Is the Prevalence of Coronary Artery Anomalies Different in Countries with Small Populations? - A Retrospective Study in Northern Cyprus.

BACKGROUND: Although the prevalence of coronary artery anomalies (CAA) is due to accidental and rare discoveries, it varies between different countries or geographies. CAA are rare congenital disorders having various clinical definitions. Its prevalence varies in angiographic and autopsy series in adult populations and is approximately 1% in average. While the incidence ranges from 0.2% to 5.64% in coronary angiographic (CAG) studies, it is around 0.3% in autopsy series. We aimed to estimate the frequency of CAA in our patient population. METHODS: The coronary angiographic data of 4099 consecutive adult patients, who underwent CAG between January 2019 and December 2020, were analyzed and retrospectively studied. RESULTS: The mean age of the total patients who underwent CAG was 61.59 ± 13.67 years (range, 18-98 years). CAA were found in 76 patients (1.85% incidence), origin and course anomaly in 62 patients (81.6%), and coronary artery termination anomaly in 14 patients (18.4%). Separate exits of the left anterior descending (LAD) and left circumflex (LCX) coronary artery from the left sinus of Valsalva (LSV) were the most common anomalies (36.84%). Coronary artery fistulas were seen in 14 (18.42%) patients. Abnormal origin of left circumflex artery (LCX) from the right coronary artery (RCA) or right sinus valsalva (RSV) was seen in 13 (17.11%) patients. Outflow anomalies from the contralateral coronary sinus were detected in 10 (13.16%) patients. CONCLUSION: The incidence and pattern of CAA in our patient population showed similarity with previous studies. Physicians should be aware of CAA that may be associated with potentially serious cardiac incidents, because recognition of these CAA is important for the decision of treatment procedures.

The Anatomical History of a Single Coronary Artery Anomaly: A Case Report.

Single coronary artery(SCA) anomaly is a rare anomaly where the right and left coronary arteries arise from a single ostium in the sinus valsalva and feed the whole heart. Although asymptomatic in most cases, it can cause angina, syncope, myocardial infarction and sudden cardiac death. It is essential to diagnose it especially in terms of the risk of encountering clinical pictures such as sudden death at a young age and its association with other congenital anomalies. In this report, we present a patient with a SCA anomaly. During an emergency conventional angiography, a right coronary artery(RCA) arising from the left main coronary artery(LMCA) originating from a single ostium was detected in the aorta.

MicroRNA-221/222 expression in atherosclerotic coronary artery plaque versus internal mammarian artery and in peripheral blood samples.

BACKGROUND: Atherosclerosis is a disease of the arterial wall with predilection to some sites on others. MicroRNAs (miRNAs) are a class of the non-coding RNAs regulating the target gene expression at post-transcriptional level. Different miRNAs were found at distinct stages of plaque development and expression of miRNAs' might play an important role in the local behaviour of atherosclerotic plaques. OBJECTIVE: We aimed to investigate and compare mirR-221/222 expression levels in tissues and in circulation in patients with and without overt atherosclerosis. METHODS: RNA was isolated from 40 tissues as 20 tissue samples from coronary artery atherosclerotic plaques (CAAP) and internal mammary arteries (IMA), obtained from same individual) and 80 blood (44 patients with atherosclerosis and 36 healthy subjects) samples. MiR-221/222 expression levels were measured using real time PCR. RESULTS: Expression levels of miR-221 was significantly increased in CAAP compared with completely atherosclerosis-free IMA tissues with a 8.94 times fold-change (p = 0.015). The miR-221 expression in tissue samples was significantly different in patients with hypercholesterolemia (p = 0.010), hypertension (p = 0.018) and family history of CAD (p = 0.033) versus not. Expression of miR-222 was not statistically significant between the two tissue samples overall. CONCLUSIONS: MiR-221 may be a potential biomarker for local atherosclerotic behavior.

Real-world stroke prevention strategies in nonvalvular atrial fibrillation in patients with renal impairment.

