Nina Hakacova - Academia.edu (original) (raw)

Papers by Nina Hakacova

Research paper thumbnail of The utility of modified Butler-Leggett criteria for right ventricular hypertrophy in detection of clinically significant shunt ratio in ostium secundum–type atrial septal defect in adults

Journal of Electrocardiology, Mar 1, 2010

Background: This study was performed to test the hypothesis that there exists a correlation betwe... more Background: This study was performed to test the hypothesis that there exists a correlation between the Butler-Leggett (BL) criterion for right ventricular hypertrophy on the electrocardiogram and the Qp/Qs shunt ratio in adults with ostium secundum atrial septal defects (ASDs). Methods: Demographic, cardiac catheterization, ASD closure, and electrocardiographic data were acquired on 70 patients with secundum ASDs closed percutaneously. Simple linear regression and logistic regression models were created to test the hypothesis. Results: The mean Qp/Qs ratio and BL criterion value were 1.61 ± 0.46 and 0.11 ± 0.41, respectively. The BL criterion values correlated with shunt ratios (r 2 = 0.11 and P = .004). A BL criterion value greater than 0 mV predicted a significant shunt ratio (Qp/Qs ≥1.5) (odds ratio, 4.8; 95% confidence interval, 1.3, 18.1; P = b.0001) with a sensitivity of 0.68 and specificity of 0.65. Conclusion: Our results indicate that there is limited utility of the BL criterion at detecting right ventricular volume overload, although a BL criterion value greater than 0 mV being used to identify patients with significant intracardiac shunts yielded a sensitivity of 0.68 and specificity of 0.65.

Research paper thumbnail of Long-term outcome after early repair of complete atrioventricular septal defect in young infants

The Journal of Thoracic and Cardiovascular Surgery, 2021

Objective: The long-term outcome after repair of complete atrioventricular septal defect in young... more Objective: The long-term outcome after repair of complete atrioventricular septal defect in young infants is still not fully understood. The objective of this study was to evaluate data after repair for complete atrioventricular septal defect over a 25-year period to assess survival and identify risk factors for left atrioventricular valve-related reoperations. Methods: A total of 304 consecutive patients underwent surgical correction for complete atrioventricular septal defect between April 1993 and October 2018. The results for young infants (aged <3 months; n ¼ 55; mean age 1.6 AE 0.6 months) were compared with older infants (aged >3 months; n ¼ 249; mean age, 5.1 AE 5.2 months). Mean follow-up was 13.2 AE 7.8 years (median, 14.0 years; interquartile range, 7.0-20.0). The Kaplan-Meier method was used to assess overall survival and freedom from left atrioventricular valve-related reoperation. Results: Overall, 30-day mortality was 1.0% (3/304) with no difference between young and older infants (P ¼ 1.0). Overall survival in the total population at 20year follow-up was 95.1% (AE1.3%). Independent risk factors for poor survival were the presence of an additional ventricular septal defect (P ¼ .042), previous coarctation of the aorta (P < .001), persistent left superior vena cava (P ¼ .026), and genetic syndromes other than Trisomy 21 (P ¼ .017). Freedom from left atrioventricular valve-related reoperation was 92.6% (AE1.7%) at 20 years. There was no significant difference in left atrioventricular valve-related reoperation in young infants compared with older infants (P ¼ .084).

Research paper thumbnail of Impact of concomitant complex cardiac anatomy in nonsyndromic patients with complete atrioventricular septal defect

The Journal of Thoracic and Cardiovascular Surgery, 2021

OBJECTIVE We studied a cohort of patients with nonsyndromic complete atrioventricular septal defe... more OBJECTIVE We studied a cohort of patients with nonsyndromic complete atrioventricular septal defect with and without concomitant complex cardiac anatomy and compared the outcomes after surgical repair. METHODS Between 1993 and 2018, 62 nonsyndromic patients underwent complete atrioventricular septal defect repair. Sixteen patients (26%) had complex complete atrioventricular septal defect with variables representing concomitant cardiac anatomic complexity: tetralogy of Fallot, double outlet right ventricle, total anomalous pulmonary venous return, concomitant aortic arch reconstruction, multiple ventricular septal defects, staged repair of coarctation of the aorta, and a persisting left superior vena cava. The mean follow-up was 12.7 ± 7.9 years. Baseline variables were retrospectively evaluated and analyzed using univariable logistic regression. Survival was studied using Kaplan-Meier estimates, and group comparisons were performed using the log-rank test. A competing-risk analysis estimated the risk of reoperation with death as the competing event. A Gray's test was used to test equality of the cumulative incidence curves between groups. RESULTS The perioperative mortality was 3.2% (2/62). Actuarial survival was 100% versus 66.7% ± 14.9% at 10 years in the noncomplex and complex groups, respectively (P < .01). There was no significant difference in the overall reoperation rate between the noncomplex group (7/46; 15%) and the complex group (4/16; 25%) (odds ratio, 1.86; 95% confidence interval, 0.46-7.45; P = .30). The competing-risk analysis demonstrated no significant difference in reoperation between the groups (P = .28). CONCLUSIONS Our data show that nonsyndromic patients without complex cardiac anatomy have a good long-term survival and an acceptable risk of reoperation similar to contemporary outcomes for patients with complete atrioventricular septal defect with trisomy 21. However, the corresponding group of nonsyndromic patients with concomitant complex cardiac lesions are still a high-risk population, especially regarding mortality.

