PECS II block for cardiac implantable electronic device insertion: A pilot study.

AIM: Some truncal blocks could provide adequate surgical anesthesia and postoperative analgesia in cardiac implantable electronic devices (CIED) insertion. The aim of this study was to evaluate the feasibility of the pectoral nerves (PECS) II block for CIED insertion. METHODS: PECS II blocks were performed on the left side using the ultrasound-guided single injection technique in all patients. The primary outcome for feasibility was the percentage of the cases completed without intraoperative additional local anesthesia. Secondary outcomes were the amount of intraoperative additional local anesthetic, intraoperative opioid requirement, postoperative pain scores, first requirement for postoperative analgesia, postoperative analgesic consumption, patient satisfaction, and block-related complications. RESULTS: Of the total 30 patients, 19 (63.3%) required intraoperative additional local anesthetic. The median (IQR [range]) volume of the additional local anesthetic used was 7 (4-10 [2.5-12]) mL. Two patients needed additional IV analgesics in the first 24 h postoperatively. No statistically significant differences were determined between the patients requiring and not requiring intraoperative additional local anesthetic in respect of age, gender, duration of surgery, block performance time, and hospital stay. A total of 26 (86.6%) patients reported a high level of satisfaction with the procedure. CONCLUSIONS: PECS II block for cardiac electronic implantable device insertion provides effective postoperative analgesia for at least 24 h. Although PECS II block alone could not provide complete surgical anesthesia in the majority of the patients, when combined with supplementary local anesthetic, contributes to a smooth intraoperative course for patients.

Effect of Bendopnea on Achievement Medical Treatment Target Doses in Heart Failure.

BACKGROUND: The newly described bendopnea in heart failure (HF) is associated with increased cardiac filling pressures. The aim of the study was to show the effect of bendopnea follow-up on reaching optimal medical treatment doses in HF. METHODS: A total of 413 patients were screened, and we included 203 patients with HF who were previously evaluated for bendopnea. Demographic data, presence or absence of bendopnea, medical history, laboratory findings, and medical treatments were evaluated. Optimal medical therapy target doses at baseline and 3rd month were compared in groups with and without bendopnea. RESULTS: On admission, 64 patients (31.5%) had bendopnea. The rate of patients with bendopnea decreased in the 3rd month (n=42, 20.7%). The proportion of patients who used at least 50% of the recommended medical treatment dose on admission and in the 3rd month was compared; angiotensin-converting enzyme inhibitor /angiotensin receptor blockers use increased from 40.6% to 71.9% in those with bendopnea (P=0.013), from 56.1% to 81.3% in those without bendopnea (P<0.001) and beta-blockers use increased from 28.2% to 60.9% in those with bendopnea (P=0.042), from 31.6% to 69.8% in those without bendopnea (P<0.001). However, aldosterone antagonists use decreased from 70.3% to 67.2% in those with bendopnea (P=0.961), from 68.4 % to 64.1% in those without bendopnea (P=0.334). Bendopnea was independently effective in achieving ACE-I/ARB target doses (OR: 0.359, CI 95%: 0.151-0.854, P=0.020). CONCLUSION: Bendopnea follow-up in HF patients can provide a significant improvement in reaching the recommended treatment target doses.

Frontal Plane QRS-T Angle as a Marker of Cardiac Iron Overload in Patients with Beta Thalassemia Major.