BACKGROUND: The data regarding stroke prevention strategies in nonvalvular atrial fibrillation (NVAF) are limited especially in patients with renal impairment (RI). We sought to evaluate management dilemmas in patients with concurrent NVAF and RI in RAMSES (ReAl-life Multicenter Survey Evaluating Stroke Prevention Strategies inTurkey) study. METHODS: We conducted a prospective, multicenter, nation-wide registry in NVAF patients in outpatient cardiology clinics. All consecutive patients with NVAF were enrolled in RAMSES study (ClinicalTrials.gov identifier NCT02344901). The baseline data were collected. Glomerular filtration rate (GFR) was estimated by Cockcroft-Gault equation. RESULTS: A total number of 6273 patients from 29 provinces of Turkey with the contribution of 83 investigators were enrolled to the study. Of the study population, 1964(33%) patients had RI which was defined as GFR < 60 mL/min. Patients with RI had significantly higher CHA2 DS2 VASc and HAS-BLED scores compared to those without RI (3·9 ± 1·5 vs. 2·9 ± 1·5, and 2·0 ± 1 vs. 1·4 ± 1; P < 0·001). Prior history of major bleeding (6·9% vs. 4·1%, P < 0·001) and stroke (16·2% vs. 11·8%, P < 0·001) was significantly higher among individuals with concomitant RI and NVAF. Although RI patients had a higher risk for thromboembolism, number of the patients who did not receive any anticoagulant therapy was higher in patients with RI than without RI (30·1 vs. 26·4%, P = 0·003). CONCLUSION: RAMSES study showed that one-third of the patients with NVAF had RI in the real-world setting. Although it is mandatory in most of the patients with concomitant NVAF and RI, nearly one-third of these patients did not receive any anticoagulant therapy.

Impact of valvular heart disease on oral anticoagulant therapy in non-valvular atrial fibrillation: results from the RAMSES study.

The definition of non-valvular atrial fibrillation (NVAF) is controversial. We aimed to assess the impact of valvular heart disease on stroke prevention strategies in NVAF patients. The RAMSES study was a multicenter and cross-sectional study conducted on NVAF patients (ClinicalTrials.gov identifier NCT02344901). The study population was divided into patients with significant valvular disease (SVD) and non-significant valvular disease (NSVD), whether they had at least one moderate valvular disease or not. Patients with a mechanical prosthetic valve and mitral stenosis were excluded. Baseline characteristics and oral anticoagulant (OAC) therapies were compared. In 5987 patients with NVAF, there were 3929 (66%) NSVD and 2058 (34%) SVD patients. The predominant valvular disease was mitral regurgitation (58.1%), followed by aortic regurgitation (24.1%) and aortic stenosis (17.8%). Patients with SVD had higher CHA2DS2VASc [3.0 (2.0; 4.0) vs. 4.0 (2.0; 5.0), p < 0.001] and HAS-BLED [2.0 (1.0; 2.0) vs. 2.0 (1.0; 2.0), p = 0.004] scores compared to patients with NSVD. Overall, 2763 (71.2%) of NSVD and 1515 (73.8%) of SVD patients were on OAC therapy (p = 0.035). When the patients with SVD were analyzed separately, the mean CHA2DS2VASc and HAS-BLED scores were higher in patients with mitral regurgitation compared to patients with aortic regurgitation and aortic stenosis [4.0 (3.0; 5.0), 3.0 (2.0; 4.0), 3.0 (2.0; 4.0) p < 0.001 and 2.0 (1.0; 3.0), 1.0 (1.0; 2.0), 1.0 (0.0; 2.0) p < 0.001, respectively]. In patients with SVD, 65.7% of mitral regurgitation, 82.6% of aortic regurgitation and 88.0% of aortic stenosis patients were on OAC therapy. One out of three NVAF patients had at least one moderate valvular heart disease with the predominance of mitral regurgitation. Patients with SVD were at greater risk of stroke and bleeding compared to patients with NSVD. Although patients with mitral regurgitation should be given more aggressive anticoagulant therapy due to their higher risk of stroke, they are undertreated compared to patients with aortic valve diseases.

Right Ventricular Dysfunction Complicates Time in Therapeutic Range in Heart Failure Patients Receiving Warfarin.

