Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter.

BACKGROUND: Mitral annular flutter (MAF) is the most common left atrial macro-reentrant arrhythmia following catheter ablation of atrial fibrillation (AF). The best ablation approach for this arrhythmia remains unclear. METHODS: This single-center, retrospective study sought to compare the acute and long-term outcomes of patients with MAF treated with an anterior mitral line (AML) versus a mitral isthmus line (MIL). Acute ablation success, complication rates, and long-term arrhythmia recurrence were compared between the two groups. RESULTS: Between 2015 and 2021, a total of 81 patients underwent ablation of MAF (58 with an AML and 23 with a MIL). Acute procedural success defined as bidirectional block was achieved in 88% of the AML and 91% of the MIL patients respectively (p = 1.0). One year freedom from atrial arrhythmias was 49.5% versus 77.5% and at 4 years was 24% versus 59.6% for AML versus MIL, respectively (hazard ratio [HR]: 0.38, confidence interval [CI]: 0.17-0.82, p = .009). Fewer patients in the MIL group had recurrent atrial flutter when compared to the AML group (HR: 0.32, CI: 0.12-0.83, p = .009). The incidence of recurrent AF, on the other side, was not different between both groups (21.7% vs. 18.9%; p = .76). There were no serious adverse events in either group. CONCLUSION: In this retrospective study of patients with MAF, a MIL compared to AML was associated with a long-term reduction in recurrent atrial arrhythmias driven by a reduction in macroreentrant atrial flutters.

PR prolongation as a predictor of atrial fibrillation onset: A state-of-the-art review.

First-degree atrioventricular block (1-AVB), characterized by a PR interval exceeding 200 milliseconds, has traditionally been perceived as a benign cardiac condition. Recently, this perception has been challenged by investigations that indicate a potential association between PR prolongation and an elevated risk of atrial fibrillation (AF). To consolidate these findings, we performed a comprehensive review to assess the available evidence indicating a relationship between these two conditions. We searched MEDLINE and EMBASE databases as well as manually searched references of retrieved articles. We selected 18 cohort studies/meta-analyses involving general and special populations. Consistent findings across expansive cohort studies reveal that incremental increases in the PR interval may serve as an independent risk factor for AF. However, our analyses underscore the need for further research into the association between 1-AVB, defined by a specified PR interval cutoff, and the risk of AF.

New pattern of atypical advanced interatrial block.

INTRODUCTION: Interatrial block (IAB) is defined as prolonged P-wave duration (≥ 120 ms) due to delayed conduction in the Bachmann bundle. This is readily identifiable using surface electrocardiogram (ECG). Advanced IAB can be classified as typical and atypical. Atypical IAB can be further categorized by (i) duration or (ii) morphology. In this report, we have identified a new pattern of atypical IAB with triphasic morphology of the P-wave in the inferior leads. METHODS: Two clinical cases were evaluated including surface ECGs. P-wave durations and amplitudes were measured with digital calipers using ECG analysis software (MUSE, GE HealthCare). Comparisons were made using prior data to evaluate IAB and P-wave duration and morphology. RESULTS: A new pattern of atypical advanced IAB shows prolonged P-wave duration (P wave >160 ms) and triphasic morphology in all inferior leads with P +/+/- and P +/-/+, respectively. We speculate that triphasic P-waves in the inferior leads represent three moments of atrial depolarization; from right to left. CONCLUSION: This study describes a novel pattern of atypical advanced IAB. Further investigation regarding the increased risk of atrial fibrillation and stroke associated with this new pattern is warranted in the future.

Non-fluoroscopic Cardioneuroablation for Deglutition-induced Syncope: Not a Bitter Pill to Swallow.

Swallowing is an uncommon trigger of reflex situational syncope. We discuss the case of a 61-year-old woman who presented without a prior cardiac history complaining of 15 years of dizzy spells and hot facial flushing provoked by the swallowing of solid foods.

A Systematic Review of Electrocardiographic Changes in Populations Temporarily Ascending to High Altitudes.