Introduction: Cardiomyopathy due to myocardial iron deposition is the leading cause of death in transfusion- dependent beta-thalassemia major (ß-TM) patients. Although cardiac T2* magnetic resonance imaging (MRI) can be used for the early detection of cardiac iron level before the onset of symptoms associated with iron overload, this expensive method is not widely available in many hospitals. Frontal QRS-T angle is a novel marker of myocardial repolarization and is associated with adverse cardiac outcomes. We aimed to investigate the relationship between cardiac iron load and f(QRS-T) angle in patients with ß-TM. Methods: The study included 95 ß-TM patients. Cardiac T2* values under 20 were considered to indicate cardiac iron overload. The patients were divided into two groups according to the presence or absence of cardiac involvement. Laboratory and electrocardiography parameters, including frontal plane QRS-T angle, were compared between the two groups. Results: Cardiac involvement was detected in 33 (34%) patients. Multivariate analysis showed that frontal QRS-T angle independently predicted cardiac involvement (p < 0.001). An f(QRS-T) angle of ≥ 24.5° had a sensitivity of 78.8% and a specificity of 79% in detecting the presence of cardiac involvement. In addition, a negative correlation was found between cardiac T2* MRI value and f(QRS-T) angle. Conclusions: A widening f(QRS-T) angle could be considered a surrogate marker of MRI T2* to detect cardiac iron overload. Therefore, calculating the f(QRS-T) angle in thalassemia patients is an inexpensive and simple method for detecting the presence of cardiac involvement, especially when cardiac T2* values cannot be determined or monitored.

Usefulness of the systemic immune-inflammation index in predicting atrial fibrillation recurrence after direct current cardioversion.

Background: We aimed to determine whether there is a relationship between the systemic immune-inflammation (SII) index and the recurrence of atrial fibrillation (AF) after successful direct current cardioversion (DCCV). Methods: The study included 99 patients with persistent AF who underwent successful cardioversion between 2015 and 2020. Results: In multiple regression analyses, the SII index was found to be a better independent predictor of AF recurrence after successful DCCV (p < 0.001). The cut-off value of SII (563) was associated with 96.9% sensitivity and 55.2% specificity to predict AF recurrence after DCCV. Conclusion: As a simple biomarker, SII index is an independent parameter for predicting AF recurrence after successful DCCV in patients with persistent AF. Also, SII levels can predict AF recurrence better than neutrophil-to-lymphocyte ratio.

A rare cause of syncope in patients with situs inversus totalis and corrected transposition of the great arteries: Very late lead perforation.

Situs inversus c-TGA refers to a complex anatomical malformation. The risk of developing AV block increases by 2% per year. Pacemaker lead perforation is a rare but serious complication after pacemaker implantation and that develops more than 1 month is defined as late lead perforation. Here, we presented a case of very late lead perforation that occurred 5 years later after pacemaker implantation in a patient with congenital heart disease who had pacemaker due to AV block. Even in the late period, this complication should be kept in mind in patients with a pacemaker who present with syncope.

Prognostic value of the combination of uric acid and NT-proBNP in patients with chronic heart failure.

OBJECTIVE: Hyperuricemia is associated with poor outcomes in chronic heart failure (HF). We aimed to evaluate whether uric acid (UA) alone or in combination with N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a good predictor of all-cause mortality, HF hospitalization, and the composite endpoint of HF hospitalization or all-cause mortality in chronic HF. METHODS: UA and NT-proBNP levels were evaluated retrospectively in 861 chronic HF patients with a left ventricular ejection fraction of ≤50%. The patients were compared by dividing them into 4 groups according to the cut-off values of UA and NT-proBNP. RESULTS: Serum UA concentrations were ≥ 7.0 mg/dL in 46.5% of the subjects. With a median follow-up of 30 months, 201 (23.3%) patients died and 308 (35.8%) patients were hospitalized during the study. The all-cause mortality rate was higher in the hyperuricemic group than that of the normouricemic group (p < 0.001). A multivariate Cox regression model revealed that UA and NT-proBNP were independent predictors of all-cause mortality (HR: 1.105, 95% CI: 1.019-1.198, p = 0.016 and HR: 3.743, CI: 2.647-5.292, p < 0.001, respectively). Patients were divided into 4 groups based on UA (≥ 7 and < 7 mg/dL) and NT-proBNP (≥ 2279 and < 2279 ng/L) levels. All-cause mortality, HF hospitalization, and the composite endpoint of HF hospitalization or all-cause mortality rates were higher in the group with high UA and NT-proBNP levels (p < 0.001, p < 0.001, p < 0.001, respectively). CONCLUSION: Hyperuricemia alone is an independent predictor of all-cause mortality in chronic HF. However, the combination of UA and NT-proBNP appears to be a stronger predictor of poor outcomes.