AIM: We aimed to evaluate the effect of echocardiographically demonstrated right ventricular dysfunction (RVD) on time in therapeutic range (TTR) in heart failure (HF) patients receiving warfarin therapy. METHODS: A total of 893 consecutive HF patients were included and classified into 4 different subgroups: HF with preserved ejection fraction (HFpEF) without RVD (n = 373), HF with reduced EF (HFrEF) without RVD (n = 215), HFpEF with RVD (n = 106) and HFrEF with RVD (n = 199). Groups were compared according to baseline, demographic and clinical data and the characteristics of warfarin therapy. RESULTS: Presence of RVD yielded lower median TTR values both in HFpEF and HFrEF patients. RVD, current smoking, New York Heart Association functional class III/IV, hypertension, diabetes mellitus, pulmonary disease, prior transient ischemic attack or stroke, chronic kidney disease (CKD) stage 4/5 and CKD stage 3 were found to be independent predictors of poor anticoagulation control in multivariate logistic regression analysis. CONCLUSIONS: The present study demonstrated that presence of RVD in HF increases the risk for poor anticoagulation.

Flow and Diameter Changes of Forearm Arteries During Temporary Unilateral Reciprocal Occlusion: A Prospective Observational Study.

PURPOSE: Transradial and transulnar artery approaches are commonly used for percutaneous interventions, with considerably low risk of developing hand ischemia, for reasons that have not been fully understood. The aim of this study was to evaluate the changes in the diameter, peak systolic flow velocity (PSV), and volume flow (VF) of the radial (RA) and ulnar artery (UA) during unilateral reciprocal temporary occlusion. METHODS: A total of 204 extremity arteries of 102 consecutive patients were evaluated using Doppler ultrasonography. At the level of the wrist, RA and UA were consecutively compressed for 60 seconds. The diameter, PSV, and VF parameters of both arteries were evaluated during unilateral reciprocal compression. RESULTS: Compared with the baseline values, the median (interquartile range) increases in diameter, PSV, and VF were 0.2 (0.1-0.3) mm, 6.8 (1.7-17.5) cm/s, and 1.9 (0.8-10) ml/min, respectively, for RA, and 0.1 (0.1-0.3) mm, 9.4 (2.6-18.0) cm/s, and 10.0 (0.0-20.0) ml/min, respectively, for UA during reciprocal compression (p < 0.001 for all). CONCLUSIONS: Reciprocal compression significantly increased the diameter, PSV, and VF of both arteries during reciprocal compression. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:197-203, 2017.

Evaluation of anatomy and variations of superficial palmar arch and upper extremity arteries with CT angiography.

AIM: To evaluate the abnormalities and variations of the arterial system of upper extremities and superficial palmar arch with computed tomography angiography and to guide the clinician during this procedure. METHODS: A total of 156 upper extremities of 78 cases were retrospectively analyzed using computed tomography angiography. The study was approved by the local ethics committee of the hospital. From the analysis of the computed tomography angiography images, the following information was recorded; the diameters and abnormalities of radial, ulnar and brachial arteries in both upper extremities, the presence of atherosclerotic changes or stenosis in these arteries, whether the superficial palmar arch was complete or incomplete, and arterial dominance. Also, the computed tomography angiography classification of superficial palmar arch distribution and anatomic configuration was performed. RESULTS: The mean baseline diameters of the radial, ulnar and brachial arteries of the cases were; 2.8 ± 0.6, 2.5 ± 0.7, and 4.7 ± 0.6 mm, respectively. A complete superficial palmar arch was observed in 69.2 % of the right hands and 70.5 % of the left hands. For the superficial palmar arches on the right side, the radial artery was dominant in two and the ulnar artery was dominant in 47 with the remaining showing codominance. On the left side, the radial artery was dominant in one hand, with the ulnar artery being dominant in 49 cases, and in 28 cases, there was codominance. In the superficial palmar arch classification, four of the arches (A-D) were defined as complete and the remaining three (E-G) as incomplete. CONCLUSION: The current study clarified different variations in palmar circulation and forearm arteries to aid the surgeon during trans-radial or trans-ulnar catheterization, hemodialysis, or coronary artery bypass grafting.

