Functional substrate mapping of atrium in patients with atrial scar: A novel method to predict critical isthmus of atrial tachycardia.

Atrial tachycardia (AT) is a common rhythm disorder, especially in patients with atrial structural abnormalities. Although voltage mapping can provide a general picture of structural alterations which are mainly secondary to prior ablations, surgery or pressure/volume overload, data is scarce regarding the functional characteristics of low voltage regions in the atrium to predict critical isthmus of ATs. Recently, functional substrate mapping (FSM) emerged as a potential tool to evaluate the functionality of structurally altered regions in the atrium to predict critical sites of reentry. Current evidence suggested a clear association between deceleration zones of isochronal late activation mapping (ILAM) during sinus/paced rhythm and critical isthmus of reentry in patients with left AT. Therefore, these areas seem to be potential ablation targets even not detected during AT. Furthermore, abnormal conduction detected by ILAM may also have a role to identify the potential substrate and predict atrial fibrillation outcome after pulmonary vein isolation. Despite these promising findings, the utility of such an approach needs to be evaluated in large-scale comparative studies. In this review, we aimed to share our experience and review the current literature regarding the use of FSM during sinus/paced rhythm in the prediction of re-entrant ATs and discuss future implications and potential use in patients with atrial low-voltage areas.

Ictal Asystole During Focal Seizures Due to Left Occipital Glioneuronal Tumor: A Report of Case Treated With Cardiac Neuromodulation.

Ictal asystole (IA) is a rare but potentially life-threatening complication of focal epilepsy. The sudden onset of loss of consciousness and drop attacks in a patient with chronic epilepsy should suggest the possibility of this complication. Once the diagnosis is established, rapid management should be considered, especially in high-risk cases. The approach does not differ between temporal and extratemporal lobe epilepsies. Strategies can be aimed at preventing the emergence of cortical epileptic activity from the beginning (surgery, antiseizure therapy), neutralizing negative chronotropic effects on the heart (cardiac neuromodulation), or restarting the heart rhythm with a pacemaker. Pacemaker implantation is not a completely complication-free treatment, and living with a device that requires care and follow-up throughout life makes alternative treatment methods more valid for young patients with many years to live or cases that could benefit from surgery. In this article, we present a patient with a left occipital glioneuronal tumor and drug-resistant occipital lobe epilepsy. IA was documented by long-term video EEG monitoring (VEM). During about 2 years of follow-up after a cardiac neuromodulation procedure, there were no drop attacks or asystole with seizures, confirmed by long-term VEM.

Long-term outcomes of left atrial appendage isolation using cryoballoon in persistent atrial fibrillation.

AIMS: There is an increasing trend evaluating the role of non-pulmonary vein (PV) triggers to improve ablation outcomes in persistent atrial fibrillation (AF) as pulmonary vein isolation (PVI) strategy alone has modest outcomes. We investigated the long-term safety and efficacy of left atrial appendage isolation (LAAi) in addition to PVI using cryoballoon (CB) in persistent AF. METHODS AND RESULTS: In this multicentre retrospective analysis, we included a total of 193 persistent AF patients (mean age: 60 ± 11 years, 50.3% females) who underwent PVI and LAAi using CB. Baseline and follow-up data including electrocardiography (ECG), 24 h Holter ECGs, and echocardiography were recorded for all patients. Atrial tachyarrhythmia (ATa) recurrence was defined as the detection of AF, atrial flutter, or atrial tachycardia (≥30 s) after a 3-month blanking period. At a median follow-up of 55 (36.5-60.0) months, 85 (67.9%) patients with PVI + LAAi were in sinus rhythm after the index procedure. Ischaemic stroke/transient ischemic attack occurred in 14 (7.2%) patients at a median of 24 (2-53) months following catheter ablation. Multivariate regression analysis revealed heart failure with preserved ejection fraction [hazard ratio (HR) 2.29, 95% confidence interval (CI) 1.04-5.02; P = 0.038], male gender (HR 0.53, 95% CI 0.29-0.96; P = 0.037), and LA area (HR 1.04, 95% CI 0.53-1.32; P = 0.023) as independent predictors of ATa recurrence. CONCLUSION: Our findings demonstrated that the LAAi + PVI strategy using CB had acceptable long-term outcomes in patients with persistent AF. Systemic thrombo-embolic events are an important concern throughout the follow-up, which were mostly observed in case of non-adherence to anticoagulants.

