Physiologic Assessment of Coronary Stenosis: Current Status and Future Directions.

PURPOSE OF REVIEW: Percutaneous coronary intervention (PCI) is a commonly used treatment option in coronary artery disease (CAD). Reduced major adverse cardiovascular events (MACE) in those randomized to PCI compared to optimal medical therapy have been demonstrated only if it is performed for physiologically significant coronary lesions. Despite data demonstrating improved outcomes primarily in stable CAD and then acute settings, physiology-guided PCI remains underutilized. This review summarizes the evidence and commonly used methods for physiologic assessment of coronary stenosis. RECENT FINDINGS: Fractional flow reserve (FFR) is the gold standard for the analysis of lesion severity. Its use is limited by the need for adenosine, which adds time, complexity, and potential adverse effects. Non-hyperemic instantaneous wave-free ratio-guided revascularization and quantitative flow reserve ratio assessment both have shown safety and effectiveness with improved patient outcomes. Coronary physiological assessment solves the ambiguity of coronary angiography. Detecting physiologically significant stenoses is crucial to decide which lesion needs to be treated. Technological advances have led to the development of new assessment indices in addition to FFR.

Effects of angiotensin receptor neprilysin inhibition on P-wave dispersion in heart failure with reduced ejection fraction.

BACKGROUND: Angiotensin receptor neprilysin inhibitors (ARNI; sacubitril/valsartan combination) decrease morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). Increased P­wave duration and P­wave dispersion (Pd) reflect prolongation of atrial conduction and correlate with atrial fibrillation. Here, we aimed to assess the effects of switching from valsartan to ARNI treatment on the basis of P­wave indices. METHODS: A total of 28 patients with HFrEF (mean age, 64.8 ± 10.6 years; 18 males, 78.6% ischemic etiology) were included. All patients had New York Heart Association functional class II-III, left ventricular ejection fraction ≤35%, and had been switched from valsartan to ARNI treatment. Standard 12-lead electrocardiograms from patients on valsartan treatment and electrocardiograms 1 month after ARNI treatment were analyzed; heart rate, maximum P­wave duration (Pmax), minimum P­wave duration (Pmin), and Pd were calculated. Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores and N­terminal pro-brain natriuretic peptide (NT-proBNP) values were recorded. RESULTS: The Pmax (135.6 ± 32.1 ms vs. 116.1 ± 14.1 ms, p = 0.041) and Pd (33.6 ± 7.9 vs. 28.6 ± 5.3, p = 0.006) values were significantly reduced after ARNI treatment. Furthermore, ARNI treatment was associated with an improvement in MLWHFQ scores (31.2 ± 6.2 ms vs. 23.2 ± 7.0 ms, p < 0.001) and with a reduction in NT-proBNP values (1827.3 ± 1287.3 pg/ml vs. 1074.4 ± 692.3 pg/ml, p < 0.001). There were moderately positive correlations between the reduction in Pd and the improvement in MLWHFQ scores (r = 0.408, p = 0.031) and the reduction in NT-proBNP values (r = 0.499, p = 0.007) CONCLUSION: Switching to ARNI treatment alters Pd and Pmax favorably in patients with HFrEF. The reduction in atrial inhomogeneous conduction assessed by Pd was correlated with clinical improvement and reduced NT-proBNP levels in patients with HFrEF.

Higher levels of TWEAK and matrix metalloproteinase-3 during the acute phase of myocardial infarction are associated with adverse left ventricular remodeling.

