Publications by authors named "Ahmet Demirkiran"

48 Publications

Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients after Anterior Myocardial Infarction.

Am J Med Sci 2021 Nov 27. Epub 2021 Nov 27.

Cardiology Department, Istanbul Faculty of Medicine, Istanbul, Turkey.

Background: The presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction (MI). Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential. We aimed to compare the two-dimensional echocardiography (2DE), contrast-2DE and real-time three-dimensional echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior.

Methods: The study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (<40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and magnetic resonance imaging (MRI) were performed on all patients within one month after anterior MI.

Results: Transthoracic 2DE detected thrombi in 29 patients, contrast-2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast-2DE and RT-3DE, respectively.

Conclusions: We found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT.
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http://dx.doi.org/10.1016/j.amjms.2021.06.028DOI Listing
November 2021

Impaired left atrial reservoir and conduit strain in patients with atrial fibrillation and extensive left atrial fibrosis.

J Cardiovasc Magn Reson 2021 Nov 11;23(1):131. Epub 2021 Nov 11.

Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands.

Background: Atrial fibrillation (AF) is associated with profound structural and functional changes in the atria. In the present study, we investigated the association between left atrial (LA) phasic function and the extent of LA fibrosis using advanced cardiovascular magnetic resonance (CMR) imaging techniques, including 3-dimensional (3D) late gadolinium enhancement (LGE) and feature tracking.

Methods: Patients with paroxysmal and persistent AF (n = 105) underwent CMR in sinus rhythm. LA global reservoir strain, conduit strain and contractile strain were derived from cine CMR images using CMR feature tracking. The extent of LA fibrosis was assessed from 3D LGE images. Healthy subjects underwent CMR and served as controls (n = 19).

Results: Significantly lower LA reservoir strain, conduit strain and contractile strain were found in AF patients, as compared to healthy controls (- 15.9 ± 3.8% vs. - 21.1 ± 3.6% P < 0.001, - 8.7 ± 2.7% vs. - 12.6 ± 2.5% P < 0.001 and - 7.2 ± 2.3% vs. - 8.6 ± 2.2% P = 0.02, respectively). Patients with a high degree of LA fibrosis (dichotomized by the median value) had lower reservoir strain and conduit strain compared to patients with a low degree of LA fibrosis (- 15.0 ± 3.9% vs. - 16.9 ± 3.3%, P = 0.02 and - 7.9 ± 2.7% vs. - 9.5 ± 2.6%, P = 0.01, respectively). In contrast, no difference was found for LA contractile strain (- 7.1 ± 2.4% vs. - 7.4 ± 2.3%, P = 0.55).

Conclusions: Impaired LA reservoir and conduit strain are present in AF patients with extensive atrial fibrosis. Future studies are needed to examine the biologic nature of this association and possible therapeutic implications.
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http://dx.doi.org/10.1186/s12968-021-00820-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8582184PMC
November 2021

Esophageal Cancer After Bariatric Surgery: Increasing Prevalence and Treatment Strategies.

Obes Surg 2021 11 7;31(11):4954-4962. Epub 2021 Sep 7.

Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, Postbus 7075, 1007 MB, Amsterdam, The Netherlands.

Purpose: The number of bariatric procedures has increased exponentially over the last 20 years. On the background of ever-increasing incidence of esophageal malignancies, the altered anatomy after bariatric surgery poses challenges in treatment of these cancers. In this study, an epidemiological estimate is presented for the future magnitude of this problem and treatment options are described in a retrospective multicenter cohort.

Methods: The number of bariatric procedures, esophageal cancer incidence, and mortality rates of the general population were used for epidemiological estimates. A retrospective multicenter cohort was composed; patients were treated in three large oncological centers with a high upper gastrointestinal cancer caseload. Consecutive patients with preceding bariatric surgery who developed esophageal cancer between 2014 and 2019 were included.

Results: Approximately 3200 out of 6.4 million post bariatric surgery patients are estimated to have developed esophageal cancer between 1998 and 2018 worldwide. In a multicenter cohort, 15 patients with esophageal cancer or Barrett's esophagus and preceding bariatric surgery were identified. The majority of patients had a history of Roux-en-Y gastric bypass (46.7%) and had an adenocarcinoma of the distal esophagus (60%). Seven patients received curative surgical treatment, five of whom are still alive at last follow-up (median follow-up 2 years, no loss to follow-up).

Conclusion: Based on worldwide data, esophageal cancer development following bariatric surgery has increased over the past decades. Treatment of patients with esophageal cancer after bariatric surgery is challenging and requires a highly individualized approach in which optimal treatment and anatomical limitations are carefully balanced.
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http://dx.doi.org/10.1007/s11695-021-05679-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8490213PMC
November 2021

Left ventricular function, strain, and infarct characteristics in patients with transient ST-segment elevation myocardial infarction compared to ST-segment and non-ST-segment elevation myocardial infarctions.

Eur Heart J Cardiovasc Imaging 2021 Jul 1. Epub 2021 Jul 1.

Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.

Aims: This study aims to explore cardiovascular magnetic resonance (CMR)-derived left ventricular (LV) function, strain, and infarct size characteristics in patients with transient ST-segment elevation myocardial infarction (TSTEMI) compared to patients with ST-segment and non-ST-segment elevation myocardial infarctions (STEMI and NSTEMI, respectively).

Methods And Results: In total, 407 patients were enrolled in this multicentre observational prospective cohort study. All patients underwent CMR examination 2-8 days after the index event. CMR cine imaging was performed for functional assessment and late gadolinium enhancement to determine infarct size and identify microvascular obstruction (MVO). TSTEMI patients demonstrated the highest LV ejection fraction and the most preserved global LV strain (longitudinal, circumferential, and radial) across the three groups (overall P ≤ 0.001). The CMR-defined infarction was less frequently observed in TSTEMI than in STEMI patients [77 (65%) vs. 124 (98%), P < 0.001] but was comparable with NSTEMI patients [77 (65%) vs. 66 (70%), P = 0.44]. A remarkably smaller infarct size was seen in TSTEMI compared to STEMI patients [1.4 g (0.0-3.9) vs. 13.5 g (5.3-26.8), P < 0.001], whereas infarct size was not significantly different from that in NSTEMI patients [1.4 g (0.0-3.9) vs. 2.1 g (0.0-8.6), P = 0.06]. Whilst the presence of MVO was less frequent in TSTEMI compared to STEMI patients [5 (4%) vs. 53 (31%), P < 0.001], no significant difference was seen compared to NSTEMI patients [5 (4%) vs. 5 (5%), P = 0.72].

Conclusion: TSTEMI yielded favourable cardiac LV function, strain, and infarct-related scar mass compared to STEMI and NSTEMI. LV function and infarct characteristics of TSTEMI tend to be more similar to NSTEMI than STEMI.
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http://dx.doi.org/10.1093/ehjci/jeab114DOI Listing
July 2021

Clinical intra-cardiac 4D flow CMR: acquisition, analysis, and clinical applications.