Mean Platelet Volume as a Predictor of Heart Failure-Related Hospitalizations in Stable Heart Failure Outpatients with Sinus Rhythm.

BACKGROUND: In this study, we investigated the relationship between the mean platelet volume (MPV) with mortality and heart failure (HF)-related hospitalization in stable chronic HF outpatients with reduced ejection fraction (HFrEF) and with sinus rhythm (SR). METHODS: This retrospective cohort study included 197 consecutive stable chronic HFrEF outpatients with SR, who were admitted to our cardiology outpatient clinics for examination between January 2014 and January 2015. According to the receiver-operating characteristic curve analysis, the optimal cut-off value of MPV to predict HF-related hospitalization was > 9.1 fL. Patients were classified into two categories according to threshold MPV levels, as group I with MPV ≤ 9.1 fL and group II with MPV > 9.1 fL. RESULTS: The mean age of patients was 65 ± 13 years. The mean follow-up duration was 10 ± 3 months, and 44 patients (22%) succumbed to cardiovascular (CV) death. The rate of CV mortality was similar between the two groups (21% vs. 24%, p = 0.649). However, the rate of patients who experienced HF-related hospitalization was lower in group I compared with group II (41% vs. 87%, p < 0.001, respectively). Univariate analysis demonstrated associations of many clinical factors in addition to increased MPV > 9.1 fL with HF-related hospitalization; however, In the multivariate Cox proportional-hazards model, only increased MPV > 9.1 fL (HR: 2.895, 95% CI: 1.774-4.724, p < 0.001), systolic pulmonary artery pressure level (HR: 1.018, 95% CI: 1.001-1.036, p = 0.048) and pre-admission beta blocker use (HR: 0.517, 95% CI: 0.305-0.877, p = 0.014) remained associated with a risk of HF-related hospitalization. CONCLUSIONS: The mean platelet volume might be a useful parameter for risk stratification with regard to HF-related hospitalization in HFrEF outpatients with SR.

Bleeding complications during cardiac electronic device implantation in patients receiving antithrombotic therapy: is there any value of local tranexamic acid?

BACKGROUND: The perioperative use of antithrombotic therapy is associated with increased bleeding risk after cardiac implantable electronic device (CIED) implantation. Topical application of tranexamic acid (TXA) is effective in reducing bleeding complications after various surgical operations. However, there is no information regarding local TXA application during CIED procedures. The purpose of our study was to evaluate bleeding complications rates during CIED implantation with and without topical TXA use in patients receiving antithrombotic treatment. METHODS: We conducted a retrospective analysis of consecutive patients undergoing CIED implantation while receiving warfarin or dual antiplatelet (DAPT) or warfarin plus DAPT treatment. Study population was classified in two groups according to presence or absence of topical TXA use during CIED implantation. Pocket hematoma (PH), major bleeding complications (MBC) and thromboembolic events occuring within 90 days were compared. RESULTS: A total of 135 consecutive patients were identified and included in the analysis. The mean age was 60 ± 11 years old. Topical TXA application during implantation was reported in 52 patients (TXA group). The remaining 83 patients were assigned to the control group. PH occurred in 7.7 % patients in the TXA group and 26.5 % patients in the control group (P = 0.013). The MBC was reported in 5.8 % patients in the TXA and 20.5 % patients in control group (P = 0.024). Univariate logistic regression analysis identified age, history of recent stent implantation, periprocedural spironolactone use, periprocedural warfarin use, perioperative warfarin plus DAPT use, cardiac resynchronization therapy, and topical TXA application during CIED implantation as predicting factors of PH. Multivariate analysis showed that perioperative warfarin plus DAPT use (OR = 10.874, 95 % CI: 2.496-47.365, P = 0.001) and topical TXA application during CIED procedure (OR = 0.059, 95 % CI: 0.012-0.300, P = 0.001) were independent predictors of PH. Perioperative warfarin plus DAPT use and topical TXA application were also found to be independent predictors of MBC in multivariate analyses. No thromboembolic complications was recorded in the study group. CONCLUSION: The present study demonstrated that the topical TXA application during CIED implantation is associated with reduced PH and MBC in patients with high bleeding risk.