Research paper thumbnail of Dr. Galen Wagner (1939-2016) as an Academic Writer: An Overview of his Peer-reviewed Scientific Publications

Journal of electrocardiology

Research paper thumbnail of In memory of Professor Galen S. Wagner M.D., Ph.D. (1939–2016): our mentor, colleague and friend

Journal of Electrocardiology, 2017

Research paper thumbnail of The Research Practicum and International Research Interdisciplinary School (IRIS) initiatives: In Memory of Professor Galen S. Wagner M.D., PhD

Journal of Electrocardiology, 2017

Research paper thumbnail of The comparative relationships between locations of the papillary muscles and electrophysiologic QRS axis in patients with atrioventricular septal defect and common as opposed to separate orifices in the valve guarding the common atrioventricular junction

Cardiology in the young, Jan 18, 2016

Knowledge regarding factors that influence deviation of the QRS axis is important when seeking to... more Knowledge regarding factors that influence deviation of the QRS axis is important when seeking to differentiate between physiological and pathological changes. We hypothesised that, in contrast to those patients with an atrioventricular septal defect and common atrioventricular junction permitting only atrial shunting, those associated with ventricular shunting would show no relationship between the positions of the papillary muscles and the degree of the leftward deviation of the QRS axis. We compared the positions of endocardial origin of the papillary muscles, and the frontal plane QRS axis, in patients with atrioventricular septal defects and common atrioventricular junction permitting exclusively atrial as opposed to atrial and ventricular shunting. We analysed 18 patients with atrial and ventricular shunting and 23 patients with exclusively atrial shunting. The correlation coefficient between the ratio of distances of the papillary muscles from the mid-septum and the amount of...

Research paper thumbnail of Building network for enhancement of scientific/research literacy: the Scientific Summer School 2009 in Szczepanow, Poland

Anadolu kardiyoloji dergisi : AKD = the Anatolian journal of cardiology, 2009

Research paper thumbnail of The effect of International Scientific Summer School research training on scientific productivity of trainees

International journal of cardiology, Jan 20, 2014

Research paper thumbnail of The utility of modified Butler-Leggett criteria for right ventricular hypertrophy in detection of clinically significant shunt ratio in ostium secundum–type atrial septal defect in adults

Journal of Electrocardiology, 2010

Background: This study was performed to test the hypothesis that there exists a correlation betwe... more Background: This study was performed to test the hypothesis that there exists a correlation between the Butler-Leggett (BL) criterion for right ventricular hypertrophy on the electrocardiogram and the Qp/Qs shunt ratio in adults with ostium secundum atrial septal defects (ASDs). Methods: Demographic, cardiac catheterization, ASD closure, and electrocardiographic data were acquired on 70 patients with secundum ASDs closed percutaneously. Simple linear regression and logistic regression models were created to test the hypothesis. Results: The mean Qp/Qs ratio and BL criterion value were 1.61 ± 0.46 and 0.11 ± 0.41, respectively. The BL criterion values correlated with shunt ratios (r 2 = 0.11 and P = .004). A BL criterion value greater than 0 mV predicted a significant shunt ratio (Qp/Qs ≥1.5) (odds ratio, 4.8; 95% confidence interval, 1.3, 18.1; P = b.0001) with a sensitivity of 0.68 and specificity of 0.65. Conclusion: Our results indicate that there is limited utility of the BL criterion at detecting right ventricular volume overload, although a BL criterion value greater than 0 mV being used to identify patients with significant intracardiac shunts yielded a sensitivity of 0.68 and specificity of 0.65.

Research paper thumbnail of Simulation of the QRS complex using papillary muscles positions as the site of early activation: first QRS simulation in human subjects

Journal of Electrocardiology, 2009

Simulation of the electrical activation of the heart and its comparison with real in vivo activat... more Simulation of the electrical activation of the heart and its comparison with real in vivo activation is a promising method in testing potential determinants of excitation. Simulation of the electrical activity of the human heart is now emerging as a step forward for understanding and predicting electrophysiologic patterns in humans. Initial points of excitation and the manner in which the activation spreads from these points are important variables determining QRS complex characteristics. It has been suggested that in humans, the initial excitation of the left ventricle is a primary determinant of QRS complex characteristics, and that excitation begins at the papillary muscles and septum, where the fascicles of the left bundle branch insert. The aim of this study is to test the hypothesis that QRS duration and direction of QRS axis in the frontal plane have excellent agreement between real QRS and simulated QRS using papillary muscle position to indicate the border of the origin of early ventricular activation. Fourteen healthy adult volunteers were included in the study. Magnetic resonance imaging data were obtained to assess the papillary muscle positions. Twelve-lead electrocardiographic (ECG) recordings were used to obtain real ECG data for assessment of QRS duration and QRS axis in each subject. Simulation software developed by ECG-TECH Corp (Huntington, NY) was used to simulate the ECG of each subject to determine simulated QRS duration and QRS frontal plane axis. QRS duration and QRS axis data were compared between simulated and real ECG and agreement between these variables was calculated. Seventy-nine percent of subjects had a difference of the QRS duration between real and simulated ECG of less than 10 milliseconds. The calculated strength of agreement between simulated and real QRS duration was 71% and considered as &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;good&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; (kappa statistics). In 70% of subjects, the difference in the QRS axis was less than 10 degrees . The calculated strength of agreement between simulated and real QRS axis was 80% and considered as &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;excellent&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; (kappa statistics). The results of this study suggest that the sites of the initiation of electrical activity in the left ventricle, as assessed by the positions of papillary muscles, may be considered as primary determinants of the QRS duration and QRS axis in humans. This knowledge may help in predicting normal QRS characteristic on a patient-specific basis. In this study, simulation of the QRS complex was based on papillary muscles from human hearts.

