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BACKGROUND: Numerous studies show that percutaneous coronary intervention has no clinical benefit in patients with total occlusion. Both regional and global left ventricle (LV) functions may be evaluated in detail by strain (S) and strain rate (SR) echocardiography. The purpose of this study is to evaluate whether S and SR echocardiography may be used to determine the total occlusion. METHOD: Sixty stable patients who have total or subtotal occlusion in the infarct-related left anterior descending artery were enrolled (Total occlusion group: 35 and subtotal occlusion group: 25 patients). In all patients, LV longitudinal S and SR data were obtained from total 14 segments. RESULTS: S values of middle and apical segments of LV were significantly lower in the total occlusion groups. In SR analysis, middle and apical values of all walls were significantly different between the groups. The total SR of the middle and apical segments was significantly lower in the total occlusion group (respectively, total SR in middle segments: -3.4 ± 0.8% vs. -4.6 ± 1.0%, P < 0.00001 and total SR in apical segments: -1.7 ± 0.5% vs. -2.8 ± 0.6%, P = 0.001). The total SR values of four walls were also significantly lower in the total occlusion group (-10.3 ± 2.0% vs. -13 ± 3.1%, P < 0.0001). For predicting total occlusion, the highest sensitivity levels (84%) were obtained in SR of middle-anterior segment. SR of middle-septum and middle-lateral segments has the highest specificity levels (86%). CONCLUSION: Total occlusion in stable patients with acute coronary syndrome has an unfavorable effect on the LV regional and global functions. Patients with total occlusion may be identified by S and SR echocardiography.

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BACKGROUND: Large randomized studies revealed that percutaneous coronary intervention has no clinical benefit in patients with total occlusion. The purpose of this study is to evaluate left ventricular remodelling after PCI for total and subtotal infarct-related left anterior desending artery in stable patients who have not received trombolytic theraphy. METHODS: Sixty stable patients with subacute anterior myocardial infarction who have total or subtotal occlusion in the infarct-related left anterior descending artery were enrolled the study (20 patient in the total-medical group, 20 patient in the total-PCI group and 20 patient in the subtotal-PCI group). All patients' left ventricular diameters, volumes and ejection fractions measured at admission and after a month. RESULTS: The necrotic segment number in scintigraphy were similar in three groups. In the total-PCI group, there were significant increases in left ventricular diastolic diameter, left ventricular end-diastolic volume and left ventricular end-systolic volume at first month. A borderline significant increase was observed in LVEDV in the total-medical group at first month. No significant difference was seen in all echocardiographic parameters in the subtotal-PCI group at a month after discharge. The percentage of increase in LVEDV was significantly higher and the percentage of increase in LVESV was borderline significantly higher in the total-PCI group than the other groups. CONCLUSIONS: In stable patients, PCI for total occlusion in the subacute phase of anterior MI causes an increase in LV remodeling. Nevertheless PCI for subtotal occlusion in the subacute phase of anterior MI may prevent LV remodeling.

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Acute myocardial infarction is a rare event in pregnant patients. Mechanical valves are naturally thrombogenic and require careful anticoagulation. Pregnancy produces a hypercoagulable situation and necessitates close follow-up in pregnant patients with mechanical heart valves. We present a 34-year-old pregnant woman who had mitral and aortic valve prosthesis. She developed resistant pulmonary oedema in the post-partum period after myocardial infarction. Oxytocin was used in this patient to induce midterm labour and prevent post-partum bleeding. Issues surrounding management of pulmonary oedema and use of oxytocin therapy during pregnancy are discussed. We emphasize the need for awareness of this condition and call attention to the risk of pulmonary oedema during labour.

