Integrating the Left Atrium Diameter to Improve the Predictive Ability of the Age, Creatinine, and Ejection Fraction Score for Atrial Fibrillation Recurrence After Cryoballoon Ablation.

BACKGROUND: Several clinical trials have assessed predictors for atrial fibrillation recurrence following cryoballoon catheter ablation. With these predictors, a practical and new scoring system can be developed to evaluate atrial fibrillation recurrence. The present study aimed to analyze the predictive value of the age, creatinine, and ejection fraction-left atrium score for potential recurrence of atrial fibrillation following cryoballoon catheter ablation in patients with symptomatic paroxysmal or persistent atrial fibrillation. METHODS: We retrospectively analyzed records of patients undergoing cryoballoon cath-eter ablation. atrial fibrillation recurrence was defined as an emerging atrial fibrillation episode around 12-month follow-up (with the exclusion of a 3-month blanking period). Univariate and multivariate analyses were performed to assess predictors of atrial fibrillation recurrence. In addition, receiver operating characteristic analysis was harnessed to evaluate the performance of the age, creatinine, and ejection fraction, left atrium score in determining the risk of atrial fibrillation recurrence. RESULTS: The study population comprised 106 subjects (age 52 ± 13 years, 63.2% women) with paroxysmal (84.9%, n = 90) or persistent (15.1%, n = 16) atrial fibrillation. age, creatinine, and ejection fraction, left atrium score was significantly higher in subjects with atrial fibrillation recurrence in comparison to those with the maintenance of sinus rhythm. However, on multivariate logistic regression analysis, only the age, creatinine, and ejection fraction, left atrium score (OR = 12.93, 95% CI: 2.22-75.21, P =.004) served as an independent predictor of atrial fibrillation recurrence following cryoballoon catheter ablation. CONCLUSION: Age, creatinine, and ejection fraction, left atrium score had an independent association with the risk of atrial fibrillation recurrence in subjects with atrial fibrillation undergoing cryoballoon catheter ablation. Therefore, this score might potentially serve as a useful tool for risk stratification of patients with atrial fibrillation.

Evaluation of acute alterations in electrocardiographic parameters after cryoballoon ablation of atrial fibrillation and possible association with recurrence.

OBJECTIVE: This study aimed to evaluate the acute effect of cryoballoon ablation (CB-A) on electrocardiographic parameters that have been suggested to reflect heterogeneity in atrial conduction and ventricular repolarization. METHODS: A total of 67 patients (52.6±13.2 years, 43 men) without any exclusion criteria who had undergone CB-A for atrial fibrillation (AF) between January 01, 2015, and December 31, 2018, constituted our study population. Electrographic recordings obtained before and after the ablation procedure on the same day were retrospectively evaluated for the P-wave dispersion, QTc dispersion, Tp-Te interval, and Tp-Te/QT ratio. The pre- and post-ablation values were tested for significant differences. The association of the possible CB-A-related changes in these parameters with AF recurrence during follow-up was evaluated. RESULTS: P dispersion (30.1±6.8 vs. 35.9±9.4 ms, p<0.001), QT dispersion (20.7±7.5 vs. 24.0±8.8 ms, p<0.001), Tp-Te duration (on V5 83.6±8.1 vs. 110.2±9.5 ms, p<0.001), and Tp-Te/QT ratio (on V5 0.22±0.03 vs. 0.28±0.02, p<0.001) were observed to increase significantly after CB-A. There was no association between the magnitudes of change in any parameter and AF recurrence. CONCLUSION: CB-A had significant effects on electrocardiographic parameters related to atrial conduction and ventricular repolarization in the acute phase after CB-A. Further prospective studies are required to examine the time-related course of these alterations and their impact on clinical outcomes.

The Predictive Role of a Novel Risk Index in Patients Undergoing Carotid Artery Stenting: Systemic Immune-Inflammation Index.