Research paper thumbnail of Right and left ventricular pressure overload as imaged by electrocardiogram

Journal of Electrocardiology, 2014

Right and left ventricular pressure overload as imaged by electrocardiogram Electrical changes in... more Right and left ventricular pressure overload as imaged by electrocardiogram Electrical changes in the heart evolve as pressure load of either the right (RV) or the left ventricle (LV) changes [1]. So called "electro-mechanical feedback" has been studied mostly in the left ventricle, with pressure overloads caused by aortic stenosis or systemic hypertension [2,3]. Regarding the RV, electro-mechanical changes have been described with pressure overloads caused by pulmonary stenosis or pulmonary hypertension [4-6]. Currently however, electrocardiography (ECG) is used rarely, in prediction and/or follow-up of changing ventricular pressure overloading conditions in clinical practice. Only the mechanical change of heart function, and the anatomical change of increase in mass are being followed by imaging modalities such as ultrasound or MRI [7]. Even though "electrical instability" is mentioned as an important predictive factor of lifethreatening events in patients with pressure overload of the ventricles, the ECG has become obsolete as a clinical tool, except to detect arrhythmias [8,9]. In clinical practice, many abnormalities imposed by acquired or congenital heart disease can lead to pressure overload of the right and/or left ventricle and can subsequently lead to heart failure, when the compensatory mechanisms become inadequate. Can clinicians monitor these conditions by ECG, to identify changes that can detect the severity of pressure overload non-invasively? How does pressure overloading or unloading change electrical potentials and how rapidly does this evolve? Can clinicians then guide the therapy by responding to these "clinical electrophysiologic" changes? There are compelling data to suggest that appreciation and understanding of electrophysiologic changes can facilitate recognition of pathophysiological processes in the heart [1,6,10]. Appreciation of both right-left heart interactions and electro-mechanical interactions may be possible by using the clinically available standard ECG as a non-invasive "electrophysiologic imaging" technology. The Journal of Electrocardiology is preparing a symposium on right and/or left ventricular pressure overload as imaged by the ECG in its September-October 2014 issue. Papers concerning both adult and pediatric cardiology will be included after emerging from the Journal's peer-review process. The purpose of this letter is to invite contributions from those who can share their understanding on this topic. Not only strengths, but also vulnerabilities of the ECG should be discussed, and thus potentially lead to innovations in use of the ECG as a method of monitoring the clinical course of these patients.

Research paper thumbnail of Importance of standardized assessment of late gadolinium enhancement for quantification of infarct size by cardiac magnetic resonance: implications for comparison with electrocardiogram

Journal of Electrocardiology, 2011

Cardiac magnetic resonance (CMR) is currently considered the reference standard for in vivo asses... more Cardiac magnetic resonance (CMR) is currently considered the reference standard for in vivo assessment of myocardial infarction (MI). There is, however, no international consensus on how MI quantification from CMR should be performed. The aim of this study was to test how previously published manual quantification of MI using CMR images compares with MI quantification using a semiautomated, validated method and how this impacts the relationship with MI size estimated by 12-lead electrocardiogram (ECG). Twenty-five patients, from a previously published cohort, were included in the study. All patients had presented with clinical signs of acute coronary syndrome 6 to 12 months before undergoing a CMR examination. The patients had a standard 12-lead ECG recorded at the time of the CMR examination. The previously reported manually quantified MI size was compared with MI size determined using a semiautomated method validated by computer phantom data, experimental in vivo and ex vivo data, and patient data. The MI sizes from the 2 CMR approaches were then compared with the ECG-estimated MI size. There was a strong correlation between MI size determined with the 2 CMR methods (r(2) = 0.94, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). There was, however, a systematic overestimation of MI size of approximately 50% by the previously published manually quantified MI size compared with the semiautomated method. This affected the comparison with estimated MI size by ECG, which showed a significant underestimation of MI size compared with manual CMR measurements, but no bias compared with the semiautomated CMR method. Manual quantification of MI size by CMR can differ significantly from semiautomated, validated methods taking partial volume effects into account and can lead to erroneous conclusions when compared with ECG.

Research paper thumbnail of Relationships between cardiac magnetic resonance imaging abnormalities in the inter-ventricular septum and Selvester QRS scoring criteria for anterior–septal myocardial infarction in patients with right ventricular volume overload

Journal of Electrocardiology, 2013

Patients with ostium secundum atrial septal defects (ASDs) were studied to determine the prevalen... more Patients with ostium secundum atrial septal defects (ASDs) were studied to determine the prevalence of Selvester anteroseptal myocardial infarction QRS points, and to test the hypothesis that there is a relationship between these criteria and thinning and/or scarring of the inter-ventricular septum (IVS). Demographic, electrocardiographic (ECG), and cardiac magnetic resonance imaging (CMR) data were acquired on 46 patients with a secundum ASD closed percutaneously. Selvester QRS scoring on patient ECGs was performed for areas representing the anteroseptal region of the left ventricle (LV). The IVS to LV free wall thickness ratio was used to assess thinning of the IVS while late gadolinium enhancement (LGE) of the IVS was used for scarring; both using CMR. Twenty-four (52%) patients scored Selvester QRS points in the anteroseptal region with a mean score of 2.6±1.8. The mean IVS/LV free wall thickness ratio at the basal level and mid-ventricular level was 1.1±0.3 and 1.3±0.3, respectively. There was no association of Selvester QRS points with IVS/LV free wall ratio at the basal (p=0.59) or mid-ventricular (p=0.13) levels. The one patient with LGE in the IVS had 4 Selvester anteroseptal QRS points. The results of our study demonstrate that in our patient population there is a 52% prevalence of Selvester anteroseptal QRS points which are due to thinning and/or scarring of the IVS in only one patient.