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INTRODUCTION: Fatty acid-binding protein (FABP) is an independent predictor of cardiac events. However, the relation between increasing FABP and coronary atherosclerosis is unknown. We have investigated the relation between FABP and angiographic properties of coronary atherosclerosis in patients with acute coronary syndrome (ACS). METHODS: The study population consisted of 93 patients with ACS (mean age: 56±10 years). Patients presenting to the emergency department within 2 h after onset of anginal symptoms were enrolled in the study. FABP was measured at second, fourth and sixth hours of chest pain. Cut-off FABP was accepted as 1.9 ng/ml. Coronary atherosclerosis was assessed with diseased vessel number (≥50 and ≥70% luminal narrowing), Gensini and extent scores. RESULTS: Median FABP-2 was 2.9 ng/ml (interquartile range: 1.6-10.4). Peak FABP was measured at fourth hour [median: 35.0 ng/ml (interquartile range: 2-77)]. There was a nonsignificant relation between angiographic findings and FABP-2. At fourth hour, Gensini, extent score and diseased vessel number were significantly higher above the cut-off level of FABP-4 (Gensini score: 3.7±3.4 vs. 6.2±3.4, P=0.005; extent score: 11.1±10 vs. 22.3±19.2, P=0.007; diseased vessel: 0.7±0.6 vs. 1.6±1.0, P=0.003, respectively). The sensitivity of FABP-2 for at least 50% lesion was 70%. The highest sensitivity was obtained at fourth hour (85% for ≥50% and 88% for ≥70% lesions). The sensitivity and positive predictive values for revascularization were 70 and 77% for FABP-2, 89 and 80% for FABP-4 and 89 and 81% for FABP-6. CONCLUSION: FABP levels are closely related with angiographic properties of patients with ACS. FABP may be an early and important marker for predicting the coronary anatomy and decision of treatment.

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We report the case of a 38-year-old man with a long-standing history of a small ventricular septal defect presented with chest pain. Electrocardiography revealed sinus rhythm, ST-segment elevation in leads V1-6. The chest X-ray showed mild cardiomegaly. He underwent cardiac catheterisation laboratory to primary coronary angioplasty. Coronary angiography showed normal coronary arteries. Aortic root angiography revealed type A aortic dissection. Transthoracic and transesophageal echocardiography showed aortic dissection in ascending aorta and a perimembranous ventricular septal defect. Thoracoabdominal CT angiography confirmed the aortic dissection before the surgery. The patient underwent cardiac surgery immediately. The ventricular septal defect and aortic dissection were repaired successfully. The postoperative recovery was uneventful and he has thus far remained asymptomatic at 6 months' follow-up.

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OBJECTIVES: Increased platelet activation plays an important role in the development of atherosclerosis. Mean platelet volume (MPV) is a determinant of platelet activation. In our study, we aimed to determine whether MPV levels are elevated in non-dipper patients compared with dippers and healthy controls. In addition, we tried to find out if MPV levels are correlated with blood pressure measurements in hypertensive patients. METHODS: This cross-sectional study included 56 hypertensive patients; 27 age- and sex-matched healthy volunteers were enrolled to study as a control subjects. Ambulatory blood pressure monitoring was performed for all patients. Hypertensive patients were divided into two groups: 28 dipper patients (10 male, mean age 51 +/-8 years) and 28 non-dipper patients (11 male, mean age 53+/-10 years). MPV was measured in a blood sample collected in EDTA tubes and was also used for whole blood counts in all patients. RESULTS: In non-dipper patients, 24-h systolic blood pressure (141.5+/-10.21 vs 132.3+/-7.7 mmHg, p<0.001), 24-h diastolic blood pressure (88.2+/-8.5 vs 81.0+/-8.2 mmHg, p<0.01) and 24-h average blood pressure (105.7+/-8.5 vs 97.7+/-7.4 mmHg, p<0.001) are significantly higher than dippers. Whereas daytime measurements were similar between dippers and non-dippers, there was a significant difference between each group during night-time measurements (night-time systolic 137.1 +/-11.0 vs 120.2+/-8.0 mmHg, p<0.001; night-time diastolic 85.3+/-8.0 vs 72.8+/-7.9 mmHg, p<0.001). Non-dipper patients (9.61 +/-0.42 fl) demonstrated higher levels of MPV compared with dippers (9.24+/-0.35 fl) and normotensives (8.87+/-0.33 fl) (p<0.001 and p<0.001, respectively). There was significant correlation between MPV and ambulatory diastolic and systolic blood pressure in non-dipper hypertensives. CONCLUSION: Our results suggest that MPV, a determinant of platelet activation, has a positively correlation with blood pressure and elevated in non-dipper compared with dippers and controls. Increased platelet activation could contribute to increase the atherosclerotic risk in non-dipper patients compared with dippers.

