Springer Nature, 2009) Biteker, Murat; Ekşi Duran, Nilüfer; Sungur Biteker, Funda; Ayyıldız Civan, Hasret; Kaya, Hasan; Gökdeniz, Tayyar; Yıldız, Mustafa; Özkan, MehmetKounis Syndrome was first described by Kounis as "allergic angina syndrome" progressing to "allergic myocardial infarction". This report describes the first children in the literature presented with Kounis syndrome.Yayın Aortic elastic properties in patients with venous thromboembolism(Sage Journals, 2010) Ekşi Duran, Nilüfer; Oğuz, Emrah; Duran, İbrahim; Aykan, Ahmet Çağrı; Ertürk, Emine; Bayram, Zübeyde; Gürsoy, M. Ozan; Biteker, Murat; Karavelioğlu, Yusuf; Kaya, Hakkı; Özkan, MehmetObjectives: The relationship between venous thrombosis (VT) and atherosclerosis is controversial in recent studies. Aortic elastic properties have a predictive value in detecting early stages of atherosclerosis. The aim of this study is to evaluate the relationship between aortic elastic properties and VT. Methods: Elastic properties of aorta in patients with spontaneous VT, without history of known cardiovascular disease and cardiovascular risk factors (n: 31), and in healthy subjects without cardiovascular risk factors (n: 30) were compared. Elastic properties of the aorta were assessed with transthoracic echocardiography. Results: A significant increase in aortic stiffness index (6.5 ± 1.0 versus 6 ± 0.7, P = 0.03) and a significant decrease in aortic strain and aortic distensibility were found in patients with VT compared with healthy subjects (8.4 ± 7 versus 13 ± 8, P = 0.01, 4.9 ± 4.8 versus 6.5 ± 4.4, P = 0.03, respectively). Conclusions: Elastic properties of aorta in patients with spontaneous VT were impaired. These results may support the role of endothelial dysfunction in the pathogenesis of VT.Yayın Aynı hastada tıkayıcı tipte mekanik mitral kapak trombüsü ve sol atriyum trombüsü(Türk Kardiyoloji Derneği, 2008) Ekşi Duran, Nilüfer; Biteker, Murat; Özkan, MehmetMitral darlığı nedeniyle mitral kapak replasmanı uygulanmış 55 yaşında erkek hasta acil servisimize, son üç gündür olan nefes darlığı ve çarpıntı yakınması ile başvurdu. Başvuru anında hastanın fonksiyonel kapasitesi NYHA sınıf IV idi. Tansiyonu 100/85 mmHg, nabzı düzensizdiYayın Broken heart syndrome in a 17-year-old girl(Springer Nature, 2009) Biteker, Murat; Ekşi Duran, Nilüfer; Ayyıldız Civan, Hasret; Gündüz, Sabahattin; Gökdeniz, Tayyar; Kaya, Hasan; Özkan, MehmetBroken heart syndrome is characterized by transient left ventricular dysfunction with chest pain, electrocardiographic changes, and release of myocardial enzymes mimicking acute myocardial infarction. Physical and emotional stress usually precede the onset of symptoms. This dysfunction, known as takotsubo cardiomyopathy (TC), has been observed predominantly in women older than 60 years of age but very rarely reported in younger adults or children. Here we describe a 17-year-old girl with TC.Yayın Broken heart syndrome in an 83-year-old woman(National Library of Medicine, 2008) Biteker, Murat; Ekşi Duran, Nilüfer; Gündüz, Sabahattin; Candan, Özkan; Sungur Biteker, Funda; Gökdeniz, Tayyar; Güler, Ahmet; Özkan, MehmetAn 83?year?old woman was admitted to the emergency department because of severe chest pain that had begun 2 hours before and radiated to the neck and left arm. Except for advanced age, she had no coronary risk factors. Her husband had died that day after 58 years of marriage. On admission, physical examination revealed no pathological findings other than slightly high blood pressure and tachycardia. Her blood pressure was 175/90?mmHg, and heart rate was 110?beats/min. Electrocardiogram showed sinus tachycardia and 2?mm ST elevation in leads I, aVL, and V2 to V6 (Figure 1A). After being given 300?mg of aspirin and 5,000?U of intravenous heparin the patient was taken to the coronary intensive care unit. Transthoracic echocardiography (TTE), performed in the coronary intensive care unit immediately, revealed apical akinesia, midventricular hypokinesia and basal hyperkinesia of the left ventricle, moderate mitral regurgitation with ejection