Supraventricular arrhythmia in mitral valve prolapse : Predictive value of P-wave dispersion and atrial conduction time.

BACKGROUND: The incidence of supraventricular arrhythmia (SVA) is high in patients with mitral valve prolapse (MVP). The purpose of our study was to determine the role of parameters showing atrial conduction heterogeneity such as P­wave dispersion (PWD) and atrial electromechanical delay (AEMD) in predicting the development of SVA in MVP patients. METHODS: A total of 76 patients with MVP (56 female, 20 male) were included in the study. The patients were divided into two groups according to the presence or absence of SVA: 36 patients were allocated to the non-SVA group and 40 patients to the SVA group. Heart rate variability (HRV), PWD, and AEMD values were determined and compared. RESULTS: The PWD was found to be higher in the SVA group. Interatrial EMD was 32.00 ms (25.00-35.00) in patients with SVA while it was 18.00 ms in patients without SVA (11.00-23.75); the intra-atrial EMD was 17.0 ms (10.00-20.00) in patients with SVA whereas it was 10.00 ms (4.00-14.00) in patients without SVA. Lower HRV was found in the SVA group. CONCLUSION: In the SVA group, PWD and AEMD were increased while HRV values were decreased. Noninvasive parameters may help predict the presence and incidence of SVA during the follow-up of this group of patients.

Transcatheter aortic valve implantation through the brachial artery.

Transcatheter aortic valve implantation (TAVI) has been increasingly used in patients with severe aortic stenosis. The femoral artery is the most commonly used entry site for TAVI; however, other entry sites were also reported as transapical, transaortic, transaxillary/subclavian, and transcarotid in patients with occlusive peripheral arterial disease. In this report, a case of TAVI procedure through the brachial artery is presented.

Pulmonary vein isolation using multi-electrode radiofrequency vs conventional point-by-point radiofrequency ablation: A meta-analysis of randomized and non-randomized studies.

AIMS: Pulmonary vein isolation is effective in reducing atrial fibrillation (AF) episodes. Previous studies suggest single-shot techniques are effective and safe for this purpose. Procedural and clinical outcomes were compared between multi-electrode and point-by-point radiofrequency ablations by performing a meta-analysis of all randomized and non-randomized studies. METHODS AND RESULTS: Systematic reviews of MEDLINE and Cochrane Library databases were performed. Studies comparing procedural (procedure and fluoroscopy times) and clinical (AF recurrence) outcomes were included in the meta-analysis. A total of 13 clinical studies (5 randomized and 8 non-randomized) including 2152 patients met the inclusion criteria. In patients underwent multi-electrode ablation, there were significant reductions in both total procedure and fluoroscopy times, compared with point-by-point ablation (mean difference = -34.3 min [95% CI (-50.1 to -18.5)], p < 0.001 and mean difference = -7.1 min [95% CI (-12.0 to -2.2)], p < 0.01, respectively). These significances also continued in patients with paroxysmal AF. No such difference was observed in regard to AF recurrence between the 2 ablation strategies (RR = 0.90 [95% CI (0.80-1.01)], p = 0.066). This insignificance was also observed in patients with paroxysmal AF. CONCLUSIONS: In a heterogeneous AF population, multi-electrode ablation is as effective as point-by-point ablation, with better procedural and fluoroscopy durations.

Heart Rate Recovery as a Novel Test for Predicting Cardiac Involvement in Beta-Thalassemia Major.