Research paper thumbnail of Computer-based rhythm diagnosis and its possible influence on nonexpert electrocardiogram readers

Journal of Electrocardiology, 2012

Systems providing computer-based analysis of the resting electrocardiogram (ECG) seek to improve ... more Systems providing computer-based analysis of the resting electrocardiogram (ECG) seek to improve the quality of health care by providing accurate and timely automatic diagnosis of, for example, cardiac rhythm to clinicians. The accuracy of these diagnoses, however, remains questionable. We tested the hypothesis that (a) 2 independent automated ECG systems have better accuracy in rhythm diagnosis than nonexpert clinicians and (b) both systems provide correct diagnostic suggestions in a large percentage of cases where the diagnosis of nonexpert clinicians is incorrect. Five hundred ECGs were manually analyzed by 2 senior experts, 3 nonexpert clinicians, and automatically by 2 automated systems. The accuracy of the nonexpert rhythm statements was compared with the accuracy of each system statement. The proportion of rhythm statements when the clinician&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s diagnoses were incorrect and the systems instead provided correct diagnosis was assessed. A total of 420 sinus rhythms and 156 rhythm disturbances were recognized by expert reading. Significance of the difference in accuracy between nonexperts and systems was P = .45 for system A and P = .11 for system B. The percentage of correct automated diagnoses in cases when the clinician was incorrect was 28% ± 10% for system A and 25% ± 11% for system B (P = .09). The rhythm diagnoses of automated systems did not reach better average accuracy than those of nonexpert readings. The computer diagnosis of rhythm can be incorrect in cases where the clinicians fail in reaching the correct ECG diagnosis.

Research paper thumbnail of Electrocardiographic Measures of Myocardial Function and Necrosis

JACC: Cardiovascular Imaging, 2009

Research paper thumbnail of Electroanatomic Relationships in Patients With Primum Atrioventricular Septal Defect

JACC: Cardiovascular Imaging, 2009

The objective of this study was to test the hypothesis that patients with primum atrioventricular... more The objective of this study was to test the hypothesis that patients with primum atrioventricular septal defect (AVSD) have an imbalance in the positions of the left ventricular papillary muscles compared with healthy subjects, and that this anatomic imbalance correlates with left deviation of the QRS axis. B A C K G R O U N D The function and contraction pattern of the heart is best predicted when cardiac anatomy is considered together with its electrical activation sequence. Understanding the electroanatomic relationships is essential for discovering the developmental relationships between the conduction system and heart structures. Left deviation of the QRS axis is typically present in patients with primum AVSD. However, the pathophysiology of this phenomenon is not understood. M E T H O D S Thirty-five patients with primum AVSD and 35 healthy subjects were included in the study. Echocardiographic images were used to determine the papillary muscle positions. A 12-lead electrocardiogram was used to determine the QRS axis in the frontal plane in both patients and healthy subjects. R E S U L T S An imbalance between papillary muscle positions in primum AVSD patients was defined as the position of the anterior papillary muscle closer to the septum and/or the position of the posterior papillary muscle further from the septum compared with the position of the papillary muscles in healthy subjects. In primum AVSD patients compared with control subjects, there was significant imbalance in the positions of the papillary muscles (p ϭ 0.0007). The imbalance of papillary muscles correlated with deviation of the QRS (r ϭ 0.5, p ϭ 0.0019).

Research paper thumbnail of Determination of the mitral papillary muscle positions by the septal‐to‐free wall arc ratio method

Clinical Physiology and Functional Imaging, 2009

SummaryBackground: Determination of mitral papillary muscle positions is of increasing interest ... more SummaryBackground: Determination of mitral papillary muscle positions is of increasing interest in wide spectrum of clinical cardiology fields. Particularly, relative positioning of the papillary muscles between the inter‐ventricular septum and the left ventricular free wall is of interest. A reproducible method for determination of papillary muscle positions has not been established. In this study a new ‘septal‐to‐free wall arc ratio’ (SFAR) method for measuring papillary muscle positions is presented. The reproducibility of the SFAR method between echocardiographic (ECHO) and magnetic resonance (MRI) modalities and between observers is tested.Methods: Twenty subjects with structurally normal hearts in whom both MRI and ECHO were performed in 2007 were included in the study. Papillary muscle positions were determined using the SFAR method. Inter‐modality (ECHO and MRI) and inter‐observer reproducibility of the methods was assessed by calculating correlation coefficients and the m...

Research paper thumbnail of Aspects of Left Ventricular Morphology Outperform Left Ventricular Mass for Prediction of QRS Duration

Annals of Noninvasive Electrocardiology, 2010

Background: The knowledge of the case-specific normal QRS duration in each individual is needed w... more Background: The knowledge of the case-specific normal QRS duration in each individual is needed when determining the onset, severity and progression of the heart disease. However, large interindividual variability even of the normal QRS duration exists. The aims of the study were to develop a model for prediction of normal QRS complex duration and to test it on healthy individuals. Methods: The study population of healthy adult volunteers was divided into a sample for development of a prediction model (n = 63) and a testing sample (n = 30). Magnetic resonance imaging data were used to assess anatomical characteristics of the left ventricle: the angle between papillary muscles (PM A), the length of the left ventricle (LV L) and left ventricular mass (LV M). Twelve-lead electrocardiogram (ECG) was used for measurement of the QRS duration. Multiple linear regression analysis was used to develop a prediction model to estimate the QRS duration. The accuracy of the prediction model was assessed by comparing predicted with measured QRS duration in the test set. Results: The angle between PM A and the length of the LV L were statistically significant predictors of QRS duration. Correlation between QRS duration and PM A and LV L was r = 0.57, P = 0.0001 and r = 0.45, P = 0.0002, respectively. The final model for prediction of the QRS was: QRS Predicted = 97 + (0.35 × LV L) − (0.45 × PM A). The predicted and real QRS duration differed with median 1 ms. Conclusions: The model for prediction of QRS duration opens the ability to predict case-specific normal QRS duration. This knowledge can have clinical importance, when determining the normality on case-specific basis.