Eur Heart J Cardiovasc Imaging 2021 Jun 18. Epub 2021 Jun 18.

Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.

Identification of flow patterns within the heart has long been recognized as a potential contribution to the understanding of physiological and pathophysiological processes of cardiovascular diseases. Although the pulsatile flow itself is multi-dimensional and multi-directional, current available non-invasive imaging modalities in clinical practice provide calculation of flow in only 1-direction and lack 3-dimensional volumetric velocity information. Four-dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR) has emerged as a novel tool that enables comprehensive and critical assessment of flow through encoding velocity in all 3 directions in a volume of interest resolved over time. Following technical developments, 4D flow CMR is not only capable of visualization and quantification of conventional flow parameters such as mean/peak velocity and stroke volume but also provides new hemodynamic parameters such as kinetic energy. As a result, 4D flow CMR is being extensively exploited in clinical research aiming to improve understanding of the impact of cardiovascular disease on flow and vice versa. Of note, the analysis of 4D flow data is still complex and accurate analysis tools that deliver comparable quantification of 4D flow values are a necessity for a more widespread adoption in clinic. In this article, the acquisition and analysis processes are summarized and clinical applications of 4D flow CMR on the heart including conventional and novel hemodynamic parameters are discussed. Finally, clinical potential of other emerging intra-cardiac 4D flow imaging modalities is explored and a near-future perspective on 4D flow CMR is provided.
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http://dx.doi.org/10.1093/ehjci/jeab112DOI Listing
June 2021

The relation between postprandial glucagon-like peptide-1 release and insulin sensitivity before and after bariatric surgery in humans with class II/III obesity.

Surg Obes Relat Dis 2021 Aug 24;17(8):1440-1448. Epub 2021 May 24.

Department of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. Electronic address:

Background: Glucagon-like peptide-1 (GLP-1) receptor agonist treatment is beneficial for the human glucose metabolism, and GLP-1 secretion is greatly enhanced following Roux-en-Y gastric bypass (RYGB).

Objectives: To elucidate the relationship between GLP-1 concentrations and insulin sensitivity in subjects with class II/III obesity without diabetes and to assess the relation between GLP-1 and the improvements in glucose metabolism following RYGB.

Setting: Clinical research facility in a university hospital.

Methods: We recruited 35 patients scheduled for RYGB and assessed their plasma GLP-1, insulin, and glucose responses to a high-fat mixed meal. Basal and insulin-mediated glucose fluxes were determined during a 2-step hyperinsulinemic-euglycemic clamp with stable isotope-labeled tracers. Out of 35 subjects, 10 were studied both before surgery and at 1 year of follow-up.

Results: Plasma GLP-1 increased following the high-fat mixed meal. Postprandial GLP-1 excursions correlated positively with hepatic and peripheral insulin sensitivity, but not with body mass index. At 1 year after RYGB, participants had lost 24% ± 6% of their body weight. Plasma GLP-1, insulin, and glucose levels peaked earlier and higher after the mixed meal. The positive association between the postprandial GLP-1 response and peripheral insulin sensitivity persisted.

Conclusions: Postprandial GLP-1 concentrations correlate with insulin sensitivity in subjects with class II/III obesity without diabetes before and 1 year after RYGB. Increased GLP-1 signaling in postbariatric patients may, directly or indirectly, contribute to the observed improvements in insulin sensitivity and metabolic health.
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http://dx.doi.org/10.1016/j.soard.2021.04.022DOI Listing
August 2021

The effect of immediate coronary angiography after cardiac arrest without ST-segment elevation on left ventricular function. A sub-study of the COACT randomised trial.

Resuscitation 2021 07 28;164:93-100. Epub 2021 Apr 28.

Department of Intensive care medicine, Noord West Ziekenhuisgroep, Alkmaar, The Netherlands.

Background: The effect of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients who are successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) on left ventricular function is currently unknown.

Methods: This prespecified sub-study of a multicentre trial evaluated 552 patients, successfully resuscitated from out-of-hospital cardiac arrest without signs of STEMI. Patients were randomized to either undergo immediate coronary angiography or delayed coronary angiography, after neurologic recovery. All patients underwent PCI if indicated. The main outcomes of this analysis were left ventricular ejection fraction and end-diastolic and systolic volumes assessed by cardiac magnetic resonance imaging or echocardiography.

Results: Data on left ventricular function was available for 397 patients. The mean (± standard deviation) left ventricular ejection fraction was 45.2% (±12.8) in the immediate angiography group and 48.4% (±13.2) in the delayed angiography group (mean difference: -3.19; 95% confidence interval [CI], -6.75 to 0.37). Median left ventricular end-diastolic volume was 177 ml in the immediate angiography group compared to 169 ml in the delayed angiography group (ratio of geometric means: 1.06; 95% CI, 0.95-1.19). In addition, mean left ventricular end-systolic volume was 90 ml in the immediate angiography group compared to 78 ml in the delayed angiography group (ratio of geometric means: 1.13; 95% CI 0.97-1.32).

Conclusion: In patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, immediate coronary angiography was not found to improve left ventricular dimensions or function compared with a delayed angiography strategy.

Clinical Trial Registration: Netherlands Trial Register number, NTR4973.
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http://dx.doi.org/10.1016/j.resuscitation.2021.04.020DOI Listing
July 2021

Potential Risk and Safety Measures in Laparoscopy in COVID-19 Positive Patients.

Surg Innov 2021 Mar 31:15533506211003527. Epub 2021 Mar 31.

Department of Gynecology, 4501Leiden University Medical Center, Leiden, The Netherlands.

During the COVID-19 pandemic the question arises if laparoscopy, as an aerosol forming procedure, poses a potential risk for viral transmission of SARS-CoV-2 to healthcare workers. A literature search was conducted using PubMed, Embase and MEDLINE. Articles reporting information regarding COVID-19 or other relevant viruses and laparoscopy, surgical smoke, aerosols and viral transmission were included. Although aerosols produced during laparoscopy do not originate from the respiratory tract, the main transmission route of SARS-CoV-2, research did show SARS-CoV-2 to be present in other body fluids. The transmission risk via this route is however considered very low. As previous research showed potential viral transmission during laparoscopy for viruses that spread through contaminated body fluids, there might be a potential risk of SARS-CoV-2 transmission during laparoscopy, albeit considered very small. Due to the small risk compared to widely known benefits of laparoscopy, there is no reason to replace laparoscopy by laparotomy due to COVID-19 infection. To avoid the potential small risk of viral transmission, additional safety measures are advised.
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http://dx.doi.org/10.1177/15533506211003527DOI Listing
March 2021

Altered left atrial 4D flow characteristics in patients with paroxysmal atrial fibrillation in the absence of apparent remodeling.