BACKGROUND: Inflammatory mechanisms play an important role in both atherosclerosis and stroke. There are several inflammatory peripheral blood count markers associated with carotid artery stenosis degree, symptomatic carotid artery lesions and carotid artery stent restenosis that reported in previous studies. However, the prognostic role of the blood cell counts and their ratios in predicting in-hospital and long-term outcomes in patients undergoing carotid artery stenting (CAS) has not been comprehensively investigated. Systemic immune-inflammation index (SII) proved its' efficiency in patients with solid tumors and its' role was rarely examined in cardiovascular disorders and stroke. The current study evaluated the effect of this novel risk index on in-hospital and long-term outcomes in a large patient population who underwent CAS. METHOD: A total of 732 patients with carotid artery stenosis who underwent CAS were enrolled to the study. SII was calculated using the following formula: neutrophil-to-lymphocyte ratio × total platelet count in the peripheral blood (per mm3) and the patients were stratified accordingly: T1, T2 and T3. In-hospital and 5-year outcomes were compared between the tertiles of SII. RESULTS: During the hospitalization, major stroke, ipsilateral stoke, myocardial infarction, death and major adverse cardiovascular events (MACE) rates were significantly higher in high SII level (T3) compared to SII levels (T1 and 2). In long-term outcomes, ipsilateral stroke, major stroke, transient ischemic attack, death, and MACE were significantly higher in the patients with higher SII level (T3). The 5-year Kaplan-Meier overall survival for T1, T2, and T3 were 97.5%, 96.7% and 86.0% respectively. In-hospital and 5-year regression analyses demonstrated that high SII was independently associated with MACE and mortality. CONCLUSION: SII was independently associated with in-hospital and long-term clinical outcomes in patients undergoing CAS. Immune and inflammation status, as assessed easily and quickly using SII, has a good discriminative value in these patients.

The relationship between dual antiplatelet treatment (DAPT) score and saphenous venous grafts patency after coronary artery bypass grafting surgery.

BACKGROUND: Coronary artery bypass grafting (CABG) remains the gold standard treatment for mutivessel and left main coronary artery disease (CAD). Saphenous vein graft (SVG) patency is still a problem in CAD patients after CABG surgery. The Dual Antiplatelet Treatment (DAPT) score is a clinical prediction tool that predicts ischaemic and bleeding risk in CAD patients. The aim of this study is to investigate the relationship between DAPT score and SVG patency in CABG patients. METHOD: This retrospective study enrolled a total of 398 patients (68 female; mean age 65.8 ± 9.1 years) with a history of CABG surgery. The study population was divided into two subgroups according to SVG patency. The DAPT score was calculated for each patients and compared between the two groups. RESULTS: Coronary angiography revealed SVG disease in 212 patients and SVG patency in 186 patients. The rates of diabetes mellitus and hypertension, red cell distribution width values, DAPT Score, time interval after CABG and number of SVGs were significantly higher while LVEF was significantly lower in patients with SVG disease. The presence of diabetes mellitus, high DAPT score, long time interval after CABG and high number of SVGs were found to be independent predictors of SVG patency. DAPT score above 2.5 predicted SVG disease with a sensitivity of 77.1% and a specificity of 87.1% (AUC: 0.873; 95%CI: 0.823-0.924; p < 0.001). CONCLUSION: The DAPT score may provide useful information for SVG patency in CABG patients. Patients with high DAPT score should be followed up closely for SGV occlusion. DAPT score may be useful prior to CABG in determining the duration of dual anti-platelet therapy and in encouraging the use of arterial grafts with better patency.

Presence of fragmented QRS is associated with left ventricular systolic dysfunction after surgery in patients with severe aortic regurgitation.

BACKGROUND AND AIM OF THE STUDY: Chronic severe aortic regurgitation (AR) is associated with progressive accumulation of interstitial fibrosis and disruption of myocardial structure. After aortic valve replacement (AVR), the negative remodeling process reverses, and left ventricular ejection fraction (LVEF) improves but not in all patients. In this study, we aimed to investigate the association of fragmented QRS (F-QRS), which is a possible marker of myocardial fibrosis, with postoperative left ventricular (LV) systolic dysfunction. METHODS: A total of 147 consecutive patients with AVR were included in this study. F-QRS was identified by the presence of various RSR' patterns (QRS duration <120 ms) such as additional R wave (R prime)or notching of the R or S wave in at least two consecutive leads. Patients were compared in two groups based on the presence or absence of F-QRS. A logistic regression model was used to determine independent predictors of postoperative LV systolic dysfunction (LVEF <50%). RESULTS: Patients with F-QRS were associated with poor recovery of LV systolic function after AVR compared to the patients without F-QRS, regardless of preoperative LVEF (p = .008). F-QRS was found to be an independent predictor of postoperative LV systolic dysfunction (LVEF <50%). Lower preoperative LVEF and increased LV end diastolic diameter index were also found as independent risk factors for postoperative LV systolic dysfunction. CONCLUSIONS: As a possible marker of myocardial fibrosis, F-QRS was associated with postoperative LV systolic dysfunction. Therefore, as a simple and convenient clinical parameter, F-QRS may be used to predict poor recovery of LVEF after AVR.