Research paper thumbnail of Problem-oriented education and cross-cultural collaboration: experiences and comments on the Scientific Summer School in Turkey 2010

Anadolu Kardiyoloji Dergisi/The Anatolian Journal of Cardiology, 2010

Research paper thumbnail of The utility of modified Butler-Leggett criteria for right ventricular hypertrophy in detection of clinically significant shunt ratio in ostium secundum–type atrial septal defect in adults

Journal of Electrocardiology, Mar 1, 2010

Background: This study was performed to test the hypothesis that there exists a correlation betwe... more Background: This study was performed to test the hypothesis that there exists a correlation between the Butler-Leggett (BL) criterion for right ventricular hypertrophy on the electrocardiogram and the Qp/Qs shunt ratio in adults with ostium secundum atrial septal defects (ASDs). Methods: Demographic, cardiac catheterization, ASD closure, and electrocardiographic data were acquired on 70 patients with secundum ASDs closed percutaneously. Simple linear regression and logistic regression models were created to test the hypothesis. Results: The mean Qp/Qs ratio and BL criterion value were 1.61 ± 0.46 and 0.11 ± 0.41, respectively. The BL criterion values correlated with shunt ratios (r 2 = 0.11 and P = .004). A BL criterion value greater than 0 mV predicted a significant shunt ratio (Qp/Qs ≥1.5) (odds ratio, 4.8; 95% confidence interval, 1.3, 18.1; P = b.0001) with a sensitivity of 0.68 and specificity of 0.65. Conclusion: Our results indicate that there is limited utility of the BL criterion at detecting right ventricular volume overload, although a BL criterion value greater than 0 mV being used to identify patients with significant intracardiac shunts yielded a sensitivity of 0.68 and specificity of 0.65.

Research paper thumbnail of Long-term outcome after early repair of complete atrioventricular septal defect in young infants

The Journal of Thoracic and Cardiovascular Surgery, 2021

Objective: The long-term outcome after repair of complete atrioventricular septal defect in young... more Objective: The long-term outcome after repair of complete atrioventricular septal defect in young infants is still not fully understood. The objective of this study was to evaluate data after repair for complete atrioventricular septal defect over a 25-year period to assess survival and identify risk factors for left atrioventricular valve-related reoperations. Methods: A total of 304 consecutive patients underwent surgical correction for complete atrioventricular septal defect between April 1993 and October 2018. The results for young infants (aged <3 months; n ¼ 55; mean age 1.6 AE 0.6 months) were compared with older infants (aged >3 months; n ¼ 249; mean age, 5.1 AE 5.2 months). Mean follow-up was 13.2 AE 7.8 years (median, 14.0 years; interquartile range, 7.0-20.0). The Kaplan-Meier method was used to assess overall survival and freedom from left atrioventricular valve-related reoperation. Results: Overall, 30-day mortality was 1.0% (3/304) with no difference between young and older infants (P ¼ 1.0). Overall survival in the total population at 20year follow-up was 95.1% (AE1.3%). Independent risk factors for poor survival were the presence of an additional ventricular septal defect (P ¼ .042), previous coarctation of the aorta (P < .001), persistent left superior vena cava (P ¼ .026), and genetic syndromes other than Trisomy 21 (P ¼ .017). Freedom from left atrioventricular valve-related reoperation was 92.6% (AE1.7%) at 20 years. There was no significant difference in left atrioventricular valve-related reoperation in young infants compared with older infants (P ¼ .084).

Research paper thumbnail of Impact of concomitant complex cardiac anatomy in nonsyndromic patients with complete atrioventricular septal defect

The Journal of Thoracic and Cardiovascular Surgery, 2021

OBJECTIVE We studied a cohort of patients with nonsyndromic complete atrioventricular septal defe... more OBJECTIVE We studied a cohort of patients with nonsyndromic complete atrioventricular septal defect with and without concomitant complex cardiac anatomy and compared the outcomes after surgical repair. METHODS Between 1993 and 2018, 62 nonsyndromic patients underwent complete atrioventricular septal defect repair. Sixteen patients (26%) had complex complete atrioventricular septal defect with variables representing concomitant cardiac anatomic complexity: tetralogy of Fallot, double outlet right ventricle, total anomalous pulmonary venous return, concomitant aortic arch reconstruction, multiple ventricular septal defects, staged repair of coarctation of the aorta, and a persisting left superior vena cava. The mean follow-up was 12.7 ± 7.9 years. Baseline variables were retrospectively evaluated and analyzed using univariable logistic regression. Survival was studied using Kaplan-Meier estimates, and group comparisons were performed using the log-rank test. A competing-risk analysis estimated the risk of reoperation with death as the competing event. A Gray's test was used to test equality of the cumulative incidence curves between groups. RESULTS The perioperative mortality was 3.2% (2/62). Actuarial survival was 100% versus 66.7% ± 14.9% at 10 years in the noncomplex and complex groups, respectively (P < .01). There was no significant difference in the overall reoperation rate between the noncomplex group (7/46; 15%) and the complex group (4/16; 25%) (odds ratio, 1.86; 95% confidence interval, 0.46-7.45; P = .30). The competing-risk analysis demonstrated no significant difference in reoperation between the groups (P = .28). CONCLUSIONS Our data show that nonsyndromic patients without complex cardiac anatomy have a good long-term survival and an acceptable risk of reoperation similar to contemporary outcomes for patients with complete atrioventricular septal defect with trisomy 21. However, the corresponding group of nonsyndromic patients with concomitant complex cardiac lesions are still a high-risk population, especially regarding mortality.