Comparison of atrial fibrillation ablation using cryoballoon versus radiofrequency in patients with left common pulmonary veins: mid-term follow-up results.

PURPOSE: Cryoballoon (CB) and radiofrequency (RF) ablation techniques have similar outcomes for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). However, there is limited data about the impact of different ablation strategies in patients with left common pulmonary vein (LCPV). Our aim was to compare the safety and efficacy of RF and CB ablation in AF patients with LCPV. METHODS: One hundred and twenty-seven (n = 80 CB and n = 47 RF) AF patients with LCPV detected by preprocedural computerized tomography (CT) were included in the study. Ostial dimensions and trunk distance were measured in all patients. Atrial tachyarrhythmia (ATa) recurrence was defined as detection of AF, atrial flutter, or atrial tachycardia (≥ 30 s) after a 3-month blanking period. RESULTS: There was no significant difference in acute procedural success rates for PVI (97.5% in CB and 97.9% in RF, respectively, P = 0.953) and complication rates were similar between the groups (6 (7.5%) in CB and 4 (8.5%) in RF, respectively, P = 1.000). During a median follow-up of 20.7 (4.8-50.2) months for CB and 20.5 (6.2-36.0) months for RF, ATa recurrence was 35.0% and 38.2%, respectively (P = 0.777). Multivariate analysis did not reveal any of the morphologic parameters of LCPV as a significant predictor of ATa recurrence. CONCLUSIONS: Our findings demonstrated that both CB and RF ablation techniques have similar efficacy and safety in AF patients with LCPV during the mid-term follow-up.

Value of point-of-care neutrophil gelatinase associated lipocalin in early diagnosis of acute kidney injury in patients with left ventricular systolic dysfunction after coronary angiography.

BACKGROUND: Increased neutrophil gelatinase-associated lipocalin (NGAL) levels are associated with toxic or ischemic renal injury. OBJECTIVE: This study aimed to assess the usefulness of serial NGAL measurements with a point-of-care assay in patients with left ventricular systolic dysfunction (LVSD) for earlier detection of contrast-induced nephropathy (CIN). MATERIALS AND METHODS: A total of 84 patients with LVSD patients referred for coronary angiography were consecutively enrolled in the study. The study population was divided into two groups as the CIN and the non-CIN groups according to the CIN's determination. The serum creatinine levels were calculated 24 h before the procedure and at the 48th and 72nd h after the cardiac catheterization. The plasma NGAL concentration was measured before and at 4 and 24 h after the cardiac catheterization. RESULTS: Baseline and serial NGAL levels were significantly higher in patients with CIN compared to the patients without CIN. NGAL 24th h levels after the index procedure were found to be an independent and significant predictor of CIN in multivariate analysis. CONCLUSIONS: Serial point-of-care NGAL measurements might help earlier detection of CIN in patients with heart failure after coronary angiography.

Níveis de Tiol Sérico e Homeostase Tiol/Dissulfeto em Pacientes com Doença Valvar Mitral Reumatismal e em Sujeitos Saudáveis / Serum Thiol Levels and Thiol/Disulfide Homeostasis in Patients with Rheumatic Mitral Valve Disease and Healthy Subjects