frequency of 30%. To exclude coronary artery disease, coronary angiography was performed, which revealed noncritical coronary plaques in the left anterior descending and circumflex artery. Ventriculography showed apical and midventricular ballooning with basal hyperkinesia (Figure 1B). Chest pain disappeared spontaneously. Cardiac enzyme and troponin levels were high and reached maximal degrees (creatine kinase, 623?U/L; creatine kinase?MB, 98?U/L; troponin I, 4.2??g/L) on the second day. Her hospital course was uneventful. TTE, performed on the seventh day, revealed normal left ventricular systolic function without any segmental wall motion abnormality. Her ejection fraction was 58%, with trace mitral regurgitation. On the seventh day, myocardial perfusion scintigraphy was performed, and there was no sign of ischemia. With these findings, TC was diagnosed, and a consultation with a psychiatrist was recommended. The patient was discharged from the hospital in excellent condition and at a 1?month follow?up visit was doing well.Yayın A case of acute rheumatic fever presenting with syncope due to complete atrioventricular block(KARE Publishing, 2009) Ekşi Duran, Nilüfer; Sönmez, Kenan; Biteker, Murat; Özkan, MehmetCases with acute rheumatic fever (ARF) are usually admitted to cardiology clinics withsigns and symptoms of poliartritis, pericarditis or heart failure. In these cases, the mostly observed electrocardiographic finding is the prolongation of PR interval (1). Rarely, second degree, third degree atrioventricular (AV) block and bundle branch blocks can also happen. In these cases with ARF; syncope, due to complete AV block is very rare and not frequently described. In the present study, we report a case with ARF admitted to our clinic with a history of syncope.Yayın Coronary artery disease in patients with peripheral artery disease(Elsevier, 2010) Ekşi Duran, Nilüfer; Duran, İbrahim; Gürel, Emre; Gündüz, Sebahattin; Göl, Gökhan; Biteker, Murat; Özkan, MehmetObjectives: Peripheral artery disease (PAD) is an atherosclerotic disease associated with cardiovascular risk factors, and with high cardiovascular morbidity and mortality. This study sought to assess the prevalence of angiographic coronary artery disease (CAD), and to determine the predictive value of traditional cardiovascular risk factors on the presence of CAD in patients with PAD of the lower extremities. Methods: In total, 231 patients who presented at hospital complaining of intermittent claudication were included. All patients underwent simultaneous peripheral and cardiac angiography. Age, gender, hypertension, diabetes, smoking, and lipid values were recorded. Results: The coronary angiograms of 64 (28%) patients were within normal limits, and 167 (72%) patients manifested CAD. Logistic regression analysis revealed that hypertension and diabetes were independent predictors for the presence of CAD or PAD. Conclusion: Aggressive treatment of cardiovascular risk factors, especially hypertension and diabetes, in PAD is critically important in reducing mortality and morbidity.Yayın Depicting of a cleft mitral valve by real time three-dimensional transesophageal echocardiography(National Library of Medicine, 2010) Özkan, Mehmet; Kaya, Hasan; Ekşi Duran, Nilüfer; Biteker, Murat; Avcı, Anıl; Yıldız, Mustafa; Tuncer, AltuğWe report the usefulness of real time three-dimensional transesophageal echocardiography in comprehensive delineation of cleft mitral valve. This new technique may be a useful supplement to two-dimensional and three-dimensional transthoracic echocardiography in the assessment of this pathology.Yayın Effect of levosimendan and predictors of recovery in patients with peripartum cardiomyopathy, a randomized clinical trial(Springer Nature, 2011) Biteker, Murat; Ekşi Duran, Nilüfer; Kaya, Hasan; Gündüz, Sabahattin; Tanboğa, Halil İbrahim; Gökdeniz, Tayyar; Kahveci, Gökhan; Akgün, Taylan; Yıldız, Mustafa; Özkan, MehmetBackground Levosimendan is a promising new inodilator agent but its effectiveness in peripartum cardiomyopathy (PPCM) has not been tested in a clinical