Research paper thumbnail of Dr. Galen Wagner (1939-2016) as an Academic Writer: An Overview of his Peer-reviewed Scientific Publications

Journal of electrocardiology

Research paper thumbnail of In memory of Professor Galen S. Wagner M.D., Ph.D. (1939–2016): our mentor, colleague and friend

Journal of Electrocardiology, 2017

Research paper thumbnail of The Research Practicum and International Research Interdisciplinary School (IRIS) initiatives: In Memory of Professor Galen S. Wagner M.D., PhD

Journal of Electrocardiology, 2017

Research paper thumbnail of The comparative relationships between locations of the papillary muscles and electrophysiologic QRS axis in patients with atrioventricular septal defect and common as opposed to separate orifices in the valve guarding the common atrioventricular junction

Cardiology in the young, Jan 18, 2016

Knowledge regarding factors that influence deviation of the QRS axis is important when seeking to... more Knowledge regarding factors that influence deviation of the QRS axis is important when seeking to differentiate between physiological and pathological changes. We hypothesised that, in contrast to those patients with an atrioventricular septal defect and common atrioventricular junction permitting only atrial shunting, those associated with ventricular shunting would show no relationship between the positions of the papillary muscles and the degree of the leftward deviation of the QRS axis. We compared the positions of endocardial origin of the papillary muscles, and the frontal plane QRS axis, in patients with atrioventricular septal defects and common atrioventricular junction permitting exclusively atrial as opposed to atrial and ventricular shunting. We analysed 18 patients with atrial and ventricular shunting and 23 patients with exclusively atrial shunting. The correlation coefficient between the ratio of distances of the papillary muscles from the mid-septum and the amount of...

Research paper thumbnail of Building network for enhancement of scientific/research literacy: the Scientific Summer School 2009 in Szczepanow, Poland

Anadolu kardiyoloji dergisi : AKD = the Anatolian journal of cardiology, 2009

Research paper thumbnail of The effect of International Scientific Summer School research training on scientific productivity of trainees

International journal of cardiology, Jan 20, 2014

Research paper thumbnail of The utility of modified Butler-Leggett criteria for right ventricular hypertrophy in detection of clinically significant shunt ratio in ostium secundum–type atrial septal defect in adults

Journal of Electrocardiology, 2010

Background: This study was performed to test the hypothesis that there exists a correlation betwe... more Background: This study was performed to test the hypothesis that there exists a correlation between the Butler-Leggett (BL) criterion for right ventricular hypertrophy on the electrocardiogram and the Qp/Qs shunt ratio in adults with ostium secundum atrial septal defects (ASDs). Methods: Demographic, cardiac catheterization, ASD closure, and electrocardiographic data were acquired on 70 patients with secundum ASDs closed percutaneously. Simple linear regression and logistic regression models were created to test the hypothesis. Results: The mean Qp/Qs ratio and BL criterion value were 1.61 ± 0.46 and 0.11 ± 0.41, respectively. The BL criterion values correlated with shunt ratios (r 2 = 0.11 and P = .004). A BL criterion value greater than 0 mV predicted a significant shunt ratio (Qp/Qs ≥1.5) (odds ratio, 4.8; 95% confidence interval, 1.3, 18.1; P = b.0001) with a sensitivity of 0.68 and specificity of 0.65. Conclusion: Our results indicate that there is limited utility of the BL criterion at detecting right ventricular volume overload, although a BL criterion value greater than 0 mV being used to identify patients with significant intracardiac shunts yielded a sensitivity of 0.68 and specificity of 0.65.

Research paper thumbnail of Simulation of the QRS complex using papillary muscles positions as the site of early activation: first QRS simulation in human subjects

Journal of Electrocardiology, 2009

Simulation of the electrical activation of the heart and its comparison with real in vivo activat... more Simulation of the electrical activation of the heart and its comparison with real in vivo activation is a promising method in testing potential determinants of excitation. Simulation of the electrical activity of the human heart is now emerging as a step forward for understanding and predicting electrophysiologic patterns in humans. Initial points of excitation and the manner in which the activation spreads from these points are important variables determining QRS complex characteristics. It has been suggested that in humans, the initial excitation of the left ventricle is a primary determinant of QRS complex characteristics, and that excitation begins at the papillary muscles and septum, where the fascicles of the left bundle branch insert. The aim of this study is to test the hypothesis that QRS duration and direction of QRS axis in the frontal plane have excellent agreement between real QRS and simulated QRS using papillary muscle position to indicate the border of the origin of early ventricular activation. Fourteen healthy adult volunteers were included in the study. Magnetic resonance imaging data were obtained to assess the papillary muscle positions. Twelve-lead electrocardiographic (ECG) recordings were used to obtain real ECG data for assessment of QRS duration and QRS axis in each subject. Simulation software developed by ECG-TECH Corp (Huntington, NY) was used to simulate the ECG of each subject to determine simulated QRS duration and QRS frontal plane axis. QRS duration and QRS axis data were compared between simulated and real ECG and agreement between these variables was calculated. Seventy-nine percent of subjects had a difference of the QRS duration between real and simulated ECG of less than 10 milliseconds. The calculated strength of agreement between simulated and real QRS duration was 71% and considered as &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;good&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; (kappa statistics). In 70% of subjects, the difference in the QRS axis was less than 10 degrees . The calculated strength of agreement between simulated and real QRS axis was 80% and considered as &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;excellent&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; (kappa statistics). The results of this study suggest that the sites of the initiation of electrical activity in the left ventricle, as assessed by the positions of papillary muscles, may be considered as primary determinants of the QRS duration and QRS axis in humans. This knowledge may help in predicting normal QRS characteristic on a patient-specific basis. In this study, simulation of the QRS complex was based on papillary muscles from human hearts.