Resumo Fundamento A doença valvar mitral reumatismal (DVMR) é a apresentação mais comum das doenças cardíacas reumáticas (DCR). Os processos de inflamação e fibrose também têm papéis significativos em sua patogênese. Estudos recentes demonstram que os tióis e o tiol-dissulfeto são marcadores de stress oxidativo inéditos e promissores. Objetivos O objetivo deste estudo foi avaliar diferenças entre os níveis de tiol sérico e de tiol-dissulfeto em pacientes com DVMR e no grupo de controle. Métodos Noventa e dois pacientes com DVMR foram cadastrados no estudo. Cinquenta e quatro sujeitos saudáveis, e com correspondência de sexo e idade em relação ao grupo de estudo, também foram incluídos no estudo como um grupo de controle. Foram investigados os níveis de tiol nos pacientes com DVMR e o grupo de controle. Os p-valores menores que 0,05 foram considerados estatisticamente significativos. Resultados Os pacientes com DVMR apresentaram pressão sistólica da artéria pulmonar (PSAP) e níveis de diâmetro do átrio esquerdo (AE) mais altos que os do grupo de controle. Os níveis de tiol nativo (407±83 μmol/L vs. 297±65 μmol/L, p<0,001) e tiol total (442±82 μmol/L vs. 329±65 μmol/L, p<0,001) são mais altos no grupo de controle. Níveis de dissulfeto (16,7±4,9 μmol/L vs. 14,8±3,7 μmol/L, p=0,011) são mais altos no grupo de pacientes com DVMR. Foi identificada uma correlação positiva entre as razões dissulfeto/tiol nativo e dissulfeto/tiol total com PSAP, diâmetro de AE, e gravidade da EMi. A razão dissulfeto/tiol total é significativamente mais alta em pacientes com EMi grave que em pacientes com EMi leve a moderada. Conclusões Até onde se sabe, este é o único estudo que avaliou a homeostase tiol/dissulfeto como um preditor inédito, que está relacionado de forma mais próxima à DVMR e à gravidade da EMi.

Abstract Background Rheumatic mitral valve disease (RMVD) is the most common presentation of rheumatic heart disease (RHD). Inflammation and fibrosis processes also play significant roles in its pathogenesis. Recent studies showed that thiols and thiol-disulfide are promising novel oxidative stress markers. Objectives The present study aimed to evaluate differences in the serum thiol and thiol-disulfide levels in patients with RMVD and the control group. Methods Ninety-two patients with RMVD were enrolled in the study. Fifty-four healthy subjects, age, and gender-matched with the study group, were also included in the study as a control group. This study investigated thiol levels in patients with RMVD and the control group. P-values lower than 0.05 were considered statistically significant. Results The patients with RMVD presented higher systolic pulmonary artery pressure (SPAP) and left atrial (LA) diameter levels than the control group. Native thiol (407±83 μmol/L vs. 297±65 μmol/L, p<0.001) and total thiol (442±82 μmol/L vs. 329±65 μmol/L, p<0.001) levels were higher in the control group. Disulfide (16.7±4.9 μmol/L vs. 14.8±3.7 μmol/L, p=0.011) levels were higher in the group of patients with RMVD. A positive correlation was found between disulfide/native and disulfide/total thiols ratio with SPAP, LA diameter, and MS severity. Disulfide/total thiols ratio was significantly higher in patients with severe MS than with mild to moderate MS patients. Conclusions To the best of our knowledge, this is the only study of its kind that has evaluated thiol/disulfide homeostasis as a novel predictor, which was more closely related to RMVD and the severity of MS.

Left Atrial Appendage Transcatheter Occlusion with AMPLATZER™ Amulet™ Device: Real Life Data with Mid-Term Follow-Up Results / Oclusão Transcateter do Apêndice Atrial Esquerdo com a Prótese AMPLATZER™ Amulet™: Dados Reais com Resultados de Seguimento de Médio-Prazo

Abstract Background: Left atrial appendage (LAA) occlusion is an alternative therapy for atrial fibrillation patients who have high embolic risk and contraindications to anticoagulant therapy. Objective: To evaluate the feasibility, safety, and mid-term outcomes of percutaneous LAA occlusion, including device-related thrombosis. Methods: Sixty consecutive patients who had undergone percutaneous LAA occlusion with AMPLATZER™ Amulet™ device from September 2015 to March 2018 were enrolled. Patients were followed for 21 ± 15 months (median - 20 months, interquartile range - 9 to 27 months). The postprocedural assessment was done at the 1(st), 6(th), and 12(th) month. Patients were clinically evaluated, and transesophageal echocardiography was performed at each visit. We evaluated the condition of normality of variables using the Kolmogorov-Smirnov test. P-values < 0.05 were statistically significant. Results: The most common indication for the procedure was major bleeding with anticoagulants (n: 53, 88.3%). The procedure was completed successfully in 59 (98.3%) patients. Periprocedural mortality was observed in one patient. Postprocedural antiplatelet treatment was planned as dual or single antiplatelet therapy or low-dose anticoagulant therapy in 52 (88.1%), 2 (3.4%), and 5 (8.5%) patients, respectively. We found no clinically significant cerebrovascular events, device-related thrombus, or embolization in any patient during the follow-up. Two (3.4 %) patients presented significant peri-device leak (>3 mm) at the 1st month evaluation, which disappeared at the 12th month follow-up. Conclusion: We concluded that LAA occlusion using the Amulet™ LAA occluder can be performed with high procedural success and acceptable outcomes.