trial. The authors sought to evaluate the effect of levosimendan therapy and to determine the predictors of clinical outcome in patients with PPCM. Methods and results The authors prospectively randomized 24 consecutive women with PPCM. Twelve patients (control group) were randomized to conventional heart failure therapy and 12 patients (levosimendan group) were randomized to levosimendan in addition to the conventional therapy. Mean follow-up period was 20.9 ± 9 months (ranged 12–38 months). The two groups did not differ in baseline demographic and echocardiographic characteristics. Eleven patients (45.8%) recovered completely (6 in control group and 5 in levosimendan group, p[0.05), 6 died (25%) (3 in control group and 3 in levosimendan group), and 7 (29.1%) were left with persistent left ventricular dysfunction (PLVD) (3 in control group and 4 in levosimendan group, p[0.05). There were significant differences in baseline characteristics between deceased patients and survivors including left ventricular end-diastolic diameter (7.1 ± 0.6 vs. 6.4 ± 0.5 cm, p = 0.031), left ventricular end-systolic diameter (LVESD) (6.4 ± 0.8 vs. 5.5 ± 0.6 cm, p = 0.027), left ventricular ejection fraction (LVEF) (19.7 vs. 27.4%, p = 0.025), and left atrial diameter (4.9 ± 0.3 vs. 4.3 ± 0.4 cm, p = 0.011). Conclusions Addition of levosimendan to conventional therapy did not improve outcome in patients with PPCM. In patients with PLVD or patients who died, LVEF, LVESD and left atrial diameter were worse than those with complete resolution.Yayın Huge prosthetic mitral valve thrombosis in a pregnant woman(The American Heart Association, 2009) Özkan, Mehmet; Biteker, Murat; Ekşi Duran, Nilüfer; Yıldız, MustafaA 42-year-old woman in her 30th week of pregnancy who had undergone a mitral valve replacement with a 29-mm St. Jude Medical mechanical prosthetic valve (St. Jude Medical, St. Paul, Minn) 2 years earlier was referred to our hospital with severe dyspnea. She had a history of irregular and subtherapeutic use of enoxaparin 6000 IU/d until admission. Transthoracic echocardiography revealed a mean diastolic mitral transvalvular gradient of 29 mm Hg, mitral valve area of 0.6 cm2, and a giant thrombus with mobile components on the prosthetic valve (Figure 1; online-only Data Supplement Movie I). In spite of the large prosthetic mitral valve thrombosis, she had no history of thromboembolism. Two-dimensional transesophageal echocardiography revealed an unprecedentedly large thrombus (6 cm2 in area) appended to the mitral valve that was restricting the movement of 1 of the leaflets (Figure 2; online-only Data Supplement Movie II). Real-time 3-dimensional transesophageal echocardiography demonstrated restriction of 1 of the leaflets with a thrombus located on the left atrial side of the mitral valve (Figure 3; online-only Data Supplement Movie III). After the patient was given a low-dose (25 mg), slow-infusion (6 hours) tissue plasminogen activator without bolus administration 3 times (for a total of 75 mg), 3-dimensional transesophageal echocardiography showed complete thrombolysis (Figure 4; online-only Data Supplement Movie IV). The mean transprosthetic mitral valve gradient decreased to 4 mm Hg, and mitral valve area increased to 2.7 cm2.Yayın Kounis syndrome secondary to amoxicillin/clavulanic acid use in a child(Elsevier, 2009) Biteker, Murat; Ekşi Duran, Nilüfer; Sungur Biteker, Funda; Ertürk, Emre; Çağrı Aykan, Ahmet; Ayyıldız Civan, Hasret; Özkan, MehmetThe concurrence of acute coronary syndromes with allergic or hypersensitivity as well as with anaphylactic or anaphylactoid reactions is increasingly encountered in clinical practice and there are several reports associating mast cell activation with acute cardiovascular events in adults. It was first described by Kounis as “allergic angina syndrome” progressing to “allergic myocardial infarction”. The main mechanism proposed is the vasospasm of coronary arteries. This condition has not been described in childhood. We present a 13-year-old boy, admitted to our hospital with thoracic pain, 30 