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OBJECTIVES: Data on adult congenital heart diseases (CHD) are limited in Turkey. We evaluated the types and clinical features of CHDs in adult patients followed-up in our center. STUDY DESIGN: This study included 200 adult patients (age >16 years) who were diagnosed as having CHD in our clinic between April 2006 and January 2009. The patients were evaluated in three groups based on the complexity of adult CHD (simple, moderate, or great) according to the most recent ACC/AHA guidelines. RESULTS: There were 121 females (60.5%) and 79 males (39.5%). The mean age was 34.7+/-13.4 years (range 16 to 75 years) and female-to-male ratio was 1.53. The mean age was 32.8+/-14.0 years in males, and 36.0+/-12.9 in females. Nearly half of the patients were in the age groups of 20-29 years (n=46, 23%) and 30-39 years (n=49, 24.5%). According to the ACC/AHA criteria, 145 patients (72.5%) had simple CHD, 34 patients (17%) had moderate CHD, and 21 patients (10.5%) had severe-complex CHD. The mean age tended to decrease as the severity of CHD increased (35.7+/-13.7, 33.2+/-12.4, and 30.5+/-12.2 years, respectively). The most common adult CHD was atrial septal defect (n=105, 52.5%), followed by ventricular septal defect (n=34, 17%), Ebstein's anomaly (n=7, 3.5%), and Eisenmenger's syndrome (n=6, 3%). Aortic coarctation, transposition of the great vessels, patent foramen ovale, pulmonary stenosis, and aortic valve disease showed equal distribution with five patients (2.5%). CONCLUSION: In our study, atrial and ventricular septal defects accounted for the majority of CHDs in adult patients (69.5%). Multicenter studies are required to determine the incidence of CHD among adult population in Turkey.

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INTRODUCTION: Endothelial dysfunction plays a crucial role in the process of atherosclerotic diseases and has been accepted as an early stage of atherosclerosis. Carotid intima-media-thickness (CIMT) and flow-mediated-dilatation (FMD) of the brachial artery have been recommended as noninvasive methods to assess endothelial structure and function. Angiographic properties of patients with acute coronary syndrome (ACS) are closely associated with cardiovascular events. In this study, we investigated the relation of atherosclerotic properties of coronary, brachial and carotid arteries with CIMT, FMD and coronary angiography in patients with ACS. METHODS: We enrolled 133 patients who were diagnosed with ACS into this study. Exclusion criteria were known coronary artery disease, diabetes mellitus and hypertension. Coronary angiography, CIMT and FMD were measured in all patients. The numbers of major stenotic coronary vessels with > or = 50% or > or = 70% were defined as diseased vessel. Gensini score was used to evaluate the severity of atherosclerosis. Morphologic properties of stenotic lesion were defined. Cutoff levels were 7% for FMD and 0.9 mm for CIMT. RESULTS: Mean age was 59.7 + or - 11.8 years. FMD, CIMT and Gensini score were 8.3 + or - 5.9%, 0.80 + or - 0.19 mm and 7.8 + or - 3.5, respectively. Only 44% of patients with ACS had impaired FMD. Gensini score, number of diseased vessels and number of critical lesions were higher in patients with impaired FMD. (Gensini: 8.7 + or - 3.6 vs. 7.0 + or - 3.1, p = 0.009, diseased vessels: 2.7 + or - 0.4 vs. 2.3 + or - 0.7, p < 0.0001, critical lesions: 3.0 + or - 2.1 vs. 2.2 + or - 1.4, p = 0.02). Increased CIMT was found in only 33% of patients. Gensini score and number of diseased vessels were significantly higher in patients with increased CIMT. Significant but weak correlations were found between CIMT, FMD and angiographic severity of coronary atherosclerosis. Angiographic properties and lesion morphology were similar between CIMT and FMD groups. CONCLUSION: There appears to be a relationship between CIMT, FMD and severity of coronary atherosclerosis in patients with ACS. However, in patients with ACS, morphologic properties of stenotic lesions are not associated with CIMT and FMD in brachial artery.