Fluoroscopy time and scattered radiation during electrophysiology procedures: analysis of one-year data of a laboratory providing electrophysiology training.

OBJECTIVES: Patients and medical staff expose to significant radiation during electro-physiological (EP) procedures. There are few data regarding the leading factors of longer fluoroscopy time and higher scattered radiation in a laboratory giving EP training during those interventions. MATERIAL AND METHODS: The patients' recordings that underwent EP procedure in a single centre arrhythmia unit from February 2019 to January 2020 were examined. Prospectively collected data regarding procedure duration, fluoroscopy time and total air kerma, demographic characteristics of the patients, type of procedure, success of ablation and the use of electro anatomic mapping were retrospectively evaluated. Predictors of total air kerma were analysed with linear regression analysis. RESULTS: Study population consisted of 437 patients with a median age of 47 (39-56); 184 (42.1%) were male. Median fluoroscopy time was 768 (420-1320) seconds and median cumulative air kerma was 369 (191-750) mGy. Fluoroscopy time and cumulative air kerma were significantly lower in diagnostic EP studies compared to other procedures. There was no difference in terms of total air kerma between the procedures other than the diagnostic EP study. In multivariable linear regression analysis; body surface area, fluoroscopy time, not using the electro-anatomical mapping, unsuccessful ablation and atrial flutter ablation were predictors of total air kerma in EP studies performed by trainees. CONCLUSION: Scattered radiation during EP procedures performed by in-training operators is related with some factors. Awareness about those may help to effort reducing the harmful effect of ionising radiation.

Right ventricular free wall perforation during pericardiocentesis, and an inappropriate device selection for percutaneous treatment.

Right ventricular (RV) perforation is a rare but life-threatening complication of pericardiocentesis and is usually treated surgically. We presented a case of RV free wall perforation, which occurred during pericardiocentesis and tried to be closed percutaneously with the Amplatzer vascular plug-III (AVP-III) device. The occluder device sealed the perforation, but it was in an insecure position; therefore, the patient underwent surgical repair. As an AVP-III device, with a middle disk thicker than the RV myocardium, it may cause the RV myocardium to stretch outwards, so it should not be used for the treatment of RV perforation by the transcatheter way.

Prognostic significance of pre-procedural prognostic nutritional index in patients with carotid artery stenting.

BACKGROUND: Inflammation and malnutrition play a critical role in the outcomes of patients undergoing carotid artery stenting (CAS). Prognostic nutritional index (PNI) is commonly utilized to evaluate the peri-operative immune-nutritional status of patients undergoing colorectal cancer surgery and is independently associated with survival. We assessed the association between immune-nutritional status, indexed by PNI, and outcomes in CAS patients. METHODS: A total of 615 patients hospitalized for CAS in a tertiary heart center were enrolled in the study. PNI was calculated using the following formula: 10× serum albumin value (g/dL) + 0.005 × total lymphocyte count in the peripheral blood (per mm3). In-hospital and 5-year outcomes (ipsilateral stroke, major stroke, transient ischemic attack, myocardial infarction, and mortality) were compared between the tertiles of PNI. RESULTS: In-hospital outcomes were similar between the groups except the increased mortality in decreasing tertiles of PNI. During a mean follow-up duration of 51.1 months, the lower PNI tertile was related to unfavorable outcomes. After adjusting for multi-model Cox regression analysis, PNI persisted as an independent prognostic factor for mortality and major stroke. CONCLUSION: PNI was independently associated with long-term mortality and major stroke in CAS patients. Malnutrition and inflammation, which can be assessed easily and quickly using PNI, have an important prognostic value in the patients undergoing CAS.

The effect of P wave indices on new onset atrial fibrillation after trans-catheter aortic valve replacement.