min after the ingestion of an oral dose of 500 mg of amoxicillin/clavulanic acid.Yayın Kounis syndrome secondary to cefuroxime-axetil use in an octogenarian(National Library of Medicine, 2008) Biteker, Murat; Ekşi Duran, Nilüfer; Sungur Biteker, Funda; Gündüz, Sabahattin; Gökdeniz, Tayyar; Kaya, Hasan; Astarcıoğlu, Mehmet Ali; Özkan, MehmetA 90-year-old man who had been hospitalized for urinary tract infection developed chest pain and pruritic skin rashes. His complaints had started approximately 10 minutes after intramuscular injection of 750 mg of cefuroxime-axetil. His physical examination was normal upon admission, and his electrocardiogram showed ST segment elevations in leads II, III, aVF, V4, V5, and V6 (Figure 1). He had no history of coronary artery disease, diabetes mellitus, hypertension, or hyperlipidemia. Transthoracic echocardiography, performed in the coronary intensive care unit, revealed inferior wall hypokinesia. Complete blood count and liver and kidney function tests were normal except for mild leukocytosis. Coronary angiography performed to exclude coronary artery disease revealed noncritical coronary plaques in the left anterior descending and circumflex artery. Troponin-I estimated 4 hours after admission was 4 ng/mL (reference: 0–0.1 ng/mL) and rose to 22 ng/mL. Creatine kinase-MB fraction estimated 4 hours after admission was 42 U/L (reference: 0–25 U/L) and rose to 85 U/L on the second day. Total immunoglobulin E estimated on arrival was 54 IU/mL (reference: 0–100), and serum tryptase was 43.5 mg/L (reference: 5.6–13.5 mg/L). Subsequent daily estimations of serum tryptase were within normal limits. The patient was diagnosed to have Kounis syndrome type I variant, secondary to cefuroxime-axetil. He was treated with oral antihistamines and 8 mg of prednisolone every 6 hours for 5 days. Cefuroxime-axetil was stopped, and he was treated with levofloxacin for urinary tract infection. Five days later, the repeated cardiac markers were within normal limits, with resolution of electrocardiographic abnormalities and inferior wall motion echocardiographic changes. The man was discharged from hospital in excellent condition and was doing well at a 3-week follow-up visit.Yayın Kounis syndrome: first series in Turkish patients(KARE Publishing, 2009) Biteker, Murat; Ekşi Duran, Nilüfer; Biteker, Funda; Ayyıldız Civan, Haster; Gündüz, Sabahattin; Gökdeniz, Tayyar; Kaya, Hasan; Özkan, MehmetAfter the first report of acute myocardial infarction during a prolonged allergic reaction to penicillin was published in 1950 (1), the concurrence of allergic reactions and acute coronary syndromes called Kounis syndrome (KS) has gained acceptance as a new cause of coronary artery spasm (1-3). Kounis Syndrome was firstly described in 1991 as “the allergic angina syndrome” which could progress to acute myocardial infarction, which was named “allergic myocardial infarction” (2-4).Yayın Multiple spontaneous coronary artery dissection associated with Trousseau's syndrome(National Library of Medicine, 2010) Karabay, Can Yücel; Biteker, Murat; Zehir, Regayip; Bezgin, Tahir; Tanboğa, Halil; Mustafa Can, Mehmet; Güler, Ahmet; Ekşi Duran, Nilüfer; Özkan, MehmetSpontaneous coronary artery dissection (SCAD) remains a rare cause of acute coronary syndrome. SCAD has been observed in three groups of patients: those with coronary atherosclerosis, women in the peripartum period, and an idiopathic group. SCAD may also be associated with some other conditions. Herein, we present a 57 year-old man who developed SCAD concomitant with Trousseau's syndrome secondary to colon adenocarcinoma.Yayın Predictors of prognosis in patients with peripartum cardiomyopathy(Wiley, 2008) Ekşi Duran, Nilüfer; Gürses, Hacı; Duran, İbrahim; Biteker, Murat; Özkan, MehmetObjectives: To evaluate the long-term follow-up results of patients with peripartum cardiomyopathy and assess the echocardiographic findings relating to prognosis at time of diagnosis. Methods: Thirty-three patients diagnosed with peripartum cardiomyopathy and hospitalized between 1995 and 2007 were