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The study aimed to investigate the intermediate-term effects of transcatheter atrial septal defect (ASD) closure on cardiac remodeling in children and adult patients. Between December 2003 and February 2009, 117 patients (48 males, 50 adults) underwent transcatheter ASD closure with the Amplatzer septal occluder (ASO). The mean age of the patients was 15 years, and the mean follow-up period was 25.9 +/- 12.4 months. New York Heart Association (NYHA) class, electrocardiographic parameters, and transthoracic echocardiographic (TTE) examination were evaluated before the ASD closure, then 1 day, 1 month, 6 months, 12 months, and yearly afterward. Transcatheter ASD closure was successfully performed for 112 (96%) of the 117 patients. The mean ASD diameter measured by transesophageal echocardiography (TEE) was 14.0 +/- 4.2 mm, and the mean diameter stretched with a sizing balloon was 16.6 +/- 4.8 mm. The mean size of the implanted device was 18.6 +/- 4.9 mm. The Qp/Qs ratio was 2.2 +/- 0.8. The mean systolic pulmonary artery pressure was 40 +/- 10 mmHg. At the end of the mean follow-up period of 2 years, the indexed right ventricular (RV) end-diastolic diameter had decreased from 36 +/- 5 to 30 +/- 5 mm/m(2) (p = 0.005), and the indexed left ventricular (LV) end-diastolic diameter had increased from 33 +/- 5 to 37 +/- 6 mm/m(2) (p = 0.001), resulting in an RV/LV ratio decreased from 1.1 +/- 0.2 to 0.8 +/- 0.2 (p = 0.001). The New York Heart Association (NYHA) functional capacity of the patients was improved significantly 24 months after ASD closure (1.9 +/- 0.5 to 1.3 +/- 0.5; p = 0.001). At the 2-year follow up electrocardiographic examination, the P maximum had decreased from 128 +/- 15 to 102 +/- 12 ms (p = 0.001), the P dispersion had decreased from 48 +/- 11 to 36 +/- 9 ms (p = 0.001), and the QT dispersion had decreased from 66 +/- 11 to 54 +/- 8 ms (p = 0.001). Five of six patients experienced resolution of their preclosure arrhythmias, whereas the remaining patient continued to have paroxysmal atrial fibrillation. A new arrhythmia (supraventricular tachycardia) developed in one patient and was well controlled medically. Transcatheter ASD closure leads to a significant improvement in clinical status and heart cavity dimensions in adults and children, as shown by intermediate-term follow-up evaluation. Transcatheter ASD closure can reverse electrical and mechanical changes in atrial myocardium, resulting in a subsequent reduction in P maximum and P dispersion times.