Sci Rep 2021 03 16;11(1):5965. Epub 2021 Mar 16.

Department of Cardiology, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.

The pathophysiology behind thrombus formation in paroxysmal atrial fibrillation (AF) patients is very complex. This can be due to left atrial (LA) flow changes, remodeling, or both. We investigated differences for cardiovascular magnetic resonance (CMR)-derived LA 4D flow and remodeling characteristics between paroxysmal AF patients and patients without cardiac disease. In this proof-of-concept study, the 4D flow data were acquired in 10 patients with paroxysmal AF (age = 61 ± 8 years) and 5 age/gender matched controls (age = 56 ± 1 years) during sinus rhythm. The following LA and LA appendage flow parameters were obtained: flow velocity (mean, peak), stasis defined as the relative volume with velocities < 10 cm/s, and kinetic energy (KE). Furthermore, LA global strain values were derived from b-SSFP cine images using dedicated CMR feature-tracking software. Even in sinus rhythm, LA mean and peak flow velocities over the entire cardiac cycle were significantly lower in paroxysmal AF patients compared to controls [(13.1 ± 2.4 cm/s vs. 16.7 ± 2.1 cm/s, p = 0.01) and (19.3 ± 4.7 cm/s vs. 26.8 ± 5.5 cm/s, p = 0.02), respectively]. Moreover, paroxysmal AF patients expressed more stasis of blood than controls both in the LA (43.2 ± 10.8% vs. 27.8 ± 7.9%, p = 0.01) and in the LA appendage (73.3 ± 5.7% vs. 52.8 ± 16.2%, p = 0.04). With respect to energetics, paroxysmal AF patients demonstrated lower mean and peak KE values (indexed to maximum LA volume) than controls. No significant differences were observed for LA volume, function, and strain parameters between the groups. Global LA flow dynamics in paroxysmal AF patients appear to be impaired including mean/peak flow velocity, stasis fraction, and KE, partly independent of LA remodeling. This pathophysiological flow pattern may be of clinical value to explain the increased incidence of thromboembolic events in paroxysmal AF patients, in the absence of actual AF or LA remodeling.
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http://dx.doi.org/10.1038/s41598-021-85176-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7966746PMC
March 2021

Hepatic Insulin Resistance Is Not Pathway Selective in Humans With Nonalcoholic Fatty Liver Disease.

Diabetes Care 2021 02 8;44(2):489-498. Epub 2020 Dec 8.

Department of Endocrinology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands

Objective: Both glucose and triglyceride production are increased in type 2 diabetes and nonalcoholic fatty liver disease (NAFLD). For decades, the leading hypothesis to explain these paradoxical observations has been selective hepatic insulin resistance wherein insulin drives de novo lipogenesis (DNL) while failing to suppress glucose production. Here, we aimed to test this hypothesis in humans.

Research Design And Methods: We recruited obese subjects who met criteria for bariatric surgery with ( = 16) or without ( = 15) NAFLD and assessed ) insulin-mediated regulation of hepatic and peripheral glucose metabolism using hyperinsulinemic-euglycemic clamps with [6,6-H]glucose, ) fasting and carbohydrate-driven hepatic DNL using deuterated water (HO), and ) hepatocellular insulin signaling in liver biopsy samples collected during bariatric surgery.

Results: Compared with subjects without NAFLD, those with NAFLD demonstrated impaired insulin-mediated suppression of glucose production and attenuated-not increased-glucose-stimulated/high-insulin lipogenesis. Fructose-stimulated/low-insulin lipogenesis was intact. Hepatocellular insulin signaling, assessed for the first time in humans, exhibited a proximal block in insulin-resistant subjects: Signaling was attenuated from the level of the insulin receptor through both glucose and lipogenesis pathways. The carbohydrate-regulated lipogenic transcription factor was increased in subjects with NAFLD.

Conclusions: Acute increases in lipogenesis in humans with NAFLD are not explained by altered molecular regulation of lipogenesis through a paradoxical increase in lipogenic insulin action; rather, increases in lipogenic substrate availability may be the key.
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http://dx.doi.org/10.2337/dc20-1644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818337PMC
February 2021

The role of Beta-1 receptor gene polymorphism in Beta-Blocker therapy for vasovagal syncope.

Rev Invest Clin 2020 05 7;72(5). Epub 2020 May 7.

Cardiology Department of Istanbul School of Medicine, Istanbul University, Istanbul.

Background: Vasovagal syncope (VVS) is a common clinical condition involving genetic background. The role of beta-blockers in the treatment is controversial.

Objective: The aim of this study was to investigate the effect of beta-1 gene polymorphism on beta-blocker therapy in patients with VVS.

Methods: We included 123 patients who were diagnosed with VVS after the tilttable test. We searched for the polymorphism Arg389Gly (rs1801253) in the beta-1 adrenoceptor gene.

Results: Overall, 64 patients (52%) had Arg389Arg with Arg389Arg genotype were more frequent compared with patients having Arg389Gly genotype (total syncopal episodes [TSE], 7.9 ± 3.7 vs. 6.4 ± 3.0; p = 0.012). TSE in patients with Arg389Arg genotype decreased significantly after 18 months of beta-blocker treatment (7.9 ± 3.7 vs. 3.0 ± 1.4, p < 0.001). After 18 months of beta-blocker treatment, patients with Arg389Arg genotype had significantly fewer syncopal episodes than patients with Arg389Gly genotype (3.0 ± 1.4 vs. 6.8 ± 3.2, p < 0.001).

Conclusions: Results of beta-blocker therapy in patients with Arg389Arg genotype suggest that VVS pathophysiology is a multifactorial condition, with genetic, psychological, and environmental components, and therefore, treatment selection can be based on gene polymorphism.
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http://dx.doi.org/10.24875/RIC.20003319DOI Listing
May 2020

Protocol of a multicentre, prospective cohort study that evaluates cost-effectiveness of two perioperative care strategies for potential obstructive sleep apnoea in morbidly obese patients undergoing bariatric surgery.

BMJ Open 2020 10 7;10(10):e038830. Epub 2020 Oct 7.

Department of Surgery / Vitalys Clinic, Rijnstate Ziekenhuis, Arnhem, The Netherlands.

Introduction: Despite the high prevalence of obstructive sleep apnoea (OSA) in obese patients undergoing bariatric surgery, OSA is undiagnosed in the majority of patients and thus untreated. While untreated OSA is associated with an increased risk of preoperative and postoperative complications, no evidence-based guidelines on perioperative care for these patients are available. The aim of the POPCORN study (ost-perative ulse oximetry without OSA sreening vs perioperative continuous positive airway pressure (CPAP) treatment following SA sceeing by polygraphy (PG)) is to evaluate which perioperative strategy is the most cost-effective for obese patients undergoing bariatric surgery without a history of OSA.