High altitudes can cause hypobaric hypoxia, altering human physiology and the corresponding electrocardiogram (ECG). As part of the Altitude Nondifferentiated ECG Study (ANDES), this paper reviews ECG changes in subjects ascending to high altitudes. This review was conducted following PRISMA guidelines. PubMed, EMBASE, OVID Medline, and Web of Science were searched. 19 studies were ultimately included. Notable ECG changes at high altitudes include T wave inversion in the precordial leads and rightward QRS axis deviation in leads I, II and aVF. Less common findings were increases in P wave amplitude, QRS amplitude, and QTc interval. These ECG deviations typically self-resolved within 2-6 weeks following return to sea level. Consideration must be taken when interpreting ECG changes in individuals during ascent to, at, or upon return from high altitudes. Further large-scale studies are needed to elucidate temporal and altitude-dependent ECG patterns and establish reference standards for clinicians.

Influence of Intermittent Fasting During Ramadan on Circadian Variation of Symptom-Onset and Prehospital Time Delay in Acute ST-Segment Elevation Myocardial Infarction.

Ramadan interferes with circadian rhythms mainly by disturbing the routine patterns of feeding and smoking. The objective of this study was to investigate the circadian pattern of ST elevation acute myocardial infarction (STEMI) during the month of Ramadan. We studied consecutive STEMI patients 1 month before and after Ramadan (non-Ramadan group-NRG) and during Ramadan (Ramadan group-RG). The RG group was also divided into two groups, based on whether they chose to fast: fasting (FG) and non-fasting group (NFG). The time of STEMI onset was compared. A total of 742 consecutive STEMI patients were classified into 4 groups by 6 h intervals according to time-of-day at symptom onset. No consistent circadian variation in the onset of STEMI was observed both between the RG (P = .938) and NRG (P = .766) or between the FG (P = .232) and NFG (P = .523). When analyzed for subgroups of the study sample, neither smoking nor diabetes showed circadian rhythm. There was a trend towards a delay from symptom onset to hospital presentation, particularly at evening hours in the RG compared with the control group. In conclusion, there was no significant difference in STEMI onset time, but the time from symptom onset to hospital admission was significantly delayed during Ramadan.

The effect of prior COVID-19 infection on coronary microvascular dysfunction.

BACKGROUND: Thrombolysis in Myocardial Infarction Frame Count (TFC) is an index that provides a quantitative evaluation of coronary microvascular dysfunction. In this study, we aimed to examine the effect of COVID-19 infection on TFC in patients admitted with chest pain and dyspnoea after COVID-19 disease and had abnormal findings in myocardial perfusion scintigraphy. METHODS: For this single-center retrospective study, patients with and without a history of COVID-19 who were underwent coronary angiography for abnormal findings in myocardial perfusion scintigraphy between January 1, 2021 and June 30, 2021 were analysed. Patients were divided into two groups as patients with COVID-19 history and those without. After exclusion criteria, patients with adequate angiographic monitoring and data were included in the study. RESULTS: A total of 210 patients, 48 with a history of COVID-19, were included in the study. The mean age was ±55 10 years, and 122 (58%) patients were women. In patients with a history of COVID-19, TFC was significantly higher in the LAD (p < 0.001) and LCx (p < 0.001) arteries and RCA TFC (p = 0.223) was similar in both groups. In the linear mix model, male gender (ß = 2.38, 95% CI = 1.26-3.51, p < 0.001) and history of COVID-19 (ß = 1.51, 95% CI = 0.49-2.53, p = 0.004) were significantly associated with TFC. CONCLUSION: TFC may be elevated due to coronary microvascular dysfunction in patients with a history of COVID-19.

Decreasing time between first diagnosis of paroxysmal atrial fibrillation and cryoballoon ablation positively affects long-term consequences.