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OBJECTIVE: Non-dipper hypertensives had about three times the risk of atherosclerotic events than hypertensives whose blood pressure was >10% lower at night compared to daytime (dippers). Platelet activation and inflammatory response may derive from most atherosclerotic events. Mean platelet volume (MPV) is a determinant of platelet activation and high sensitive C-reactive protein (hs-CRP) is the best candidate assay to identify and monitor the inflammatory response. We aimed to determine whether MPV and hs-CRP levels are elevated in non-dipper patients compared to dippers and healthy controls. In addition, we tried to find out if MPV and CRP are related to each other or not in non-dipper hypertensives. METHOD: The total 126 patients study group included 86 patients with hypertension and 40 healthy subjects (16 male, mean age; 51+/-4) as control. Ambulatory blood pressure monitoring was performed for all patients. Hypertensive patients were divided into two groups; 46 dipper patients (18 male, mean age; 50+/-9) and 40 non-dipper patients (17 male, mean age; 53+/-11). Clinical baseline characteristics were similar between groups. We measured mean platelet volume in a blood sample collected in EDTA tubes and high-sensitive CRP was measured by using BN2 model nephlometer. RESULTS: Non-dipper patients demonstrated higher levels of MPV compared to dippers and normotensives (9.72+/-0.52 fl vs 9.38+/-0.33 fl and 8.92+/-0.42 fl, p<0.05, respectively). High-sensitive CRP levels were also significantly higher in non-dippers compared to dippers and normotensives (4.9+/-1.7mg/l vs 3.8+/-1.5mg/l and 2.7+/-0.8mg/l, p<0.05, respectively). There was significant positive correlation between MPV and CRP levels (p=0.002, r=0.482) in non-dipper hypertensives. CONCLUSION: Our results suggest that patients with non-dipping tend to have increased platelet activation and inflammatory response. Increased platelet activation and inflammatory response could contribute to increase the atherosclerotic risk in non-dipper patients compared to dippers.

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OBJECTIVES: Lipid levels of most patients receiving antilipidemic therapy are not under control as proposed by the guidelines. We evaluated adherence to statin therapy and LDL cholesterol goal attainment in type 2 diabetic and secondary prevention patients. STUDY DESIGN: A total of 194 patients (131 men, 63 women; mean age 57 ± 11 years) who had been on statin therapy for at least a year for a target LDL cholesterol level of <100 mg/dl were administered a two-part questionnaire. The first part inquired demographic and clinical characteristics, duration of hyperlipidemia, referral to a dietician, risk factors and, if present, the reasons for drug discontinuation. The second part consisted of 23 questions (total score 30) inquiring the knowledge levels of patients about hypercholesterolemia. RESULTS: There were 61 primary (31.4%, diabetics) and 133 secondary (68.6%) prevention patients. The mean LDL level was 122.6 ± 28.7 mg/dl. The incidence of attaining target LDL level was only 23.7% (n=46), being lower in diabetics compared to secondary prevention patients (6.6% vs. 31.6, p<0.0001). The mean knowledge score was 18.2 ± 5. When the threshold score was taken as 18 (median), attainment of the target LDL level was significantly higher in patients having a score of ≥ 18 (32%) compared to those with a lower score (14.9%). There were 77 patients (40%) who sought dietician counseling. Patients with a high school or higher education and those with dietician counseling had higher knowledge scores compared to those with a lower education level and without dietician counseling (p<0.0001). Intermittent drug discontinuation was seen in 109 patients (56.2%), the most common reason being decrease in cholesterol levels to normal (35%). CONCLUSION: Target LDL level was achieved in only about 24%. As the knowledge on hypercholesterolemia accrues, the success rate of LDL cholesterol goal attainment increases.

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Microalbuminuria, considered a marker for systemic vascular disease, is a significant predictor of increased risk for cardiovascular morbidity and mortality in the general population. The relationship between microalbuminuria and cardiovascular disease is unknown. The aim of this study is to examine the association between microalbuminuria and coronary collateral vessel (CCV) development in nondiabetic and nonhypertensive patients with unstable coronary artery disease (USCAD). One hundred and six patients that had USCAD without hypertension and diabetes participated in the study. Microalbuminuria was assessed by radioimmunoassay in 24-h urine collections performed on the first day, and coronary angiography was performed 2-4 days after admissions. In total, 26 patients (mean age 56+/-14 years) had the criteria of the microalbuminuria group and 80 patients with normoalbuminuria (mean age 59+/-11 years), who had one or more diseased vessels with 80% or more stenosis, were included in the control group. The CCVs are graded according to the Rentrop scoring system and a Rentrop grade >or=1 was accepted as CCV development. CCV development was detected in eight (23%) of 26 patients in the microalbuminuria group and in 53 (74%) of 80 patients in the normoalbuminuria group. CCV development in the patients in the normoalbuminuria group was significantly different from that of the patients in the microalbuminuria group (r = -0.15, P = 0.006). In conclusion, these findings suggest that CCV development is poorer in the microalbuminuria group than the normoalbuminuria group. This study shows that in patients with USCAD, microalbuminuria, which is related to systemic vascular disease, affects CCV development negatively.