Methods And Analysis: In this multicentre observational cohort study, data from 1380 patients who will undergo bariatric surgery will be collected. Patients will receive either postoperative care with pulse oximetry monitoring and supplemental oxygen during the first postoperative night, or care that includes preoperative PG and CPAP treatment in case of moderate or severe OSA. Local protocols for perioperative care in each participating hospital will determine into which cohort a patient is placed. The primary outcome is cost-effectiveness, which will be calculated by comparing all healthcare costs with the quality-adjusted life-years (QALYs, calculated using EQ-5D questionnaires). Secondary outcomes are mortality, complications within 30 days after surgery, readmissions, reoperations, length of stay, weight loss, generic quality of life (QOL), OSA-specific QOL, OSA symptoms and CPAP adherence. Patients will receive questionnaires before surgery and 1, 3, 6 and 12 months after surgery to report QALYs and other patient-reported outcomes.

Ethics And Dissemination: Approval from the Medical Research Ethics Committees United was granted in accordance with the Dutch law for Medical Research Involving Human Subjects Act (WMO) (reference number W17.050). Results will be submitted for publication in peer-reviewed journals and presented at (inter)national conferences.

Trial Registration Number: NTR6991.
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http://dx.doi.org/10.1136/bmjopen-2020-038830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542938PMC
October 2020

Total weight loss after laparoscopic Roux-en-Y gastric bypass is influenced by preoperative weight loss: can we predict the outcome?

Surg Obes Relat Dis 2020 Nov 28;16(11):1850-1856. Epub 2020 May 28.

Department of Bariatric Surgery, Red Cross Hospital, Beverwijk, the Netherlands.

Background: Preoperative weight loss (WL) is associated with higher postoperative WL at 1- to 2-year follow-up in patients who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB).

Objective: To evaluate the possible association between preoperative and postoperative WL at 3-year follow-up and identify risk factors for insufficient WL.

Setting: A single-center prospective cohort study in the Netherlands.

Methods: Patients undergoing primary LRYGB and laparoscopic conversion from band to bypass (redo LRYGB) were instructed to lose weight preoperatively. Follow-up data were collected 1, 2, and 3 years postoperatively. WL was described as percentage total weight loss (%TWL) and percentage excess body mass index (BMI) loss. Patients were divided into 2 groups: group A lost any amount of weight; group B did not lose any weight or gained weight preoperatively.

Results: Group A consisted of 230 patients (median preoperative %TWL, 4.8%), and group B consisted of 46 patients (median preoperative %TWL, -1.3%). Median BMI at intake was 44.1 kg/m. Baseline characteristics were similar. The %TWL and BMI for group A and B in the patients who underwent primary LRYGB at 1, 2, and 3 years was 32.2% (BMI, 28.6 kg/m) versus 23.9% (BMI, 32.2 kg/m), 31.8% (BMI, 28.9 kg/m) versus 25.2% (BMI, 31.9 kg/m), and 33.3% (BMI, 29.7 kg/m) versus 21.9% (BMI, 34 kg/m), respectively, all P < .05. In patients who underwent redo LRYGB no clinically significant differences in postoperative BMI were found.

Conclusions: Preoperative WL in primary patients who undergo LRYGB can be useful to identify those at risk of inadequate postoperative WL. In patients who undergo redo LRYGB different risk factors should be considered for prediction of inadequate postoperative WL.
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http://dx.doi.org/10.1016/j.soard.2020.05.026DOI Listing
November 2020

The relationship between clinical characteristics and psychological status and quality of life in patients with vasovagal syncope.

North Clin Istanb 2020 10;7(3):237-245. Epub 2020 Feb 10.

Department of Cardiology, Istanbul Medical Faculty, Istanbul, Turkey.

Objective: Syncope is characterized by sudden and short-term loss of postural tone and consciousness. Vasovagal syncope (VVS) episode is usually self-limiting, and it may affect patients' quality of life. In this study, we aimed to investigate the relationship between quality of life, Beck-depression and Beck-anxiety scales and clinical characteristics of the VVS patients.

Methods: The present study included 88 patients with VVS. Tilt table test was performed to all the patients. Patients filled out the Quality of life, Beck-depression, and Beck-anxiety scale forms. Demographics, medical history, echocardiography, blood pressures, electrocardiography and physical examination findings were recorded.

Results: There was a significant and negative correlation between the total syncope episodes (TSE) and EQ-5D index and EQ-5D-VAS index, respectively (p<0.001, r: -0.649; p<0.001, r: -0.587). TSE was significantly and positively correlated with the Beck-anxiety scale and Beck-depression scale. EQ-5D index, EQ-5D-VAS index, Beck-depression scale, and Beck-anxiety scales were defined as an independent predictor of TSE in VVS patients.

Conclusion: Psychological factors play an essential role in VVS patients. EQ-5D index, EQ-5D-VAS index, Beck-depression, and Beck-anxiety scales were an independent predictor of the TSE in patients with VVS.
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http://dx.doi.org/10.14744/nci.2020.93753DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251279PMC
February 2020

Enhanced PeriOperative Care and Health protection programme for the prevention of surgical site infections after elective abdominal surgery (EPOCH): study protocol of a randomised controlled, multicentre, superiority trial.

BMJ Open 2020 05 25;10(5):e038196. Epub 2020 May 25.

Department of Surgery, Amsterdam UMC - Locatie AMC, Amsterdam, Noord-Holland, Netherlands

Introduction: Surgical site infections (SSI) are a common postoperative complication. During the development of the new WHO guidelines on SSI prevention, also in the Netherlands was concluded that perioperative care could be optimised beyond the current standard practice. We selected a limited set of readily available, cheap and evidence-based interventions from these new guidelines that are not part of standard practice in the Netherlands and formulated an Enhanced PeriOperative Care and Health bundle (EPOCH). Here, we describe the protocol for an open-label, randomised controlled, parallel-group, superiority trial to test the effect of the EPOCH bundle added to (national) standard care in comparison to standard care alone on the incidence of SSI.

Methods And Analysis: EPOCH consists of intraoperative high fractional inspired oxygen (0.80); goal-directed fluid therapy; active preoperative, intraoperative and postoperative warming; perioperative glucose control and treatment of severe hyperglycaemia (>10 mmol) and standardised surgical site handling. Patients scheduled for elective abdominal surgery with an incision larger than 5 cm are eligible for inclusion. Participants are randomised daily, 1:1 according to variable block sizes, and stratified per participating centre to either EPOCH added to standard care or standard care only. The primary endpoint will be SSI incidence according to the Centers for Disease Control and Prevention (CDC) definition within 30 days as part of routine clinical follow-up. Four additional questionnaires will be sent out over the course of 90 days to capture disability and costs. Other secondary endpoints include anastomotic leakage, incidence of incisional hernia, serious adverse events, hospital readmissions, length of stay and cost effectiveness. Analysis of the primary endpoint will be on an intention-to-treat basis.