COHgb levels predict the long-term development of acute myocardial infarction in CO poisoning.

BACKGROUND: There are several studies evaluating the cardiac effects of carbon monoxide (CO) poisoning during the acute period; however, the number of studies evaluating the long-term cardiac effects is limited. OBJECTIVE: The present study aimed to evaluate the effects of blood carboxyhemoglobin (COHb) levels, elevated due to CO poisoning on the long-term development of acute myocardial infarction (AMI). METHODS: This cross-sectional cohort study included a total of 1013 consecutive patients who presented to the emergency department (ED) due to CO poisoning, between January 2005 and December 2007. The diagnosis of CO poisoning was made according to the medical history and a COHb level of greater than 5%. In terms of AMI development, the patients were followed up for an average of 56 months. RESULTS: At the end of follow-up, 100 (10%) of 1013 patients experienced AMI. Carboxyhemoglobin levels at the time of poisoning were higher among those who were diagnosed with AMI compared to those who were not (55%±6% vs 30%±7%; P<.001). Using a multivariate Cox proportional hazards model with forward stepwise method, age, COHb level, CO exposure time, and smoking remained associated with an increased risk of AMI after adjustment for the variables found to be statistically significant in a univariate analysis. According to a receiver operating characteristic curve analysis, the optimal cutoff value of COHb used to predict the development of AMI was found to be greater than 45%, with 98% sensitivity and 94.1% specificity. CONCLUSION: In patients presenting to the ED with CO poisoning, COHb levels can be helpful for risk stratification in the long-term development of AMI.

Is Preoperative Eosinopenia an Independent Predictor of Early Mortality for Coronary Artery Bypass Surgery?

OBJECTIVE: Coronary artery bypass graft surgery in one of the most effective and widely used methods employed in the treatment of ischemic heart disease, but many factors to various degrees are directly associated with perioperative and postoperative problems. In this study, we evaluated the relationship between preoperative eosinophil count and postoperative mortality in patients who underwent coronary artery bypass graft operation. METHODS: A total of 241 patients (157 males, 84 females) who underwent isolated on-pump coronary artery bypass graft operation between 2011 and 2013 in two centers were evaluated retrospectively. The mean age of patients was 64 ± 11 years. After the mean 6.2 ± 0.8 month follow-up period, 36 (15%) of the 241 patients experienced cardiovascular death. Patients were classified into two groups as those who survived versus those who died. RESULTS: Eosinophil levels were lower among the patients who died compared to the patients who survived (0.8 [0-3.8] versus 1.7 [0-9.4] ×1000 cells/mm3; P < .001). Optimal cut-off level of eosinophils for predicting mortality was determined as ≤1.6 ×1000 cells/mm3, with a sensitivity of 85.7% and specificity of 51.0% (area under curve, 0.703; 95% CI, 0.641-0.760). CONCLUSION: Eosinopenia was used as the predictor of mortality in pediatric and adult patients in the intensive care units. Eosinopenia after coronary artery bypass graft can be related to the endogenous stress hormones, and insufficiency of the existing cardiac status. Eosinophil levels can assist and facilitate risk stratification for patients with coronary artery bypass graft.

Atrial Electromechanical Properties in Coeliac Disease.