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Paradoxical embolism across a patent foramen ovale (PFO) is a rare clinical entity and the thrombus is rarely caught passing through a PFO. A 65-year-old woman presented with dyspnea and pleuritic chest pain. Lower extremity venous Doppler ultrasound showed bilaterally extensive thrombosis at deep veins. Transthoracic echocardiographic examination showed two masses in both left and right atriums. In transesophageal echocardiography (TEE) interatrial septum was thin and aneurysmatic and a thrombus wedged through a patent foramen ovale and lodged in both atriums was demonstrated. We considered this mass as a thrombus crossing through a patent foramen ovale. He refused surgery and during anticoagulation therapy the patient had brachial artery embolism. Embolectomy material was reported as a thrombus.

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OBJECTIVES: We evaluated short-term results of transcatheter closure of secundum atrial septal defects (ASD) with the Amplatzer septal occluder (ASO) in adults. STUDY DESIGN: The study included 12 patients (6 males, 6 females; mean age 31+/-9 years; range 17 to 54 years) who underwent transcatheter ASD closure with the ASO device. Prior to the procedure, the mean pulmonary to systemic flow ratio was 1.9+/-0.3 (range 1.5 to 2.6). The mean ASD diameter measured by transesophageal echocardiography was 13.9+/-2.8 mm, the mean stretched diameter of ASD measured by balloon sizing was 15.8+/-3.4 mm, and the mean ASO device diameter was 17.3+/-4.7 mm. The patients were evaluated before and six months after the procedure by echocardiography, electrocardiography, and the New York Heart Association (NYHA) functional classification. RESULTS: Transcatheter ASD closure was successfully performed in 11 patients (91.7%). The mean procedure time was 72 minutes. There was no residual shunt at six months after closure. No serious complications occurred during the procedure and within a mean follow-up of 11.6+/-2.3 months. Echocardiographic examination at six months showed significant decreases in right ventricular end-diastolic diameter (VEDD) (p=0.007), right/left VEDD ratio (0.003), systolic pulmonary artery pressure (p=0.017), and significant increases in left ventricular ejection fraction (p=0.014) and left VEDD (p=0.005). There were significant decreases in maximum (p=0.003) and minimum (p=0.006) P-wave durations, and P-wave dispersion (p=0.028). The NYHA functional capacity improved significantly from 1.8+/-0.8 to 1.3+/-0.5 (p=0.014). CONCLUSION: Transcatheter closure of secundum ASD with the ASO device is a safe and effective method in adult patients, resulting in significant improvement in clinical symptoms and cardiac dimensions.