Ethics And Dissemination: Ethics approval is granted by the Amsterdam UMC Medical Ethics Committee (reference 2015_121). Results will be disseminated through peer-reviewed journals and summaries shared with stakeholders. This protocol is published before analysis of the results.

Trial Registration Number: Registered in the Dutch Trial Register: NL5572.
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http://dx.doi.org/10.1136/bmjopen-2020-038196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252990PMC
May 2020

Erythrocyte deformability and aggregation in morbidly obese women undergoing laparoscopic gastric bypass surgery and effects of oral omega-3 fatty acid supplementation.

Clin Hemorheol Microcirc 2020 ;75(3):303-311

Northwest Clinics Alkmaar, Alkmaar, The Netherlands.

Background: An adequate erythrocyte function is vital for tissue oxygenation and wound healing. The erythrocyte membrane phospholipid composition plays an important role in erythrocyte function and administration of omega-3 fatty acids may provide a means to improve it.

Objective: To investigate peri-operative erythrocyte function and effects of oral omega-3 fatty acids in morbidly obese women undergoing gastric bypass surgeryMETHODS:Fifty-six morbidly obese women undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery were randomized between a low calorie diet (LCD) during 2 weeks or oral omega-3 poly-unsaturated fatty acids (n-3 PUFAs) and a normal diet during 4 weeks. Peri-operative blood samples were analyzed with the Lorrca MaxSIS Ektacytometer for erythrocyte deformability and aggregability.

Results: There were no significant differences in erythrocyte function between the groups at any time point. Only erythrocyte aggregability parameters were affected by surgery. At six month follow-up, aggregation index (AI) and cholesterol, glucose and insulin were significantly improved.

Conclusions: In this study, oral Omega-3 supplementation did not affect erythrocyte function compared to a LCD. Six months after surgery a significant improvement in AI and metabolic parameters was observed in both groups, contributing to a reduction in the risk at thromboembolic and cardiovascular complications.
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http://dx.doi.org/10.3233/CH-190777DOI Listing
October 2020

Measuring quality of life in bariatric surgery: a multicentre study.

Surg Endosc 2020 12 28;34(12):5522-5532. Epub 2020 Jan 28.

Department of Surgery, Groene Hart Hospital, Gouda, The Netherlands.

Background: Current studies mainly focus on total weight loss and comorbidity reduction. Only a few studies compare Quality of Life (QoL) after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). This study was conducted to examine the extent of improvement in QoL on different domains after primary bariatric surgery and compare these results to Dutch reference values.

Methods: The study included prospectively collected data from patients who underwent primary bariatric surgery in five Dutch hospitals. The RAND-36 questionnaire was used to measure the patient's QoL; preoperatively and twelve months postoperatively. Postoperative scores were compared to Dutch reference values, standardized for age, using t-test. A difference of more than 5% was considered a minimal important difference. A multivariate linear regression analysis was used to compare SG and RYGB on the extent of improvement, adjusted for case-mix factors.

Results: In total, 4864 patients completed both the pre- and postoperative questionnaire. Compared with Dutch reference values, patients postoperatively reported clinically relevant better physical functioning (RYGB + 6.8%), physical role limitations (SG + 5.6%; RYGB + 6.2%) and health change (SG + 77.1%; RYGB + 80.0%), but worse general health perception (SG - 22.8%; RYGB - 17.0%). Improvement in QoL was similar between SG and RYGB, except for physical functioning (β 2.758; p-value 0.008) and general health perception (β 2.607; p-value < 0.001) for which RYGB patients improved more.

Conclusions: SG and RYGB patients achieved a better postoperative score in physical functioning, physical role limitations and health change compared to Dutch reference values, and a worse score in general health perception.
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http://dx.doi.org/10.1007/s00464-019-07350-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644534PMC
December 2020

Serum Asymmetric Dimethylarginine Levels in Patients with Vasovagal Syncope.

Medicina (Kaunas) 2019 Oct 29;55(11). Epub 2019 Oct 29.

Cardiology Department, Bagcilar Training ve Research Hospital, Bagcilar Center, 34100 Istanbul, Turkey.

: Vasovagal syncope (VVS) is the most common cause of syncope and has multiple pathophysiological mechanisms. Asymmetric dimethylarginine (ADMA) is the major inhibitor of nitric oxide (NO). In this study, we aimed to investigate the relationship between plasma ADMA levels and syncope during the head-up tilt (HUT) test. : Overall, 97 patients were included in this study. They were above 18 years of age and were admitted to our clinic with the complaint of at least one episode of syncope consistent with VVS. The HUT test was performed in all patients. Patients were divided into the following two groups based on the HUT test results: group 1 included 57 patients with a positive HUT test and group 2 included 35 patients with a negative HUT test. Blood samples were taken before and immediately after the HUT test to measure ADMA levels. : No significant intergroup differences were observed concerning gender and age (female gender 68% vs 60%; mean age 24.85 ± 4.01 vs 25.62 ± 3.54 years, respectively, for groups 1 and 2). ADMA values were similar between groups 1 and 2 before the HUT test [ADMA of 958 (544-1418) vs 951 (519-1269); 0.794]. In the negative HUT group, no significant differences were observed in ADMA levels before and after the HUT test [ADMA of 951 (519-1269) vs 951 (519-1566); 0.764]. However, in the positive HUT group, ADMA levels were significantly decreased following the HUT test [pretest ADMA of 958 (544-1418) vs post-test ADMA of 115 (67-198); < 0.001]. : ADMA levels significantly decreased after the HUT test in patients with VVS.
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http://dx.doi.org/10.3390/medicina55110718DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6915676PMC
October 2019

Cardiac Magnetic Resonance for Evaluating Nonculprit Lesions After Myocardial Infarction: Comparison With Fractional Flow Reserve.

JACC Cardiovasc Imaging 2020 03 18;13(3):715-728. Epub 2019 Sep 18.

Department of Cardiology, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; Department of Cardiology, Radboud University Medical Centers, Nijmegen, the Netherlands. Electronic address:

Objectives: This study sought to determine the agreement between cardiac magnetic resonance (CMR) imaging and invasive measurements of fractional flow reserve (FFR) in the evaluation of nonculprit lesions after ST-segment elevation myocardial infarction (STEMI). In addition, we investigated whether fully quantitative analysis of myocardial perfusion is superior to semiquantitative and visual analysis.

Background: The agreement between CMR and FFR in the evaluation of nonculprit lesions in patients with STEMI with multivessel disease is unknown.