BACKGROUND: Patients with atrial fibrillation (AF) usually experience a worsening of their AF burden over time. We aimed to investigate timing of pulmonary vein isolation (PVI) by cryoballoon (CB-2) after the first clinical diagnosis of AF on ablation-related outcomes. METHODS: A total of 132 consecutive patients with paroxysmal AF undergoing PVI by CB-2 were included in the study. The patients were retrospectively sorted into two groups to evaluate differences in AF recurrence risk associated with early ablation (n = 89), defined as within 365 days of first AF diagnosis, and late ablation (n = 365), defined as > 365 days after first AF diagnosis. AF-free survival during follow-up was compared between groups. RESULTS: Although mean procedure times were comparable between groups, mean fluoroscopy times were lower in the early ablation group. For the whole study group, median (interquartile range) time from AF diagnosis to first ablation was 4.0 (2.0-11.3) months [3.0 (1.0-4.0) vs 14.0 (12.0-22.5) months in the early and late ablation groups, respectively]. Median follow-up for the whole population was 12.0 (12.0-18.0) months, and after the blanking period, 14 (10.6%) patients had arrhythmia recurrence (2 in the early and 12 in the late ablation groups). In the univariable Cox regression analysis and propensity score adjusted penalized Cox regression analysis, there was a significant association between delay in ablation time and AF recurrence (unadjusted hazard ratio = 7.74, 95% CI 2.26-40.1, p < 0.001, adjusted hazard ratio = 7.50, 95% CI 2.23-38.6, p < 0.001). CONCLUSION: Delays in treatment with CB-2 ablation may negatively affect AF-free survival rates among patients with paroxysmal AF.

Prognostic value of C-reactive protein to albumin ratio for long-term outcomes of patients with peripheral arterial disease underwent endovascular treatment.

BACKGROUND: Peripheral artery disease (PAD) is part of the systemic atherosclerotic process that is highly associated with cardiovascular diseases. Despite successful endovascular treatment (EVT) strategies, mortality and morbidity rates still remain higher in PAD patients. C-reactive protein (CRP) and albumin are biomarkers of inflammation and malnutrition that play key roles in the progression of peripheral arterial disease. In this study, we aimed to investigate the relationship between CRP-to-albumin ratio (CAR) and mortality and amputation-free survival in patients with PAD after successful EVT. METHOD: Our study enrolled 149 consecutive patients who underwent EVT on atherosclerotic obstruction of iliac, femoral, popliteal and/or below-knee arteries with the clinical features of PAD and/or chronic limb-threatening ischaemia between January 2015 and January 2020. Clinical and prognostic follow-up of patients had been done at the outpatient clinic and were collected from institution's medical records. RESULTS: The mean follow-up period was 22 months (14-40). All-cause mortality and amputation rates of patients in the high CAR group were significantly higher than those in the low CAR group (21.3% vs. 6.8% and 18.7% vs. 5.4%, respectively). Kaplan-Meier survival analysis showed significantly better survival for patients in the low CAR group (log-rank p = 0.0058). In multivariate logistic regression analysis, CAR was found to be an independent predictor of amputation and all-cause mortality even after adjusting for other confounding risk factors. ROC curve analysis revealed the optimal cut-off value of CAR for predicting all-cause mortality and amputation to be >1.476 with a sensitivity of 48.5% and specificity of 94.0%. CONCLUSION: The inflammatory state reflected by CAR levels was strongly associated with all-cause mortality and amputation after EVT in patients with PAD. Furthermore, CAR was found to be an independent predictor of these clinical outcomes after adjusting for other clinically associated parameters.

SPECT myocardial perfusion imaging identifies myocardial ischemia in patients with a history of COVID-19 without coronary artery disease.

We aimed to examine the effect of a history of COVID-19 on myocardial ischemia in single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in patients who presented with shortness of breath and/or chest pain after recovery. For this single-center retrospective study, patients who presented at cardiology outpatient clinics and had SPECT-MPI were screened. A total of 1888 patients were included in the study, 340 of whom had a history of COVID-19. 64 patients with > 50% stenosis on coronary angiography were excluded from the study. The primary outcome of the study was abnormal MPI. In the study population, the median age was 56 (49-64 IQR) years, and 1127 (65%) of the patients were female. Abnormal MPI was detected in 77 patients (23%) in the COVID-19 group and in 244 patients (16%) in the non-COVID-19 group. After adjustment was performed for clinical predictors using Bayesian logistic regression, an important association was found between the presence of a confirmed prior COVID-19 infection and abnormal MPI (posterior median odds ratio, 1.70 [95% CrI, 1.20-2.40], risk difference, 9.6% [95% CrI, 1.8%, 19.7%]). In SPECT-MPI, ischemia rates were observed to be higher in COVID-19 group and it was found that a confirmed prior COVID-19 might predict of abnormal MPI.