Research paper thumbnail of Right and left ventricular pressure overload as imaged by electrocardiogram

Journal of Electrocardiology, 2014

Right and left ventricular pressure overload as imaged by electrocardiogram Electrical changes in... more Right and left ventricular pressure overload as imaged by electrocardiogram Electrical changes in the heart evolve as pressure load of either the right (RV) or the left ventricle (LV) changes [1]. So called "electro-mechanical feedback" has been studied mostly in the left ventricle, with pressure overloads caused by aortic stenosis or systemic hypertension [2,3]. Regarding the RV, electro-mechanical changes have been described with pressure overloads caused by pulmonary stenosis or pulmonary hypertension [4-6]. Currently however, electrocardiography (ECG) is used rarely, in prediction and/or follow-up of changing ventricular pressure overloading conditions in clinical practice. Only the mechanical change of heart function, and the anatomical change of increase in mass are being followed by imaging modalities such as ultrasound or MRI [7]. Even though "electrical instability" is mentioned as an important predictive factor of lifethreatening events in patients with pressure overload of the ventricles, the ECG has become obsolete as a clinical tool, except to detect arrhythmias [8,9]. In clinical practice, many abnormalities imposed by acquired or congenital heart disease can lead to pressure overload of the right and/or left ventricle and can subsequently lead to heart failure, when the compensatory mechanisms become inadequate. Can clinicians monitor these conditions by ECG, to identify changes that can detect the severity of pressure overload non-invasively? How does pressure overloading or unloading change electrical potentials and how rapidly does this evolve? Can clinicians then guide the therapy by responding to these "clinical electrophysiologic" changes? There are compelling data to suggest that appreciation and understanding of electrophysiologic changes can facilitate recognition of pathophysiological processes in the heart [1,6,10]. Appreciation of both right-left heart interactions and electro-mechanical interactions may be possible by using the clinically available standard ECG as a non-invasive "electrophysiologic imaging" technology. The Journal of Electrocardiology is preparing a symposium on right and/or left ventricular pressure overload as imaged by the ECG in its September-October 2014 issue. Papers concerning both adult and pediatric cardiology will be included after emerging from the Journal's peer-review process. The purpose of this letter is to invite contributions from those who can share their understanding on this topic. Not only strengths, but also vulnerabilities of the ECG should be discussed, and thus potentially lead to innovations in use of the ECG as a method of monitoring the clinical course of these patients.

Research paper thumbnail of Importance of standardized assessment of late gadolinium enhancement for quantification of infarct size by cardiac magnetic resonance: implications for comparison with electrocardiogram

Journal of Electrocardiology, 2011

Cardiac magnetic resonance (CMR) is currently considered the reference standard for in vivo asses... more Cardiac magnetic resonance (CMR) is currently considered the reference standard for in vivo assessment of myocardial infarction (MI). There is, however, no international consensus on how MI quantification from CMR should be performed. The aim of this study was to test how previously published manual quantification of MI using CMR images compares with MI quantification using a semiautomated, validated method and how this impacts the relationship with MI size estimated by 12-lead electrocardiogram (ECG). Twenty-five patients, from a previously published cohort, were included in the study. All patients had presented with clinical signs of acute coronary syndrome 6 to 12 months before undergoing a CMR examination. The patients had a standard 12-lead ECG recorded at the time of the CMR examination. The previously reported manually quantified MI size was compared with MI size determined using a semiautomated method validated by computer phantom data, experimental in vivo and ex vivo data, and patient data. The MI sizes from the 2 CMR approaches were then compared with the ECG-estimated MI size. There was a strong correlation between MI size determined with the 2 CMR methods (r(2) = 0.94, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). There was, however, a systematic overestimation of MI size of approximately 50% by the previously published manually quantified MI size compared with the semiautomated method. This affected the comparison with estimated MI size by ECG, which showed a significant underestimation of MI size compared with manual CMR measurements, but no bias compared with the semiautomated CMR method. Manual quantification of MI size by CMR can differ significantly from semiautomated, validated methods taking partial volume effects into account and can lead to erroneous conclusions when compared with ECG.

Research paper thumbnail of Relationships between cardiac magnetic resonance imaging abnormalities in the inter-ventricular septum and Selvester QRS scoring criteria for anterior–septal myocardial infarction in patients with right ventricular volume overload

Journal of Electrocardiology, 2013

Patients with ostium secundum atrial septal defects (ASDs) were studied to determine the prevalen... more Patients with ostium secundum atrial septal defects (ASDs) were studied to determine the prevalence of Selvester anteroseptal myocardial infarction QRS points, and to test the hypothesis that there is a relationship between these criteria and thinning and/or scarring of the inter-ventricular septum (IVS). Demographic, electrocardiographic (ECG), and cardiac magnetic resonance imaging (CMR) data were acquired on 46 patients with a secundum ASD closed percutaneously. Selvester QRS scoring on patient ECGs was performed for areas representing the anteroseptal region of the left ventricle (LV). The IVS to LV free wall thickness ratio was used to assess thinning of the IVS while late gadolinium enhancement (LGE) of the IVS was used for scarring; both using CMR. Twenty-four (52%) patients scored Selvester QRS points in the anteroseptal region with a mean score of 2.6±1.8. The mean IVS/LV free wall thickness ratio at the basal level and mid-ventricular level was 1.1±0.3 and 1.3±0.3, respectively. There was no association of Selvester QRS points with IVS/LV free wall ratio at the basal (p=0.59) or mid-ventricular (p=0.13) levels. The one patient with LGE in the IVS had 4 Selvester anteroseptal QRS points. The results of our study demonstrate that in our patient population there is a 52% prevalence of Selvester anteroseptal QRS points which are due to thinning and/or scarring of the IVS in only one patient.