Methods: Seventy-seven patients with STEMI with at least 1 intermediate (diameter stenosis 50% to 90%) nonculprit lesion underwent CMR and invasive coronary angiography in conjunction with FFR measurements at 1 month after primary intervention. The imaging protocol included stress and rest perfusion, cine imaging, and late gadolinium enhancement. Fully quantitative, semiquantitative, and visual analysis of myocardial perfusion were compared against a reference of FFR. Hemodynamically obstructive was defined as FFR ≤0.80.

Results: Hemodynamically obstructive nonculprit lesions were present in 31 (40%) patients. Visual analysis displayed an area under the curve (AUC) of 0.74 (95% confidence interval [CI]: 0.62 to 0.83), with a sensitivity of 73% and a specificity of 70%. For semiquantitative analysis, the relative upslope of the stress signal intensity time curve and the relative upslope derived myocardial flow reserve had respective AUCs of 0.66 (95% CI: 0.54 to 0.77) and 0.71 (95% CI: 0.59 to 0.81). Fully quantitative analysis did not augment diagnostic performance (all p > 0.05). Stress myocardial blood flow displayed an AUC of 0.76 (95% CI: 0.64 to 0.85), with a sensitivity of 69% and a specificity of 77%. Similarly, MFR displayed an AUC of 0.82 (95% CI: 0.71 to 0.90), with a sensitivity of 82% and a specificity of 71%.

Conclusions: CMR and FFR have moderate-good agreement in the evaluation of nonculprit lesions in patients with STEMI with multivessel disease. Fully quantitative, semiquantitative, and visual analysis yield similar diagnostic performance.
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http://dx.doi.org/10.1016/j.jcmg.2019.07.019DOI Listing
March 2020

Hypertension with primary aldosteronism is associated with increased carotid intima-media thickness and endothelial dysfunction.

J Clin Hypertens (Greenwich) 2019 07 12;21(7):932-941. Epub 2019 Jun 12.

Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.

Patients with primary aldosteronism induced hypertension are more likely to experience cardiovascular events compared to patients with essential hypertension. Primary aldosteronism may therefore have distinct adverse effects on cardiovascular structure and function, independent of hypertension. However, current data on such effects of primary aldosteronism are conflicting. The aim of the present study was to investigate the influence of primary aldosteronism on vascular structure and endothelial function, using intima-media thickness as a vascular remodeling index and flow-mediated dilation as a functional parameter. In total, 70 participants were recruited from patients with resistant hypertension. Twenty-nine patients diagnosed with primary aldosteronism and 41 patients with essential hypertension were prospectively enrolled. Primary aldosteronism was due to aldosterone-producing adenoma in 10 cases and due to idiopathic adrenal hyperplasia in 19 cases. All patients underwent ultrasound of the common carotid intima-media thickness and flow-mediated dilation of the brachial artery. Primary aldosteronism patients had significantly lower flow-mediated dilation (3.3 [2.4-7.4] % vs 14.7 [10.3-19.9] %, P < 0.01) and significantly higher carotid intima-media thickness (0.9 [0.7-1.0] mm vs 0.8 [0.6-0.9] mm, P = 0.02) compared to patients with essential hypertension. These differences remained significant after adjusting for age, sex, diabetes mellitus, 24-hours systolic blood pressure, and smoking (P < 0.01). No differences in either outcome were observed between the adenoma and adrenal hyperplasia groups (both P > 0.05). Hypertensive patients with hyperaldosteronism appear to exhibit deteriorative effects on both vascular structure and function, independent of hypertension.
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http://dx.doi.org/10.1111/jch.13585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6771730PMC
July 2019

Cardiovascular magnetic resonance techniques for tissue characterization after acute myocardial injury.

Eur Heart J Cardiovasc Imaging 2019 Jul;20(7):723-734

Department of Cardiology, Amsterdam University Medical Center - Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, HV, Amsterdam, the Netherlands.

The annual incidence of hospital admission for acute myocardial infarction lies between 90 and 312 per 100 000 inhabitants in Europe. Despite advances in patient care 1 year mortality after ST-segment elevation myocardial infarction (STEMI) remains around 10%. Cardiovascular magnetic resonance imaging (CMR) has emerged as a robust imaging modality for assessing patients after acute myocardial injury. In addition to accurate assessment of left ventricular ejection fraction and volumes, CMR offers the unique ability of visualization of myocardial injury through a variety of imaging techniques such as late gadolinium enhancement and T2-weighted imaging. Furthermore, new parametric mapping techniques allow accurate quantification of myocardial injury and are currently being exploited in large trials aiming to augment risk management and treatment of STEMI patients. Of interest, CMR enables the detection of microvascular injury (MVI) which occurs in approximately 40% of STEMI patients and is a major independent predictor of mortality and heart failure. In this article, we review traditional and novel CMR techniques used for myocardial tissue characterization after acute myocardial injury, including the detection and quantification of MVI. Moreover, we discuss clinical scenarios of acute myocardial injury in which the tissue characterization techniques can be applied and we provide proposed imaging protocols tailored to each scenario.
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http://dx.doi.org/10.1093/ehjci/jez094DOI Listing
July 2019

Four Weeks of Preoperative Omega-3 Fatty Acids Reduce Liver Volume: a Randomised Controlled Trial.

Obes Surg 2019 07;29(7):2037-2044

Department of Surgery, Red Cross Hospital Beverwijk, Beverwijk, Netherlands.

Purpose: Weight loss before bariatric surgery with a low-calorie diet (LCD) has several advantages, including reduction of liver volume and an improved access to the lesser sac. Disadvantages include performing surgery in a state of undernutrition, side effects, costs and patient compliance. Omega-3 fatty acids may serve as an alternative to reduce liver steatosis.

Materials And Methods: A randomised controlled open-label trial was done to compare the effects of a LCD with Modifast (800 kcal/day) during 2 weeks with 2 g of omega-3 fatty acids a day and a normal diet (2000 kcal/day) during 4 weeks. Total liver volume (TLV) and volume of the left liver lobe (LLL), visceral fat area (VFA) and muscle area (SMA) at the L3-L4 level were measured with MRI before and after preoperative treatment.

Results: Sixty-two morbidly obese women undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) were recruited. In both groups, there was a significant decrease in LLL, TLV and VFA. For LLL and TLV reduction, the LCD had a significantly larger effect (p < 0.05). Only in the LCD group was there a significant decrease in SMA with significantly more side effects and worse compliance.

Conclusion: Both the LCD and omega-3 diet reduced LLL, TLV and VFA. The LCD outperformed the omega-3 diet in LLL and TLV reduction, but induced significant loss of SMA and had worse compliance due to more side effects. Omega-3 fatty acids may provide a safe and more patient-friendly alternative for a LCD and further research is indicated.

Trial Registration: The study is registered at www.clinicaltrials.gov (NCT02206256).
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http://dx.doi.org/10.1007/s11695-019-03814-7DOI Listing
July 2019

Predicting critical duration and reversibility of damage in acute mesenteric ischemia: An experimental study.