Resumo Fundamento: A oclusão do apêndice atrial esquerdo (AAE) é uma terapia alternativa para pacientes com fibrilação atrial que tenham alto risco embólico e contraindicações à terapia anticoagulante. Objetivo: Avaliar a viabilidade, segurança e resultados de médio prazo da oclusão percutânea do AAE, incluindo a trombose relacionada à prótese. Métodos: Sessenta pacientes consecutivos que foram submetidos à oclusão percutânea do AAE com a prótese AMPLATZER™ Amulet™ de setembro de 2015 a março de 2018 foram incluídos no estudo. Os pacientes foram acompanhados por 21 ± 15 meses (mediana - 20 meses, intervalo interquartílico - 9 a 27 meses). A avaliação pós-procedimento foi feita no 1º, 6º e 12º mês. Os pacientes foram examinados clinicamente e um ecocardiograma transesofágico foi realizado a cada visita. A condição de normalidade das variáveis foi avaliada por meio do teste de Kolmogorov-Smirnov. Os valores de p < 0,05 foram considerados estatisticamente significativos. Resultados: A indicação mais comum para o procedimento foi sangramento significativo com anticoagulantes (n: 53, 88,3%). O procedimento foi concluído com sucesso em 59 (98,3%) pacientes. Mortalidade peri-procedimento ocorreu em um paciente. A tratamento antiplaquetário pós-procedimento foi planejado como terapia antiplaquetária única ou dupla ou terapia anticoagulante de dose baixa em 52 (88,1%), 2 (3,4%) e 5 (8,5%) pacientes, respectivamente. Não foram encontrados eventos cerebrovasculares clinicamente significativos, trombo relacionado à prótese ou embolização nos pacientes durante o seguimento. Dois (3,4%) pacientes apresentaram vazamento peri-prótese significativo (>3 mm) na avaliação do 1º mês, que desapareceu no 12º mês de seguimento. Conclusão: Concluiu-se que a oclusão do AAE com o oclusor de AAE Amulet™ pode ser realizada com grande sucesso e resultados aceitáveis.

Long-term outcomes of pulmonary vein isolation using second-generation cryoballoon during atrial fibrillation ablation.

BACKGROUND: Currently available second-generation cryoballoon (CB2) is accepted as an effective and safe tool for pulmonary vein isolation (PVI). Although much more data exist about 1-year outcomes of CB2 ablation, data on long-term outcomes are scarce. OBJECTIVE: We aimed to assess the long-term outcomes of PVI using CB2 in a large-scale symptomatic atrial fibrillation (AF) population at our tertiary referral center. METHODS: In this nonrandomized prospective observational study, a total of 486 patients with paroxysmal (71%) or persistent (29%) AF who underwent index PVI using CB2 at our hospital between January 2013 and June 2017 were enrolled. Atrial tachyarrhythmia (ATa)-free survival was defined as the absence of AF, atrial flutter, or atrial tachycardia recurrence ≥30 s following a 3 months blanking period. Predictors of recurrence were evaluated by univariate and multivariate Cox proportional hazards regression models. RESULTS: Acute procedural success rate was 99.8% (1898/1902 PVs). Mean procedural and fluoroscopy time were 64.9 ± 9.2 and 12.1 ± 2.6, respectively. At median 39 (interquartile range: 26-56) months follow-up, ATa-free survival was 78.6% after a single procedure (280/345 [81.2%] for paroxysmal AF vs. 102/141 [72.3%] for persistent AF, P = .019) and 84.4% after a mean 1.48 ± 0.42 ablations. Cox regression analysis showed that left atrium diameter, duration of AF history, and early ATa recurrence were found as the independent predictors of late recurrence. Phrenic nerve palsy was observed in 17 (3.5%) patients. CONCLUSIONS: CB2-based PVI is effective to maintain sinus rhythm in a significant proportion of paroxysmal and persistent AF patients with an acceptable complication rate at long-term follow-up.