BACKGROUND: Coeliac disease (CD) is an autoimmune and inflammatory disorder of the small intestine. There is reasonable evidence linking inflammation to the initiation and continuation of atrial fibrillation (AF) in inflammatory conditions. Atrial electro-mechanic delay (EMD) was suggested as an early marker of AF in previous studies. The objectives of this study were to evaluate atrial electromechanical properties measured by tissue Doppler imaging and simultaneous electrocardiography (ECG) tracing in patients with CD. METHODS: Thirty-nine patients with coeliac disease (CD), and 26 healthy volunteers, matched for age and sex, were enrolled in the study. Atrial electromechanical properties were measured by using transthoracic echocardiography and surface ECG. Interatrial electro-mechanic delay (EMD), left intraatrial EMD, right intratrial EMD were calculated. RESULTS: There was no difference between CD patients and healthy volunteers in terms of basal characteristics. Patients with CD had significantly prolonged left and right intraatrial EMDs, and interatrial EMD compared to healthy controls (p= 0.03, p= 0.02, p<0.0001, respectively). Interatrial EMD was positively correlated with age, disease duration, anti-gliadin IgG, anti-endomysium and disease status. In multiple linear regression, interatrial EMD was independently associated with disease duration, anti-endomysium and disease status after adjusting for age and sex. CONCLUSIONS: In the present study, atrial EMDs were found significantly higher in patients with CD compared with healthy individuals. Measurement of atrial EMD parameters might be used to predict the risk of development of AF in patients with CD.

The practical value of technetium-99m-MIBI SPET to differentiate between ischemic and non-ischemic heart failure presenting with exertional dyspnea.

OBJECTIVE: We aimed to differentiate ischemic heart failure (HF) from non-ischemic HF in patients presenting with non-acute onset exertional dyspnea using technetium-99m methoxyisobutylisonitrile gated single photon emission tomography ((99m)Tc-MIBI gSPET) imaging. SUBJECTS AND METHODS: One hundred and seventy nine consecutive patients with exertional dyspnea without concomitant chest pain referred to (99m)Tc-MIBI gSPET imaging were included in this study. All patients had a newly diagnosed HF with reduced ejection fraction (HFrEF). Imaging findings were compared between ischemic HF and non-ischemic HF groups. RESULTS: Of the 179 patients, 127 had ischemic HF and 52 had non-ischemic HF. There was no difference between ischemic and non-ischemic groups in terms of age, gender, body mass index, any smoking history, diabetes mellitus, history of hypertension and hyperlipidemia. Global dysfunction of left ventricle was more common in non-ischemic HF group than ischemic HF group (82.7% vs 41.7% respectively, P<0.001). Presence of severe (3+/4+) ischemia and large perfusion defect were higher in ischemic HF group compared to non-ischemic HF group (45.7% vs 15.4%, P<0.001 and 23.6% vs 3.8%, P=0.003, respectively). Summed stress score (SSS), summed rest score and summed difference score were higher in ischemic HF group compared to non-ischemic HF group (P<0.001, P<0.001, and P=0.021, respectively). In multivariate analysis, absence of global dysfunction (P<0.001, OR=10.338, 95%CI: 3.937-27.405) and SSS (P<0.001, OR=1.208, 95%CI: 1.090-1.339) were the independent predictors of ischemic HF. Absence of global dysfunction had 58.3% sensitivity and 86.7% specificity for diagnosis of ischemic HF at gSPET imaging in patients presenting with newly diagnosed HF and exertional dyspnea without concomitant chest pain (AUC=0.705, 95%CI: 0.632-0.771, P<0.001), whereas SSS>8 had 65.4% sensitivity and 75.0% specificity (AUC=0.732, 95%CI: 0.661-0.795, P<0.001). CONCLUSION: Absence of global dysfunction and SSS on SPET imaging were the independent predictors of ischemic etiology of HF presenting with dyspnea without concomitant chest pain. These findings had a low sensitivity, but acceptable specificity.

The value of exercise SPET for the detection of coronary artery steal syndrome secondary to unligated major side branch of left internal mammary artery.