Research paper thumbnail of Computer-based rhythm diagnosis and its possible influence on nonexpert electrocardiogram readers

Journal of Electrocardiology, 2012

Systems providing computer-based analysis of the resting electrocardiogram (ECG) seek to improve ... more Systems providing computer-based analysis of the resting electrocardiogram (ECG) seek to improve the quality of health care by providing accurate and timely automatic diagnosis of, for example, cardiac rhythm to clinicians. The accuracy of these diagnoses, however, remains questionable. We tested the hypothesis that (a) 2 independent automated ECG systems have better accuracy in rhythm diagnosis than nonexpert clinicians and (b) both systems provide correct diagnostic suggestions in a large percentage of cases where the diagnosis of nonexpert clinicians is incorrect. Five hundred ECGs were manually analyzed by 2 senior experts, 3 nonexpert clinicians, and automatically by 2 automated systems. The accuracy of the nonexpert rhythm statements was compared with the accuracy of each system statement. The proportion of rhythm statements when the clinician&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s diagnoses were incorrect and the systems instead provided correct diagnosis was assessed. A total of 420 sinus rhythms and 156 rhythm disturbances were recognized by expert reading. Significance of the difference in accuracy between nonexperts and systems was P = .45 for system A and P = .11 for system B. The percentage of correct automated diagnoses in cases when the clinician was incorrect was 28% ± 10% for system A and 25% ± 11% for system B (P = .09). The rhythm diagnoses of automated systems did not reach better average accuracy than those of nonexpert readings. The computer diagnosis of rhythm can be incorrect in cases where the clinicians fail in reaching the correct ECG diagnosis.

Research paper thumbnail of Electrocardiographic Measures of Myocardial Function and Necrosis

JACC: Cardiovascular Imaging, 2009

Research paper thumbnail of Electroanatomic Relationships in Patients With Primum Atrioventricular Septal Defect

JACC: Cardiovascular Imaging, 2009

The objective of this study was to test the hypothesis that patients with primum atrioventricular... more The objective of this study was to test the hypothesis that patients with primum atrioventricular septal defect (AVSD) have an imbalance in the positions of the left ventricular papillary muscles compared with healthy subjects, and that this anatomic imbalance correlates with left deviation of the QRS axis. B A C K G R O U N D The function and contraction pattern of the heart is best predicted when cardiac anatomy is considered together with its electrical activation sequence. Understanding the electroanatomic relationships is essential for discovering the developmental relationships between the conduction system and heart structures. Left deviation of the QRS axis is typically present in patients with primum AVSD. However, the pathophysiology of this phenomenon is not understood. M E T H O D S Thirty-five patients with primum AVSD and 35 healthy subjects were included in the study. Echocardiographic images were used to determine the papillary muscle positions. A 12-lead electrocardiogram was used to determine the QRS axis in the frontal plane in both patients and healthy subjects. R E S U L T S An imbalance between papillary muscle positions in primum AVSD patients was defined as the position of the anterior papillary muscle closer to the septum and/or the position of the posterior papillary muscle further from the septum compared with the position of the papillary muscles in healthy subjects. In primum AVSD patients compared with control subjects, there was significant imbalance in the positions of the papillary muscles (p ϭ 0.0007). The imbalance of papillary muscles correlated with deviation of the QRS (r ϭ 0.5, p ϭ 0.0019).

Research paper thumbnail of Determination of the mitral papillary muscle positions by the septal‐to‐free wall arc ratio method

Clinical Physiology and Functional Imaging, 2009

SummaryBackground: Determination of mitral papillary muscle positions is of increasing interest ... more SummaryBackground: Determination of mitral papillary muscle positions is of increasing interest in wide spectrum of clinical cardiology fields. Particularly, relative positioning of the papillary muscles between the inter‐ventricular septum and the left ventricular free wall is of interest. A reproducible method for determination of papillary muscle positions has not been established. In this study a new ‘septal‐to‐free wall arc ratio’ (SFAR) method for measuring papillary muscle positions is presented. The reproducibility of the SFAR method between echocardiographic (ECHO) and magnetic resonance (MRI) modalities and between observers is tested.Methods: Twenty subjects with structurally normal hearts in whom both MRI and ECHO were performed in 2007 were included in the study. Papillary muscle positions were determined using the SFAR method. Inter‐modality (ECHO and MRI) and inter‐observer reproducibility of the methods was assessed by calculating correlation coefficients and the m...

Research paper thumbnail of Aspects of Left Ventricular Morphology Outperform Left Ventricular Mass for Prediction of QRS Duration

Annals of Noninvasive Electrocardiology, 2010

Background: The knowledge of the case-specific normal QRS duration in each individual is needed w... more Background: The knowledge of the case-specific normal QRS duration in each individual is needed when determining the onset, severity and progression of the heart disease. However, large interindividual variability even of the normal QRS duration exists. The aims of the study were to develop a model for prediction of normal QRS complex duration and to test it on healthy individuals. Methods: The study population of healthy adult volunteers was divided into a sample for development of a prediction model (n = 63) and a testing sample (n = 30). Magnetic resonance imaging data were used to assess anatomical characteristics of the left ventricle: the angle between papillary muscles (PM A), the length of the left ventricle (LV L) and left ventricular mass (LV M). Twelve-lead electrocardiogram (ECG) was used for measurement of the QRS duration. Multiple linear regression analysis was used to develop a prediction model to estimate the QRS duration. The accuracy of the prediction model was assessed by comparing predicted with measured QRS duration in the test set. Results: The angle between PM A and the length of the LV L were statistically significant predictors of QRS duration. Correlation between QRS duration and PM A and LV L was r = 0.57, P = 0.0001 and r = 0.45, P = 0.0002, respectively. The final model for prediction of the QRS was: QRS Predicted = 97 + (0.35 × LV L) − (0.45 × PM A). The predicted and real QRS duration differed with median 1 ms. Conclusions: The model for prediction of QRS duration opens the ability to predict case-specific normal QRS duration. This knowledge can have clinical importance, when determining the normality on case-specific basis.

Research paper thumbnail of Problem-oriented education and cross-cultural collaboration: experiences and comments on the Scientific Summer School in Turkey 2010

Anadolu Kardiyoloji Dergisi/The Anatolian Journal of Cardiology, 2010