Left atrial appendage closure using Amulet device in a patient with prior percutaneous atrial septal defect closure.

Percutaneous left atrial appendage (LAA) occlusion is an alternative therapeutic option for stroke prevention in patients with atrial fibrillation and contraindications for oral anticoagulation. There are few data available regarding the technical success of percutaneous LAA closure in patients with the previous implantation of an atrial septal defect (ASD) or a patent foramen ovale closure device. This is the description of a case of a successful LAA closure performed with an Amplatzer Amulet occluder device (St. Jude Medical, Inc., St. Paul, MN, USA) in a patient with a previous history of percutaneous ASD.

Septal reduction therapy using nonalcohol agent in hypertrophic obstructive cardiomyopathy: Single center experience.

AIMS: Percutaneous septal reduction therapy by either alcohol or nonalcohol agents is an alternative approach to surgery in drug-refractory symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Nonalcohol agents have some advantages and disadvantages over alcohol during the procedure. Nowadays, a novel non-alcohol agent, named as Ethylene-vinyl alcohol (EVOH) copolymer (Onyx® and Squid® ), is used during septal ablation. Thus, in this study, we aimed to evaluate both acute and long-term efficacy and safety profile of EVOH during septal ablation in HOCM. METHODS AND RESULTS: A total of 25 patients (52% female; mean age: 55.8 ± 17.1 years) with symptomatic HOCM were enrolled in the study. All subjects underwent clinical and laboratory assessment before and after the procedure. Peak left ventricular outflow tract (LVOT) gradient was significantly reduced just after the procedure (68 vs. 20 mmHg; P < 0.001). Peak serum creatine kinase-myocardial band and troponin I levels were 112 (35-282) ng/ml and 11 (4-93) ng/ml. EVOH embolization to diagonal artery was observed in 1 patient (4%) and the complete atrioventricular block was noted in 2 (8%) patients. During the 12-month follow-up, there was no mortality. There was a significant improvement in New York Heart Association functional class of the subjects P < 0.001). Both interventricular septum thickness and LVOT gradient showed a significant reduction during follow-up (P < 0.05). However, there was no reduction in the LVOT gradient of 3 patients (12%). CONCLUSIONS: In conclusion, our small-sized preliminary study results showed that septal reduction therapy using EVOH is an effective alternative option in reducing symptoms and LVOT gradient in HOCM.

Left atrial appendage isolation in addition to pulmonary vein isolation in persistent atrial fibrillation: one-year clinical outcome after cryoballoon-based ablation.

AIMS: In this study, we sought to evaluate the safety and efficacy of cryoballoon (CB) based empirical left atrial appendage (LAA) isolation as an adjunct to pulmonary vein isolation (PVI) compared to the PVI-only strategy in patients with persistent AF. OBJECTIVES: Clinical outcomes of catheter ablation were less beneficial for persistent atrial fibrillation (AF) than paroxysmal AF. METHODS AND RESULTS: A total of 100 consecutive patients with persistent AF underwent both PVI and additional LAA isolation using CB (Group II). As a control group (Group I), among persistent AF patients, we conducted a retrospective, propensity-score matched cohort, in whom only PVI was performed using CB. Recurrence of atrial tachyarrhythmia (Ata) at the 12th month follow-up was the primary endpoint. Baseline demographic and clinical characteristics were similar between two groups. At the 12th month follow-up, 67 (67%) patients in Group I and 86 (86%) patients in Group II were free of ATa after the index procedure (P < 0.001). As a unique complication of LAA isolation, left circumflex artery spasm was observed in 4% of the Group II. After adjusting for several baseline variables, PVI-only strategy was found as a significant predictor for recurrence (HR: 3.37; 95% CI: 1.73-6.56; P < 0.001). Transoesophageal echocardiography examination during the follow-up revealed no thrombus in the LAA. CONCLUSION: Our findings indicated that LAA isolation as an adjunct to PVI improved 1-year outcomes in persistent AF compared with the PVI-only strategy using CB without an increase in thromboembolic complications.