OBJECTIVES: Data is scarce regarding the relation between P wave indices and new onset atrial fibrillation (NOAF) after trans-catheter aortic valve replacement (TAVR). AIMS: The present study aimed to find out certain characteristics of P wave that may predict NOAF after TAVR procedure. METHOD: Patients with severe calcific aortic stenosis who had undergone TAVR procedure between 2013 and 2019 in two centers were investigated. P wave abnormalities that have been resumed to reflect impaired atrial conduction; partial and advanced inter atrial block (IAB), P-wave terminal force in lead V1, P wave dispersion, reduced amplitude of P- wave in lead I, P wave peak time in D2 and V1 were evaluated on pre- procedural 12 derivation surface electrocardiography (ECG). The relationship between these parameters and incidence of NOAF during index hospitalization was evaluated. RESULTS: A total of 227 consecutive patients (median age 79 [74-83]; 134 [59%] female) were included in the study. NOAF occurred in 46 (20.3%) patients. P wave duration, P wave dispersion, number of patients with partial and advanced IAB, left atrium diameter, STS score were higher in NOAF patients. Use of general anesthesia and history of prior open heart surgery were also more frequent in NOAF group. In multivariable logistic regression analysis; advanced IAB (OR 6.413 [2.555-16.095] p < 0.01), P wave dispersion (OR 3.544 [1.431-8.780] p = 0.006) and use of general anesthesia (OR 2.736 [1.225-6.109] p = 0.014) were independent predictors of NOAF. CONCLUSION: Among P wave abnormalities evaluated on pre-procedural 12-derivation surface ECG, advanced IAB and P wave dispersion may predict NOAF after TAVR procedure.

Electrocardiographic Ccharacteristics of metastatic cardiac tumors presenting with ST-segment elevation.

INTRODUCTION: ST segment elevation (STE) in the standard 12­lead surface electrocardiography (ECG) is a well-known finding in patients with metastatic cardiac tumors. It is important to identify the specific characteristics of STE among those patients to prevent unnecessary aggressive treatments. In the present study, we aimed to demonstrate the ECG characteristics of patients with metastatic cardiac tumors who has STE. MATERIAL AND METHODS: Medical literature was searched from Pubmed database with key words "metastatic cardiac tumors" or "cardiac tumors" and "ST segment elevation" or "ST elevation". In addition, remaining articles were explored using the references of case reports which were obtained during former screening (snowball procedure). RESULTS: Thirty six of 46 case reports were included and ECG characteristics of each case were evaluated. Convex- shaped STE was observed in all patients and it showed a specific coronary territory in 35 of 36 patients (97.2%). Pathologic Q wave and/or loss of R wave progression were observed in only one patient. T wave inversion following STE was detected in 34 patients (94.4%). STE evolution was absent in 32 of 36 patients while the information regarding STE evolution were not provided in the remaining cases. CONCLUSION: STE due to tumor invasion has certain characteristics which could help clinicians in the differential diagnosis.

Colchicine's Effects on Electrocardiographic Parameters in Newly Diagnosed Familial Mediterranean Fever Patients : Colchicine may have Favourable Effects on Parameters Related to Ventricular Arrhythmias in New Diagnosed Familial Mediterranean Fever.

OBJECTIVE: Colchicine may prevent both recurrent serositis attacks and secondary amyloidosis in familial Mediterranean fever (FMF). Furthermore, colchicine may decrease the frequency of atrial fibrillation in some groups of patients without FMF. However, there is no study that evaluates the effect of colchicine on arrhythmogenic electrocardiographic indices in FMF. In this study, we evaluated the impact of 1 year of colchicine treatment on atrial and ventricular arrhythmogenic electrocardiographic (ECG) parameters in newly diagnosed FMF patients. MATERIALS AND METHODS: We enrolled 28 newly diagnosed FMF (20 female, mean age 31.4 ± 8.2 years) patients who fulfilled the modified Tel Hashomer criteria. Electrocardiographic, demographic and laboratory parameters were obtained at the first visit and at the end of the 1­year colchicine treatment. Herein, we assessed P wave dispersion (Pd) for atrial arrhythmia risk and peak-to-end interval of T wave (Tp-E), Tp-E/QT, Tp-E/QTc values for ventricular arrhythmia risk. RESULTS: Colchicine treatment significantly decreased Tp-E and Tp-E/QT values (p = 0.02 and p = 0.01, respectively) by the end of the 1­year treatment. However, Pd values did not change with treatment. CONCLUSION: Colchicine treatment may have a favourable effect on ventricular repolarisation indices that relate to ventricular arrhythmia and sudden death.

Relationship between epicardial adipose tissue thickness and coronary thrombus burden in patients with ST-elevation myocardial infarction.