Myocardial Strain Assessment by 2D Speckle-Tracking Echocardiography in Patients with Congenital Myopathy.

Background: Congenital myopathies (CMs) are a group of rare genetic muscle disorders. Cardiac involvement can be seen in these patients. We aimed to evaluate the myocardial strain parameters by 2D speckle-tracking echocardiography (STE) in patients with CM. Materials and Methods: Twenty-four patients with CM whose diagnosis was confirmed by genetic analysis or muscle biopsy were included in the study, and 48 patients were involved as a control group. Left ventricular ejection fraction (LVEF%) was calculated by biplane Simpson method, and myocardial strain analysis was performed by 2D STE. Results: The median age of the study population was 26 (19-35 interquartile range [IQR]) and 43 (60%) were women. In the analysis performed after the exclusion of two patients with multiminicore disease (MMD) who developed heart failure, although mild, LVEF% (62 [60-65 IQR] vs. 64 [63-66 IQR], P = 0.008) and right ventricular global longitudinal strain (RVGLS) were significantly lower in the CM group (-21.8 [-19.7, -24.9 IQR] vs. -23.9 [-22.4, -25.6 IQR], P = 0.0017). Left ventricular global longitudinal strain (LVGLS) was observed similarly in both groups (-19.9 [-18.7, -20.7 IQR] vs. -20.5 [-19.3, -21.9 IQR], P = 0.069). LVEF% (33 and 46), LVGLS (-7.5 and -10.7), and RVGLS (-14.9 and -16.1) values were low in two siblings with MMD. Conclusion: Although LVEF% and RVGLS were significantly lower in the CM group, LVGLS was similar. The decrease in RVGLS and LVEF% was mild, and heart failure was not observed in any patient except MMD patients who were not included in the analysis.

The effect of favipiravir on QTc interval in patients hospitalized with coronavirus disease 2019.

BACKGROUND: The effect of favipiravir on the QTc interval during the treatment of Coronavirus Disease 2019 (COVID-19) patients is unclear. Thus, the current study objective was to evaluate any change in the QTc interval in patients who were hospitalized due to COVID-19 receiving favipiravir treatment. METHOD: Patients hospitalized with COVID-19 were assessed in this single-center retrospective study. 189 patients, whose diagnosis was confirmed using real-time PCR, were included in the study. The patients were divided into three groups: those using hydroxychloroquine (Group 1, n = 66), hydroxychloroquine plus favipiravir (Group 2, n = 66), and favipiravir only (Group 3, n = 57). The QTc interval was measured before treatment (QTc-B) and 48 h after (i.e., the median) starting treatment (QTc-AT). RESULTS: The median age was 53 (39-66 IQR) and 97 (51%) of patients were female. The median QTc(Bazett)-change was 7 ms (p = 0.028) and 12 ms (p < 0.001) and in Group 1 and 2, respectively. In Group 3, the median QTc(Bazett)-change was observed as -3 ms and was not statistically significant (p = 0.247). In multivariable analysis, while there was a significant relationship between QTc-AT(Bazett) and hydroxychloroquine (ß coefficient = 2687, 95%CI 2599-16,976, p = 0,008), there was no significant relationship with favipiravir (ß coefficient = 0,180, 95% CI -6435-7724, p = 0,858). Similarly, there was a significant relationship between the QTc-AT interval calculated using the Fredericia formula and hydroxychloroquine (ß coefficient = 2120, 95% CI 0,514-14,398, p = 0,035), but not with favipiravir (ß coefficient = 0,111, 95% CI -6450- 7221, p = 0,911). CONCLUSION: In the ECG recordings received in the following days after the treatment was started in COVID-19 patients, there was a significant prolongation in the QTc interval with hydroxychloroquine, but there was no significant change with favipiravir.

The predictive value of RS time for short term mortality in patients with acute pulmonary embolism.