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BACKGROUND: B-type natriuretic peptide (BNP) is secreted from the ventricles in response to volume expansion and pressure overload. We aimed to investigate plasma BNP levels in inferior myocardial infarction (MI) with and without right ventricular MI (RVMI). METHODS: We enrolled 49 patients (mean age: 60+/-10 years, 45 males) who were admitted with first acute inferior MI. Sixteen patients (mean age: 58+/-10 years, 15 males) had also RVMI. The BNP levels were measured at admission. All patients underwent echocardiographic examination in the first day of hospitalization. Receiver-operating characteristic curve was obtained for prediction of inferior MI with RVMI. RESULTS: Inferior MI with RVMI had lower RV fractional area change (36+/-14% vs. 48+/-15%, P=0.03) and right ventricle lateral annulus S velocity (10.6+/-1.9 m/s, 12.2+/-2.6 m/s, P=0.02). The BNP levels were higher in inferior MI with RVMI than isolated inferior MI (75+/-44 pg/ml vs. 32+/-24 pg/ml, P=0.001). On the basis of the receiver-operating characteristic analysis, the cutoff value of BNP concentration >46 pg/ml provided the best discrimination of patients with and without RVMI (sensitivity 76%, specificity 88%) with positive and negative predictive values of 92 and 63%, respectively. CONCLUSION: Plasma BNP levels are higher in inferior MI with RVMI than isolated inferior MI. RV involvement may be suspected when BNP levels are higher than 46 pg/ml in inferior MI.

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OBJECTIVE: In this study, we tested in patients with metabolic syndrome whether allopurinol through decreasing oxidative stress improves endothelial function, and ameliorates inflammatory state represented by markers of myeloperoxidase, C-reactive protein (CRP) and fibrinogen. METHODS: In a randomized, double-blind fashion; subjects with metabolic syndrome were treated with allopurinol (n = 28) or placebo (n = 22) for one month. Before and after treatment, blood samples were collected and the flow-mediated dilation (FMD) and isosorbide dinitrate (ISDN)-mediated dilation of the brachial artery were performed. RESULTS: Baseline clinical characteristics of the allopurinol and placebo groups demonstrated no differences in terms of clinical characteristics, endothelial function and inflammatory markers. After the treatment with allopurinol, FMD was increased from 8.0 +/- 0.5 % to 11.8 +/- 0.6% (P < 0.01), but there were no change in the placebo group. In both groups, ISDN-mediated dilation is unaffected by the treatment. As a marker of oxidative stress, allopurinol significantly reduced malondialdehyde. Moreover, myeloperoxidase levels were reduced by the treatment with allopurinol (56.1 +/- 3.4 ng/ml vs. 44.4 +/- 2.4 ng/ml, P < 0.05) but there were no change in the placebo group. Surprisingly, neither CRP nor fibrinogen levels were affected by the treatment in both groups. CONCLUSION: Xanthine oxidoreductase inhibition by allopurinol in patients with metabolic syndrome reduces oxidative stress, improves endothelial function, ameliorates myeloperoxidase levels and does not have any effect on CRP and fibrinogen levels.

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A 60-year-old woman was admitted to cardiology clinic because of typical chest pain. The presenting electrocardiography (ECG) revealed sinus rhythm and T wave inversion on inferolateral wall. Her chest pain relapsed at second day of admission and electrocardiogram recorded during chest pain had ECG changes consistent with Wolf Parkinson White (WPW) syndrome. She underwent cardiac catheterization and borderline lesion was detected in proximal of left anterior descending artery and direct stent implantation was performed. This is the first case report in which acute ischemia may induce typical ECG changes of WPW in a patient with concealed WPW syndrome. We concluded that acute coronary ischemia may manifest concealed WPW syndrome.

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We report a 27-year-old woman who presented with worsening exertional dyspnea and palpitation. Transthoracic echocardiography showed ventricular septal defect, with left-to-right shunting and mild aortic regurgitation detected. Cardiac catheterization was performed that revealed sinus of Valsalva aneurysm with rupture into the right ventricle. Transesophageal echocardiography (TEE) confirmed a rupture of sinus of Valsalva aneurysm and ventricular septal defect. The patient underwent elective surgical repair of the ruptured sinus and intraoperative TEE demonstrated severe aortic regurgitation after repair and mechanical prosthetic valve was implanted. This case illustrates that TEE frequently establishes the diagnosis and provides more information concerning additional cardiac lesions in a patient with ruptured sinus of Valsalva aneurysm. Aortic regurgitation should be evaluated after repair of rupture of sinus of Valsalva by TEE.

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