BACKGROUND: Abnormal heart rate recovery (HRR) is predictive of cardiac mortality. Autonomic abnormalities in beta-thalassemia major (TM) patients have been reported in previous studies. However, the importance of low HRR in exercise stress test in TM patients has not yet been ascertained. Therefore, this study will be the first of its kind in the literature. METHODS: Exercise stress test was performed on 56 TM patients who were being treated at the Thalassemia Center of our hospital, along with 46 non-TM iron deficiency anemia (IDA) patients as a control group. Values for HHR were recorded at 1, 2, 3, 4 and 5 min, and HRR was calculated by the difference of heart rate at peak exercise and at a specific time interval following the onset of recovery. RESULTS: All HRR values were found to be lower in TM patients compared to those in the IDA group. Exercise capacity [metabolic equivalents (METs)] was also found to be low in these patients (p < 0.001) as well. Total exercise time was significantly lower in the TM group compared to the IDA group (8.40 ± 1.7 min vs. 11.17 ± 1.51 min, p < 0.001). Exercise capacity (METs) was also lower in the TM group compared to the IDA group. Mean T2* value was 28.3 ± 13.7 ms in TM patients on magnetic resonance imaging (MRI). In addition, there are 18 TM patients with T2* value was < 20 ms. CONCLUSIONS: This study found that TM was independently associated with low HRR. Such a condition is an indicator of autonomic dysfunction in TM patients, since abnormal HRR is related to impaired autonomic response. In addition, impaired HRR may be a marker of early cardiac involvement in patients, whose T2* value is high on MRI. Modifying HRR with a cardiac rehabilitation program in TM patients with impaired HRR is a field open for further investigation.

Is neutrophyl to lymphocyte ratio really a useful marker for all grades of degenerative aortic stenosis?

OBJECTIVE: Inflammatory processes play an important role in cardiac valve calcification and ossification. The aim of this study was to investigate the relationship between the neutrophil-lymphocyte ratio (NLR) and degenerative aortic stenosis (AS). METHODS: A total of 220 patients with AS and 158 healthy individuals who were a control group were included in the study. The NLR was calculated by dividing the number of neutrophils by number of lymphocytes in peripheral blood samples. RESULTS: The study group consisted of 220 AS patients (mild/ moderate group: n=110; severe group: n=110) and 157 healthy controls. Both the mild/moderate AS group (p<0.001) and the severe AS group (p<0.001) had a significantly higher NLR compared with the control group. The NLR in the severe AS group was significantly higher than that of the mild/moderate AS group (p<0.001). The groups were similar with respect to other baseline characteristics. A receiver operating characteristic curve analysis yielded a strong predictive ability of NLR for the presence of AS (Area under the curve=0.930; 95% CI [confidence interval], 0.898-0.963; p<0.001). A cut-off value of 2.310 for NLR had a sensitivity and specificity of 80.4% and 92.4%, respectively, for the presence of AS. In multivariate logistic regression analysis, NLR (Odds ratio: 43.8; 95% CI, 14.7-130.7) was the only independent predictor of AS. CONCLUSION: The discriminative performance of NLR for AS is high. NLR is strongly and independently associated with AS.

Assessment of left ventricular function with tissue Doppler echocardiography and of B-type natriuretic peptide levels in patients undergoing transcatheter aortic valve implantation.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is an emerging minimally invasive treatment modality in high surgical risk or inoperable patients. AIM: The aim of this study was to ascertain the effect of TAVI on left ventricular (LV) systolic and diastolic function and serum B-type natriuretic peptide (BNP) levels in high surgical risk or inoperable patients with severe aortic stenosis. METHODS: Fifty-five patients were included in our retrospective study. LV systolic and diastolic function was assessed with conventional and tissue Doppler imaging (TDI) prior to and after TAVI. Additionally, BNP was measured 24 h before and three months after the procedure. Echocardiographic controls were performed at one, three and six months and one year and mean values were taken. At the end of the study, LV systolic and diastolic function, serum BNP levels and New York Heart Association functional capacity were assessed and compared to baseline parameters. RESULTS: The TAVI procedure was successful in all patients. In-hospital mortality was 1.8% (one patient). There was a substantial improvement in LV function and functional capacity at follow-up. In addition, a statistically significant decrease was detected in serum BNP levels post-TAVI (median 380 pg/ml [176.6-929.3] vs. 215 pg/ml [96.0-383.0], p=0.0001). Only one patient required a permanent pacemaker (1.8%) and there was no mortality after TAVI during follow-up. There were significant increases in LV ejection fraction and aortic valve area (51.0±13.1% vs. 58.4±9.1%, p<0.001, and 0.6±0.1 cm2 vs. 2.1±0.2 cm2, p=0.0001, respectively). At the end of the study, conventional Doppler echocardiography revealed improvement in diastolic function, with an increase in mitral E wave, a decrease in mitral A wave and an increase in E/A ratio. Deceleration time and isovolumetric relaxation time were shortened and myocardial performance (Tei) index decreased. TDI showed an increase in systolic myocardial velocity (Sm) and early diastolic velocity (Em). Septal mitral annular Sm and Em were increased, whereas MPI was reduced. CONCLUSION: We found that LV structural changes and diastolic dysfunction occur in patients with severe aortic stenosis and that TAVI is able to reverse these abnormalities, which we demonstrated by both conventional echocardiography and TDI. In addition, serum BNP levels were decreased after TAVI.