Ulus Travma Acil Cerrahi Derg 2018 Nov;24(6):507-513

Department of Emergency Medicine, Adnan Menderes University Faculty of Medicine, Aydın-Turkey.

Background: The objective of the current study was to investigate the value of the ischemic biomarkers endothelial cell-specific molecule-1 (endocan) and signal peptide-CUB-EGF domain-containing protein-1 (SCUBE-1) in the diagnosis and assessment of earlystage and irreversible damage in acute mesenteric ischemia.

Methods: An experimental mesenteric ischemia reperfusion model was designed using 54 rats. Nine groups were created: Three sham groups [Groups I (30th minute), IV (2nd hour), and VII (6th hour)], in which only blood and tissue specimens were sampled; 3 ischemia groups [Groups II (30th minute), V (2nd hour), and VIII (6th hour)], in which blood and tissue specimens were sampled after ligation of the superior mesenteric artery (SMA); and 3 reperfusion groups [Groups III (30th minute), VI (2nd hour), and IX (6th hour)], in which blood and tissue specimens were sampled after declamping the SMA and reperfusion for 1 hour. SCUBE-1 and endocan samples obtained from blood and tissue were examined histopathologically.

Results: The SCUBE-1 level was higher in the ischemia groups when compared with the sham groups (p<0.05), and the endocan level was markedly different in the late ischemia (6th hour) group. When these 2 markers were used together to assess irreversible mesenteric damage in the histopathological examination, the sensitivity in distinguishing between reversible or irreversible damage was 94.1% with a specificity of 73.7%.

Conclusion: The elevation of SCUBE-1 alone seems to be significant for predicting early mesenteric ischemia in laboratory rats. The combination of SCUBE-1 and endocan may be useful to detect irreversible intestinal damage.
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http://dx.doi.org/10.5505/tjtes.2018.69710DOI Listing
November 2018

Author`s Reply.

Anatol J Cardiol 2018 11;20(5):308

Department of Cardiology, Baðcýlar Training and Research Hospital; Ýstanbul-Turkey.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280284PMC
November 2018

Evaluation of the Tp-Te interval, Tp-Te/QTc ratio, and QT dispersion in patients with Turner syndrome.

Anatol J Cardiol 2018 Aug;20(2):93-99

Department of Cardiology, Bağcılar Training and Research Hospital; İstanbul-Turkey.

Objective: To evaluate ventricular repolarization parameters using the interval from the peak to the end of the T wave (Tp-Te), together with QT and corrected QT (QTc) intervals, QT dispersion (QTd), and Tp-Te/QTc ratio in patients with Turner syndrome (pwTS) and to compare the results with those from healthy controls.

Methods: In total, 38 patients previously diagnosed with Turner syndrome (TS) and 35 healthy girls (controls) were included in our cross-sectional study. Twelve-lead electrocardiography (ECG) and echocardiography after a 30-min rest were performed. The QT, QTc, QTd, Tp-Te interval, and Tp-Te/QTc ratio were determined.

Results: No differences in age or sex were observed between the groups. QT intervals were similar in both groups [pwTS: 354.76±25.33 ms, controls (C): 353.29±17.51 ms, p=0.775]. pwTS had significantly longer QTc and QTd than controls (411.87±22.66 ms vs. 392.06±13.21 ms, p<0.001 and 40.31±2.02 ms vs. 37.54±1.83 ms, p<0.001, respectively). Similarly, the Tp-Te interval and Tp Te/QTc ratio were significantly longer in pwTS than in controls (71.89±3.39 ms vs. 65.34±2.88 ms, p<0.001 and 0.17±0.01 vs. 0.16±0.01, p=0.01).

Conclusion: As pwTS have longer QTc, QTd, Tp-Te interval, and Tp-Te/QTc ratio, an annual follow-up with ECG can provide awareness and even prevent sudden death in them. Also avoiding the use of drugs that makes repolarization anomaly and having knowledge about the side effects of these drugs are essential in pwTS.
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http://dx.doi.org/10.14744/AnatolJCardiol.2018.98250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6237954PMC
August 2018

Predicting Symptom Relief After Reoperation for Suspected Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass.

Obes Surg 2018 12;28(12):3801-3808

Department of Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands.

Background: Internal herniation (IH) is one of the most common long-term complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Diagnosis of IH may be difficult, and not all patients with suspected IH will have full relief of symptoms after closure of both mesenteric defects.

Objectives: To investigate possible predictive factors for relief of symptoms in patients with suspected IH.

Methods: All patients that underwent reoperation for (suspected) IH after LRYGB from June 2009 to December 2016 were retrospectively evaluated in this multicentre cohort study. Logistic regression analysis was used to identify predictive factors for pain relief after closure of the mesenteric defects.

Results: A total of 193 patients underwent laparoscopy for (suspected) IH during the study period. The median interval between LRYGB and reoperation was 18.3 ± 19.0 months. In 40.2% of cases, IH was identified on computed tomography (CT), and IH was objectified during surgery in 61.1%. Postoperative symptom relief was observed in 146 patients (77.2%). For patients in which IH was present during surgery, 82.8% had relief of pain postoperatively, as compared to 68.5% for those procedures in which no IH was found. The only significant predictor for postoperative pain relief was a swirl sign on CT (OR 4.24, 95%CI 1.63-11.05).

Conclusions: Pain relief after closure of the mesenteric defects for IH remains unpredictable. A positive CT for IH was a predictive factor for symptom relief after reoperation for (suspected) IH after LRYGB. However, many patients benefit from closure of the mesenteric defects, irrespective of perioperative presence of IH.
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http://dx.doi.org/10.1007/s11695-018-3404-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6223761PMC
December 2018

Calibration of the Gastric Pouch in Laparoscopic Roux-en-Y Gastric Bypass: Does It Matter? The Influence on Weight Loss.

Obes Surg 2018 11;28(11):3400-3404

Department of Surgery, Red Cross Hospital Beverwijk, Vondellaan 13, 1942 LE, Beverwijk, The Netherlands.

Purpose: To determine the effect of an orogastric tube for calibration of the gastric pouch on percentage excess weight loss (%EWL) and percentage total weight loss (%TWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB).

Material And Methods: A retrospective case-matched control study in 132 patients. Group A (a 40 French orogastric tube was used to calibrate the gastric pouch) was compared to group B (no orogastric tube was used). All other surgical steps were identical in both groups. Postoperative %EWL and %TWL were recorded at 3, 6, 9, 12, and 24 months postoperatively.