OBJECTIVE: The clinical significance of unligated major left internal mammary artery (LIMA)-side branches (SB) remains controversial in patients with previous coronary artery bypass graft (CABG) surgery. The aim of this study was to investigate the clinical significance of unligated major LIMA-SB by using exercise myocardial perfusion imaging (MPI) with single-photon emission tomography. SUBJECTS AND METHODS: We conducted a retrospective analysis of 2819 consecutive patients who underwent diagnostic angiography. There were 407 CABG patients with LIMA graft. The demographic, laboratory, pre-angiographic stress test and angiographic data of these patients were collected. A subgroup of patients with unligated major LIMA-SB who were referred to angiography with the diagnosis of stable angina pectoris and positive exercise MPI was identified and divided into two groups for comparison: anterior wall vs non-anterior wall ischemia groups. RESULTS: Among 407 patients with LIMA graft, 112 (27.5%) patients were found to have unligated major LIMA-SB. In a subgroup of patients (n=45) with positive exercise MPI and patent LAD-LIMA system with unligated major LIMA-SB, the median values of diameter and length of unligated major LIMA-SB were statistically higher in anterior wall ischemia group (n=24) compared to non-anterior wall ischemia group (1.8mm vs 0.6mm, P<0.001 and 17.0cm vs 8.0cm, P<0.001, respectively). The cut-off values of unligated major LIMA-SB length and diameter were 11cm and 1.3mm respectively. Unligated major LIMA-SB with a length of ≥11.0cm and a diameter of >1.3cm had 95.8% of sensitivity and 100% of specificity for predicting anterior wall ischemia on exercise MPI. In patients with anterior wall ischemia, summed stress score and summed difference score were improved after percutaneous coil embolization of large unligated major LIMA-SB with ≥11.0cm length and >1.3mm diameter. CONCLUSION: Large unligated major LIMA-SB with ≥11.0cm length and >1.3mm diameter seems to be a potential source of ischemia in CABG patients. We suggest that exercise MPI might be a first option noninvasive test in evaluating the clinical significance of unligated major LIMA-SB and the effectiveness of embolization therapy.

Lymphocytopenia is associated with poor NYHA functional class in chronic heart failure patients with reduced ejection fraction.

OBJECTIVE: In heart failure (HF) patients, functional capacity has been demonstrated to be a marker of poor prognosis, independent of left ventricular ejection fraction (EF). Lymphocyte count is currently recognized in certain risk stratification scores for chronic HF, and severe HF is associated with lymphocytopenia. However, no data exists on the association between lymphocyte count and functional capacity in patients with stable HF. This study aimed to assess the relationship between lymphocyte count and New York Heart Association (NYHA) functional capacity in systolic HF outpatients. METHODS: The Turkish Research Team-HF (TREAT-HF) is a network which undertakes multi-center observational studies in HF. Data on 392 HF reduced ejection fraction (HFREF) patients from 8 HF centers are presented here. The patients were divided into two groups and compared: Group 1 comprised stable HFREF patients with mild symptoms (NYHA Class I-II), while Group 2 consisted of patients with NYHA Class III-IV symptoms. RESULTS: Patient mean age was 60±14 years. Lymphocyte count was lower in patients with NYHA functional classes III and IV than in patients with NYHA functional classes I and II, (0.9 [0.6-1.5]x1000 versus 1.5 [0.7-2.2]x1000, p<0.001). In multivariate logistic regression analysis, lymphocyte count (OR: 0.602, 95% CI: 0.375-0.967, p=0.036), advanced age, male gender, presence of hypertension, EF, left atrium size, systolic pulmonary artery pressure, neutrophil and basophil counts, creatinine level, and diuretic usage were associated with poor NYHA functional class in systolic HF outpatients. CONCLUSION: The present study demonstrated that in stable HFREF outpatients, lymphocytopenia was strongly associated with poor NYHA function, independent of coronary heart disease risk factors.

Long-Term Results of Pulmonary Vein Isolation Plus Modified Posterior Wall Debulking Utilizing High-Power Short-Duration Strategy: An All-Comers Study in Real World.