analyzed. Initial echocardiographic data were recorded and long-term clinical status was evaluated. Results: Eight (24%) patients recovered completely, 10 (30%) died, 2 (6%) underwent heart transplants, and 13 (39%) were left with persistent left ventricular dysfunction. Cut-off values for initial left ventricular end-systolic diameter (< or =5.5 cm) and left ventricular ejection fraction (>27%) were obtained from patients who had completely recovered. Conclusion: Cut-off values for initial left ventricular ejection fraction of >27% and left ventricular end-systolic diameter of < or =5.5 cm may predict recovery of left ventricle function.Yayın Prosthetic mitral valve thrombosis demonstrated by real-time 3D transesophageal echocardiography(Türk Kardiyoloji Derneği, 2009) Özkan, Mehmet; Kaya, Hasan; Biteker, Murat; Ekşi Duran, NilüferA 46-year-old man presented with dyspnea four years after mitral valve replacement. The INR was 1.2 on presentation. Cardiac auscultation revealed loss of valve sounds. On transthoracic echocardiography, the mean diastolic mitral transvalvular gradient was 20 mmHg and mitral valve area was 0.7 cm2 (Fig. A).Yayın Successful treatment of massive pulmonary embolism in a pregnant woman, with low-dose, slow infusion of tissue plasminogen activator(Türk Kardiyoloji Derneği, 2010) Biteker, Murat; Ekşi Duran, Nilüfer; Özkan, MehmetPulmonary embolism (PE) is an important cause of morbidity and mortality during pregnancy. A 21-year-old pregnant woman presented with chest pain and progressive shortness of breath at 35 weeks of gestation. Her respiratory rate was 26 breaths/min. Electrocardiography showed sinus tachycardia and nonspecific ST-T changes. Her plasma D-dimer level was elevated (1,325 ng/ml). Transthoracic echocardiography revealed enlargement of the right ventricle and a large, highly mobile thrombus in the right atrium moving during diastole into the right ventricle. Doppler ultrasonography of the lower extremities showed bilateral acute deep femoral vein thrombosis. Following the diagnosis of right heart thrombosis with massive PE, low-dose and prolonged infusion of tissue-type plasminogen activator (25 mg in three hours) was administered. Echocardiography performed six hours after thrombolysis showed a significant decrease in the right ventricular size and complete lysis of the thrombus in the right heart. Thrombosis risk panel studies showed factor V Leiden homozygote mutation. A live newborn was delivered by cesarean section at 37 weeks of gestation. No complications were seen during a 6-month follow-up.Yayın Takotsubo cardiomyopathy mimicking acute high lateral myocardial infarction(KARE Publishing, 2010) Biteker, Murat; Ekşi Duran, Nilüfer; Gökdeniz, Tayyar; Gündüz, Sabahattin; Güler, Ahmet; Kaya, Hasan; Yıldız, Mustafa; Özkan, MehmetA 47-year-old-woman was admitted to emergency department because of severe chest pain of an one hour in duration. The patient had no coronary risk factors. As a remarkable fact, her son had died that day. On admission, physical examination revealed no pathological findings. Electrocardiogram (ECG) showed 1 mm ST elevation in leads I and aVL.Yayın Thrombolysis of an acute prosthetic mitral valve thrombosis presented with cardiogenic shock under the guidance of continuous transoesophageal monitoring(National Library of Medicine, 2009) Biteker, Murat; Ekşi Duran, Nilüfer; Gündüz, Sabahattin; Gökdeniz, Tayyar; Kaya, Hasan; Ayhan, Ahmet Çağrı; Özkan, MehmetThrombotic occlusion of prosthetic valves continues to be an uncommon but serious complication. Intravenous thrombolytic treatment has been proposed as an alternative to surgical intervention. Due to the lack of a generally accepted standard regimen, various infusion protocols and thrombolytic doses were used for the management of prosthetic heart valve thrombosis. However, rapid thrombolytic infusion, especially in the presence of large thrombus, may increase the risk of embolization. Continuous transoesophageal echocardiography may provide monitoring the efficacy of thrombolysis especially in critically ill patients.