Results: Baseline characteristics and comorbidities were similar for both groups; a mean age of 43.6 years, 84% of the patients were female and mean initial BMI was 44 kg/m. At 24 months, 9% of the patients were lost to follow-up. At 1-year follow-up, %EWL and %TWL were 80% and 33.3% in group A versus 70% and 28.6% in group B with p = 0.013 and p = 0.007 respectively. At 2 years, EWL% and %TWL were 79.5% and 32.8% in group A and 67.18% and 28.1% in group B with a p value of 0.019 and 0.001 respectively. The use of a calibration tube, initial BMI, and age predicted the %TWL best with R squared at 30.7%.

Conclusion: The use of a calibration tube for creating the gastric pouch may lead to a higher %EWL and %TWL at 2-year follow-up. The standardization of the technique for LRYGB is desirable to achieve the maximum success rate in the surgical therapy of morbid obesity.
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http://dx.doi.org/10.1007/s11695-018-3352-3DOI Listing
November 2018

Long-Term Prognostic Implications of Previous Silent Myocardial Infarction in Patients Presenting With Acute Myocardial Infarction.

JACC Cardiovasc Imaging 2018 12 18;11(12):1773-1781. Epub 2018 Apr 18.

Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands. Electronic address:

Objectives: This study investigated the prevalence of silent myocardial infarction (MI) in patients presenting with first acute myocardial infarction (AMI), and its relation with mortality and major adverse cardiovascular events (MACE) at long-term follow-up.

Background: Up to 54% of MI occurs without apparent symptoms. The prevalence and long-term prognostic implications of previous silent MI in patients presenting with seemingly first AMI are unclear.

Methods: A 2-center observational longitudinal study was performed in 392 patients presenting with first AMI between 2003 and 2013, who underwent late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) examination within 14 days post-AMI. Silent MI was assessed on LGE-CMR images by identifying regions of hyperenhancement with an ischemic distribution pattern in other territories than the AMI. Mortality and MACE (all-cause death, reinfarction, coronary artery bypass grafting, and ischemic stroke) were assessed at 6.8 ± 2.9 years follow-up.

Results: Thirty-two patients (8.2%) showed silent MI on LGE-CMR. Compared with patients without silent MI, mortality risk was higher in patients with silent MI (hazard ratio: 3.87; 95% confidence interval: 1.21 to 12.38; p = 0.023), as was risk of MACE (hazard ratio: 3.10; 95% confidence interval: 1.22 to 7.86; p = 0.017), both independent from clinical and infarction-related characteristics.

Conclusions: Silent MI occurred in 8.2% of patients presenting with first AMI and was independently related to poorer long-term clinical outcome, with a more than 3-fold risk of mortality and MACE. Silent MI holds prognostic value over important traditional prognosticators in the setting of AMI, indicating that these patients represent a high-risk subgroup warranting clinical awareness.
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http://dx.doi.org/10.1016/j.jcmg.2018.02.009DOI Listing
December 2018

The FGF21 response to fructose predicts metabolic health and persists after bariatric surgery in obese humans.

Mol Metab 2017 11 4;6(11):1493-1502. Epub 2017 Sep 4.

Department of Endocrinology and Metabolism, Academic Medical Center, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands. Electronic address:

Objective: Fructose consumption has been implicated in the development of obesity and insulin resistance. Emerging evidence shows that fibroblast growth factor 21 (FGF21) has beneficial effects on glucose, lipid, and energy metabolism and may also mediate an adaptive response to fructose ingestion. Fructose acutely stimulates circulating FGF21 consistent with a hormonal response. We aimed to evaluate whether fructose-induced FGF21 secretion is linked to metabolic outcomes in obese humans before and after bariatric surgery-induced weight loss.

Methods: We recruited 40 Roux-en-Y gastric bypass patients and assessed the serum FGF21 response to fructose (75-g fructose tolerance test) and basal and insulin-mediated glucose and lipid fluxes during a 2-step hyperinsulinemic-euglycemic clamp with infusion of [6,6-H] glucose and [1,1,2,3,3-H] glycerol. Liver biopsies were obtained during bariatric surgery. Nineteen subjects underwent the same assessments at 1-year follow-up.

Results: Serum FGF21 increased 3-fold at 120 min after fructose ingestion and returned to basal levels at 300 min. Neither basal FGF21 nor the fructose-FGF21 response correlated with liver fat content or liver histopathology, but increased levels were associated with elevated endogenous glucose production, increased lipolysis, and peripheral/muscle insulin resistance. At 1-year follow-up, subjects had lost 28 ± 6% of body weight and improved in all metabolic outcomes, but fructose-stimulated FGF21 dynamics did not markedly differ from the pre-surgical state. The association between increased basal and stimulated FGF21 levels with poor metabolic health was no longer present after weight loss.

Conclusions: Fructose ingestion in obese humans stimulates FGF21 secretion, and this response is related to systemic metabolism. Further studies are needed to establish if FGF21 signaling is (patho)physiologically involved in fructose metabolism and metabolic health.
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http://dx.doi.org/10.1016/j.molmet.2017.08.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5681276PMC
November 2017

Influence of coronary calcification patterns on hemodynamic outcome of coronary stenoses and remodeling.

Turk Kardiyol Dern Ars 2017 Oct;45(7):606-613

Department of Cardiology, Istanbul University Faculty of Medicine, İstanbul, Turkey.

Objective: The histological characteristics of plaque may affect the hemodynamic outcome of a given coronary stenosis. In particular, the potential effect of volumetric calcium content and the topographical distribution in the lesion segment on physiological outcome has not yet been investigated. The aim of this study was to identify any potential correlation between patterns of calcification and the fractional flow reserve (FFR) and the coronary remodeling index (RMI).

Methods: A total of 26 stable angina pectoris and 34 acute coronary syndrome patients without persistent ST-segment elevation constituted the study population. FFR was used to assess 70 intermediate coronary stenosis lesions. After obtaining hemodynamic measurements, quantitative grayscale and virtual histology-intravascular ultrasound analyses were performed. The depth, length, and circumferential distribution of calcification of the lesions were also recorded.

Results: Within the analyzed segment (area of interest, lesion segment), FFR was correlated with maximal thickness of deep calcification (r=-0.285; p=0.021) and calcification angle (r=-0.396; p=0.001). In lesions with a calcification angle >180°, the mean FFR value was significantly lower compared with those <180° (0.64±0.17 vs. 0.78±0.08; p=0.024). RMI was correlated with maximal angle of superficial (r=-0.437; p<0.001) and deep (r=0.425; p<0.001) calcification. RMI was correlated with maximal thickness of superficial (r=-0.357; p=0.003) and deep (r=0.417; p<0.001) calcification. RMI was also correlated with FFR (r=-0.477; p<0.001).

Conclusion: This study demonstrated that the geometry, location, and amount of calcification of a plaque could affect hemodynamic and anatomical outcome measures in functionally significant stenoses by affecting vessel wall compliance.
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http://dx.doi.org/10.5543/tkda.2017.94493DOI Listing
October 2017
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