BACKGROUND: High-power short-duration radiofrequency ablation has improved lesion durability in pulmonary vein isolation. In this study, we investigate long-term clinical out-comes of high-power short-duration pulmonary vein isolation and posterior wall debulk- ing as an initial treatment modality in all corner atrial fibrillation patients. METHODS: This is a single-center, retrospective, observational study including all patients who have undergone high-power short-duration pulmonary vein and posterior wall deb-ulking, regardless of atrial fibrillation type and/or duration. High-power short-duration power delivery protocol was defined as 45 W at all ablation sites. Clinical and electrocar-diographic follow-up were performed in all patients. RESULTS: One hundred forty-two patients were enrolled in this study. Paroxysmal atrial fibrillation was present in 88 (62%) of patients. The mean follow-up of this study was 36.9 months ± 12.2 months. During the follow-up period, 10 patients (11.4%) with a diag- nosis of paroxysmal atrial fibrillation had recurrence, while recurrence in patients with persistent and long-standing persistent atrial fibrillation was slightly higher (15 patients (28.1%) and 5 patients (50%), respectively). No major life-threatening complicationsoccurred. CONCLUSION: This study has demonstrated excellent arrhythmia-free outcomes in unselected, real world atrial fibrillation patients undergoing high-power short-duration pulmonary vein and debulking posterior wall isolations, however larger randomized trials are warranted.

Which is the best for the warfarin monitoring: Following up by fixed or variable physician?

Objective: Warfarin therapy has some difficulties in terms of close monitoring and dosage. This study aims to evaluate the effect of same-fixed versus different-variable physician-based monitoring of warfarin therapy on treatment quality and clinical end-points. Methods: A total of 625 consecutive patients requiring warfarin treatment were enrolled at seven centers. INR values of the patients measured at each visit and registered to hospital database were recorded. Time in therapeutic range (TTR) was calculated using linear interpolation method (Rosendaal's method). A TTR value of ≥65% was considered as effective warfarin treatment. If a patient was evaluated by the same-fixed physician at each INR visit, was categorized into the same-physician (SP) group. In contrast, if a patient was evaluated by different-variable physicians at each INR visit, was categorized into variable physician (VP) group. Enrolled patients were followed up for bleeding and embolic events. Results: One hundred and fifty-six patients (24.9%) were followed by SP group, 469 (75.1%) patients were followed by VP group. Median TTR value of the VP group was lower than that of SP group (56.2% vs. 65.1%, respectively, p=0.009). During median 25.5 months (9-36) of follow-up, minor bleeding, major bleeding and cerebral embolic event rates were higher in VP group compared to SP group (p<0.001, p=0.023, p<0.001, respectively). In multivariate analysis, INR monitoring by VP group was found to be an independent predictor of increased risk of bleeding events (OR 2.55, 95% CI 1.64-3.96, p<0.001) and embolism (OR 3.42, 95% CI 1.66-7.04, p=0.001). Conclusion: INR monitoring by same physician was associated with better TTR and lower rates of adverse events during follow-up. Hence, it is worth encouraging an SP-based outpatient follow-up system at least for where warfarin therapy is the only choice.

Procedural Characteristics, Safety, and Follow-up of Modified Right-Sided Approach for Cardioneuroablation.

BACKGROUND: Cardioneuroablation is one of the emerging therapies in vasovagal syncope. In this study, we present a simple method of cardioneuroablation performed via a rightsided approach, targeting anterior-right and right-inferior ganglionated plexi, along with procedural and follow-up data. METHODS: Patients who had underwent cardioneuroablation between March 2018 and September 2019 with vasovagal syncope in 2 clinics were enrolled in the study. All patients underwent radio-anatomically guided radiofrequency ablation targeting anterior-right ganglionated plexi and right-inferior ganglionated plexi. Syncope and symptom burden, 24-hour ambulatory electrocardiogram data at presentation, and at follow-up were assessed along with procedural data. RESULTS: A total of 23 patients underwent modified right-sided cardioneuroablation. Mean basal cycle length decreased significantly from 862.3 ± 174.5 ms at the beginning of the procedure 695.8 ± 152.1 ms following the final radiofrequency ablation (P < .001). Mean 24-hour ambulatory heart rate increased significantly from 66.4 ± 10.7 bpm at baseline to 80 ± 7.6 bpm at follow-up (P < .001). Only 1 patient had 1 episode of syncope following the procedure at the mean follow-up period of 10 ± 2.9 months. The same patient had recurrent presyncope. CONCLUSION: The right-sided cardioneuroablation approach was found to be an effective treatment for vasovagal syncope and may be regarded as a default initial cardioneuroablation technique.