BACKGROUND: Epicardial fat reflects abdominal visceral adiposity and visceral fat plays an important role in the development of an unfavorable metabolic and atherosclerosis risk profile. Intracoronary thrombus burden is an important factor affecting the success of the procedure particularly in patients undergoing percutaneous coronary intervention (PCI). Therefore, determining the factors predicting thrombus burden has great importance in predicting adverse cardiovascular events as well as determining the most appropriate treatment strategy to prevent failure in PCI. AIM: The aim of the current study was to evaluate the relationship between Epicardial adipose thickness (EAT) and thrombus burden in the patients with ST-elevation myocardial infarction (STEMI) who undergo primary PCI (pPCI). METHODS: The study was prospective and included patients (n=156) who were referred to Kosuyolu Research and Education hospital with STEMI between 2016 and 2017. Thrombus burden was scored as follows: 0 (no thrombus), 1 (possible thrombus), 2 (definite thrombus <0.5xreference vessel diameter), 3 (definite thrombus 0.5-2xreference vessel diameter), 4 (definite thrombus >2xreference vessel diameter), and 5 (complete vessel occlusion). According to thrombus grade the patients were grouped as low thrombus burden (grades 0-3) and high thrombus burden (grades 4 and 5). EAT, identified as an echo-free space between the myocardium and visceral pericardium, was measured perpendicularly, on the free wall of the right ventricle at both parasternal long- and short-axis views at end-diastole in three cardiac cycles. RESULTS: Fifty-one subjects were in the low thrombus burden group and 105 in the high thrombus burden group. There were no differences in the two groups for LVEF, smoking status, family history of coronary artery disease (CAD), diabetes mellitus (DM), hypertension (HT), and hypercholesterolemia and for total cholesterol, triglyceride, GFR, LDL-C and HDL-C. In multivariate logistic regression analysis the EAT (odds ratio: 2.53, 95% CI: 1.76-3.67; p < .001) was found as an independent predictor of high thrombus burden. CONCLUSIONS: The present study showed that EAT was an independent predictor of coronary thrombus burden in STEMI.

Multimodality imaging of an aortic graft infection.

Aortic prosthetic vascular graft infections (PVGI) are rare complications of the aortic surgery, with an incidence of 0.5%-6%. Although rare, they carry mortality rates as high as 25%-88%. Improvement in diagnostic imaging modalities in the last two decades, together with early diagnosis, aortic PVGI associated mortality was reduced. These imaging methods include transesophageal echocardiography (TEE), computed tomography angiography (CTA), and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT). In this case report, we focus mainly on three imaging modalities as TEE, CTA, and 18F-FDG PET/CT and showed their role in the assessment of aortic PVGI.

Evaluation of the potential predictors of embolism in patients with left atrial myxoma.

INTRODUCTION: Cardiac myxomas are the most common primary intracardiac tumors. Although myxomas are histologically benign, they are potentially dangerous due to potential risk of systemic and cerebral embolism. In this study, we aimed to investigate the potential predictors of embolism in patients with left atrial myxoma. METHODS: This single-center retrospective study enrolled 93 patients (mean age: 52.9 ± 15.3 years, female: 70 [75.3%]) with left atrial myxomas between 2014 and 2018. The patients were classified into two groups (embolic vs nonembolic) to investigate possible predictors of embolism. Demographic, laboratory, and echocardiographic parameters were recorded into a dataset and compared between patients with and without embolism. RESULTS: The study population was composed of 13 (14%) patients in embolic (11 cerebrovascular and 2 peripheral) and 80 (86%) patients in nonembolic group. Demographic and laboratory parameters were similar between the groups. Tumor sizes were significantly higher in the embolic group than in the nonembolic group (5.59 ± 1.08 vs 4.29 ± 0.61; P = 0.001). By multivariate analysis, increased tumor size, increased left atrial diameter, and the presence of atrial fibrillation and irregular tumor surface were identified as independent predictors of embolism. In ROC curve analyses, tumor size above 4.6 cm predicted embolism with a sensitivity of 77% and a specificity of 73% (AUC: 0.858; 95% CI: 0.752-0.964; P < 0.001). CONCLUSION: The presence of atrial fibrillation, irregular tumor surface, increased tumor size, and increased left atrial diameter is associated with increased risk of embolism in patients with left atrial myxoma. Early surgery should be scheduled for such patients due to increased potential for embolism.

A successful catheter ablation of a ventricular fibrillation.

Malignant ventricular arrhythmias are challenging to manage, requiring a multidisciplinary approach. The mechanism, which triggers ventricular fibrillation (VF) associated with ventricular extrasystoles has not been clarified yet, however, abolishing ventricular extrasystoles may stop ventricular fibrillation in these patients. By this case presentation, we aimed to present a successful treatment of an electrical storm (ES), which developed after an acute myocardial infarction, by catheter ablation.