OBJECTIVE: Many studies have examined the capability of electrocardiography (ECG) changes to predict the severity and prognosis of patients with acute pulmonary embolism (APE). RS time in ECG is potentially valuable in evaluating the prognosis of APE. In our study, we aimed to assess the predictive value of RS time, which is a novel electrocardiographic parameter of one-month mortality of APE. METHODS: This retrospective study included 216 patients who were diagnosed with APE by pulmonary computed tomography angiography. RS time was measured from the ECG (inferolateral leads) at the time of hospital admission using a computer program (imagej.nih.gov/ij/). The patients were divided into two groups according to the median values of RS time: the group with RS time ≤ 60 msec (n:108) and the group with RS time > 60 msec (n:108). The groups were compared in terms of mortality. RESULTS: In our study, the one-month mortality was 15.3% (33) in the patients hospitalized with APE. In the multivariate analysis, RS time prolongation (HR: 1.037; 95%CI: 1.005-1.065; p = .02) was independently correlated with mortality. The ROC curve analysis revealed that RS time > 64.8 msec predicted the one-month mortality in APE with a sensitivity of 68.6% and a specificity of 73.9% (AUC: 0.708; 95% CI: 0.643-0.768; p < .001). CONCLUSION: As a novel ECG parameter, RS time could be measured for each patient with APE. Prolongation of RS time could be a useful index for predicting the one-month mortality of patients diagnosed with APE.

Assessment of the relation between C-reactive protein to albumin ratio and the severity and complexity of peripheral arterial disease.

BACKGROUND: Peripheral arterial disease is associated with increased cardiovascular mortality and morbidity. C-reactive protein and albumin are biomarkers of inflammation and malnutrition that play key roles in the pathophysiological pathways involved in the progression of atherosclerosis and peripheral arterial disease. In this study, we aimed to assess the relationship between C-reactive protein to albumin ratio and the suprapopliteal peripheral arterial disease severity and complexity as assessed by TransAtlantic Inter-Society Consensus-II (TASC-II) classification. METHOD: Our study enrolled 224 consecutive patients referred for peripheral angiography with the clinical features of possible peripheral arterial disease at a tertiary care center between January 2016 and September 2019. Level of disease and lesion characteristics were defined with reference to angiographic findings according to the TASC-II classification. RESULTS: C-reactive protein/albumin ratio levels were significantly higher in TASC-II class C and D than in TASC-II class B patients with a median level of 1.8 to 2.1 vs 1.4, respectively (p = 0.018). In multivariate regression analysis, C-reactive protein to albumin ratio remained an independent predictor of severe peripheral arterial disease. The predictive performance of C-reactive protein to albumin ratio, C-reactive protein, and albumin were compared by Receiver Operating Characteristic curve analysis. C-reactive protein to albumin ratio surpassed C-reactive protein and albumin in predicting peripheral arterial disease severity and complexity. A level of C-reactive protein to albumin ratio > 0.14 predicted a higher grade of suprapopliteal TASC-II class with sensitivity and specificity of 68.2% and 56.0%, respectively. CONCLUSION: C-reactive protein to albumin ratio was strongly associated with peripheral arterial disease severity and complexity, as assessed by TASC-II classification. Also, C-reactive protein to albumin ratio was found to be a more accurate marker than C-reactive protein and albumin alone in predicting more severe and complex lesions in patients with peripheral arterial disease.

The Association of Fractional Pulse Pressure with Acute Kidney Injury in Patients Undergoing Coronary Intervention due to ST-Segment Elevated Myocardial Infarction.