Should physicians instead of industry representatives be the main actor of cardiac implantable electronic device follow-up? (Super Follow-up).

OBJECTIVE: This retrospective study sought to research the adequacy of the follow-up and optimization of cardiac implantable electronic devices (CIEDs) performed by industry representatives. METHODS: A total of 403 consecutive patients (35% females; median age, 67 years; age range 18-97 years) with either pacemakers (n=246), implantable cardioverter-defibrillators (ICDs), (n=117) or cardiac resynchronization therapy with defibrillator (CRT-D) (n=40) applied to our hospital's outpatient pacemaker clinic for follow-up. These patients had been followed up by industry representatives alone until September 2013 and then by a cardiologist who is dealing with cardiac electrophysiology and has a knowledge of CIED follow-up. RESULTS: It was ascertained that 117 (47.6%) of 246 patients with pacemakers had a programming error. Forty-three (36.8%) of 117 patients were symptomatic, and after reprogramming, all symptoms diminished partially or completely during the follow-up. Moreover, 30 (25.6%) of 117 patients with ICDs had a programming error. Furthermore, 6 (15%) of 40 patients with CRT-Ds had a programming error. To conclude, when all patients with CIEDs were assessed together, it was ascertained that 153 (38%) of 403 patients had programming errors. CONCLUSION: The prevalence of inappropriate programming of CIEDs by industry representatives was quite higher than expected. Therefore, our study strongly demonstrates that CIED follow-up should not be allowed to be performed entirely by manufacturers' representatives alone.

The Relationship between Vitamin D and Coronary Artery Ectasia in Subjects with a Normal C-Reactive Protein Level.

BACKGROUND AND OBJECTIVES: Vitamin D is generally known to be closely related to inflammation. The effects of vitamin D on coronary artery disease (CAD) are not fully explained. Nowadays, coronary artery ectasia (CAE) cases are common and are regarded as being a kind of CAD. We aimed to investigate, in a case-control study, the relationship between vitamin D and CAE without an associated inflammatory process. SUBJECTS AND METHODS: This study population included 201 patients (CAE group, 121 males; mean age, 61.2±6.4 years) with isolated CAE; and 197 healthy individuals (control group, 119 males; mean age, 62.4±5.8 years), comprising the control group, who had normal coronary arteries. These participants concurrently underwent routine biochemical tests, tests for inflammatory markers, and tests for 25-OH vitamin D in whole-blood draws. These parameters were compared. RESULTS: There are no statistical significance differences among the groups for basic clinical characteristics (p>0.05). Inflammatory markers were recorded and compared to exclude any inflammatory process. All of them were similar, and no statistical significance difference was found. The average parathyroid hormone (PTH) level of patients was higher than the average PTH level in controls (41.8±15.1 pg/mL vs. 19.1±5.81 pg/mL; p<0.001). Also, the average 25-OH vitamin D level of patients was lower than the average 25-OH vitamin D level of controls (14.5±6.3 ng/mL vs. 24.6±9.3 ng/mL; p<0.001). In receiver operating characteristic curve analysis, the observed cut-off value for vitamin D between the control group and patients was 10.8 and 85.6% sensitivity and 75.2% specificity (area under the curve: 0.854, 95% confidence interval: 0.678-0.863). CONCLUSION: We found that there is an association between vitamin D and CAE in patients who had no inflammatory processes. Our study may provide evidence for the role of vitamin D as a non-inflammatory factor in the pathophysiology of CAE.