OBJECTIVE: Acute kidney injury (AKI), which is prevalent in ST-segment elevated myocardial infarction (STEMI) patients who have undergone primary percutaneous coronary intervention (PCI), is associated with poor cardiovascular outcomes. As high pulse pressure (PP) is associated with adverse cardiovascular events, the present study's aim was to evaluate the relationship between fractional PP (PPf) and AKI in patients with STEMI who underwent primary PCI. SUBJECTS AND METHODS: All laboratory findings as well as echocardiographic and angiographic data of 1,170 consecutive STEMI patients were retrospectively screened. PPf was calculated from the pressures invasively measured after sheath insertion and before performing coronary angiography. RESULTS: From 1,170 eligible STEMI patients (mean age 56 years, 18.2% female), AKI developed in 143 (12.2%) patients. The PPf and pulsatility index were significantly higher in patients with AKI than those without (0.53 ± 0.10 vs. 0.61 ± 0.10, p < 0.001, and 0.80 ± 0.03 vs. 0.82 ± 0.03, p < 0.001, respectively). PPf was also found to be associated with AKI in univariable (OR 2.183, 95% CI 1.823-2.614, p< 0.001) and multivariable (OR 1.874, 95% CI 1.513-2.322, p < 0.001) analysis. In-hospital mortality was higher in patients with AKI than those without. CONCLUSION: Invasively measured PPf, which can be easily measured and has no additional cost in STEMI patients undergoing coronary intervention, is an independent predictor of AKI. In addition, PPf is superior to other blood pressure values and derivatives in AKI prediction.

The prognostic value of the serum albumin level for long-term prognosis in patients with acute pulmonary embolism.

INTRODUCTION AND OBJECTIVES: The aim of this study was to investigate the association of serum albumin (SA) level with long-term prognosis in patients with acute pulmonary embolism (PE). MATERIALS AND METHODS: We retrospectively enrolled 269 patients with acute PE. The SA level was obtained within 12-24 hours following admission. The primary endpoints were the incidence of short- and long-term mortality in acute PE patients. The mean duration of the study follow-up was 21 ± 19 months. RESULTS: During the follow-up period, short- and long-term mortality rates were higher in patients who had low SA level compared to those who did not have. In multivariate Cox regression analysis, the SA level was found to be independently associated with long-term mortality (HR: 0.47, 95%CI: 0.28-0.78, P = 0.004). In receiver operating characteristics analysis, the SA level of ≤3.17 predicted long-term mortality with a sensitivity of 77.5% and a specificity of 79.5% (area under the curve 0.82, 95%CI: 0.76-0.87, P < 0.001). In addition, when the SA plus simplified pulmonary embolism severity index (sPESI) risk score compared to the sPESI risk score alone, it produced a net reclassification improvement of 0.22 with P < 0.001, that is a 22% improved classification. CONCLUSION: To the best of our knowledge, this is the first study to demonstrate that the low SA level is a strong and independent predictor for long-term mortality in patients with acute PE.

Relationship between the Severity of Coronary Artery Disease and Catheter-Associated Urethral Stricture in Patients with Acute Coronary Syndrome.

Background: Different arterial segments throughout the vascular system develop similar grades of atherosclerosis concomitantly. Urethral ischemia has been proposed as a cause of urethral stricture. Therefore, we aimed to investigate the relationship between coronary artery disease severity using a SYNTAX score and urethral stricture occurrence after urethral catheterization in patients with non-ST-segment-elevation acute coronary syndrome (ACS). Methods: This retrospective study consisted of 306 men with urethral catheters that were diagnosed with ACS and underwent coronary angiography between January 2016 and January 2018 in Kars Kafkas University and Osmaniye Government Hospital, Turkey. Hospital records were reviewed to collect the follow-up data of the patients regarding the occurrence of urethral stricture after urethral catheterization. The study population was divided into 2 groups according to urethral stricture development, and both groups were compared statistically. Results: SYNTAX scores were significantly higher in patients with urethral stricture than in those without urethral stricture (14.86±7.11 vs. 29.25±9.79; P<0.001). The SYNTAX score (OR=1.27; 95% CI: 1.16-1.39; P<0.001), diabetes, and serum albumin were found to be the independent predictors of urethral stricture. The receiver operating characteristic curve analysis showed that the cutoff value of the SYNTAX score for urethral stricture prediction was greater than 22.5, with 76.7% sensitivity and 85.1% specificity (AUC=0.88, 95% CI: 0.84-0.91; P<0.001). Conclusion: Coronary artery disease severity graded according to the SYNTAX score is an independent predictor of urethral stricture occurrence in ACS patients with a urethral catheter inserted.