INTRODUCTION: It is known that the levels of tumor necrosis factor-like weak inducer of apoptosis (TWEAK/TNFSF12) increase after myocardial infarction (MI) and that it interacts with sCD163. It has also been argued that TWEAK can induce matrix metalloproteinases (MMPs) in macrophages. AIM: To investigate the roles of TWEAK, sCD163, and MMPs in left ventricular (LV) adverse remodeling (AR) in the early post-MI period. MATERIAL AND METHODS: Forty-six patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention were enrolled in the study. Post-MI LV functions and volumes were assessed by cardiac magnetic resonance imaging at 2 weeks and 6 months. Cytokines and MMPs were measured using a bead-based multiplex immunoassay system at 1 day (baseline) and 2 weeks post-MI. AR was defined as an increase in LV end-diastolic volume of ≥ 10% at the 6-month follow up. RESULTS: The TWEAK, MMP-2, and MMP-3 baseline levels were higher in the patients with AR than those without AR. At 2 weeks post-MI, these expression levels were similar in patients with and without AR, but sCD163 expression was increased in patients without AR. The TWEAK and MMP levels were positively correlated in the early period post-MI. At first day post-MI, higher levels of TWEAK and MMP-3 were predictors of AR (OR = 1.03, p = 0.006; OR = 1.08, p = 0.015; respectively). CONCLUSIONS: TWEAK can induce MMPs in the early period post-MI, and these higher levels contribute to development of AR. Increased sCD163 levels at 2 weeks post-MI seem to be associated with the healing process through neutralizing the excessive inflammatory effects of TWEAK.

A systematic review on durability and structural valve deterioration in TAVR and surgical AVR.

Mechanical valves and bioprosthetic heart valves are widely used for aortic valve replacement (AVR). Mechanical valves are associated with risk of bleeding because of oral anticoagulation, while the durability and structural valve deterioration (SVD) represent the main limitation of the bioprosthetic heart valves. The implantation of bioprosthetic heart valves is increasing precipitously due aging population, and the widespread use of transcatheter aortic valve replacement (TAVR). TAVR has become the standard treatment for intermediate or high surgical risk patients and a reasonable alternative to surgery for low risk patients with symptomatic severe aortic stenosis. Moreover, TAVR is increasingly being used for younger and lower-risk patients with longer life expectancy; therefore it is important to ensure the valve durability for long-term transcatheter aortic valves. Although the results of mid-term durability of the transcatheter heart valves are encouraging, their long-term durability remains largely unknown. This review summarises the definitions, mechanisms, risk factors and assessment of SVD; overviews available data on surgical bioprosthetic and transcatheter heart valves durability.

Mitral Paravalvular Leak Closure: Transcatheter and Surgical Solutions.

Paravalvular leak (PVL) is an important complication after surgical valve replacement and might lead to serious clinical results, including heart failure and/or hemolytic anemia. PVLs are the result of an incomplete seal between the sewing ring and annulus. It frequently affects surgical valves in the mitral position, occurring in 5% to 15% of valve replacements. For years, surgery has been considered the only treatment for symptomatic patients with PVLs. However, surgical re-intervention for PVLs is associated with a high risk of morbidity and mortality. Therefore, percutaneous treatment of PVL has become first-line therapy for most patients with symptomatic PVL. In this review, we will briefly summarize clinical findings, diagnostic modalities, laboratory assessment, surgical treatment, transcatheter approaches, device choice and outcomes of interventions in mitral PVLs.

Switching from ramipril to sacubitril/valsartan favorably alters electrocardiographic indices of ventricular repolarization in heart failure with reduced ejection fraction.

Background: Angiotensin receptor neprilysin inhibitor (ARNI, sacubitril/valsartan) reduces sudden death in heart failure with reduced ejection fraction (HFrEF). Corrected QT (QTc), T-wave peak to T-wave end interval (Tp-e) and Tp-e/QTc are electrocardiographic indices of ventricular repolarization heterogeneity. We aimed to assess the effects of switching from ramipril to ARNI on electrocardiographic indices of ventricular repolarization.Methods: A total of 48 patients with HFrEF (mean age: 63.3 ± 11.7 years; 36 males, 77.1% ischaemic etiology) were enrolled. All patients had New York Heart Association functional class II-III, left ventricular ejection fraction ≤35% and previously switched from ramipril to ARNI treatment. The standard 12-lead electrocardiograms on ramipril treatment and 1 month after ARNI treatment were analysed; heart rate, QTc, Tp-e and Tp-e/QTc were calculated. Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores and N-terminal pro-BNP (NT-proBNP) values were recorded.Results: QTc (415.2 ± 19.7 ms vs. 408.5 ± 20.8 ms, p = 0.022), Tp-e (100.7 ± 13.8 ms vs. 92.9 ± 12.1 ms, p < 0.001), Tp-e/QTc (0.242 ± 0.028 vs. 0.227 ± 0.029, p = 0.003) and heart rate (73.2 ± 4.7 bpm vs. 71.1 ± 4.9 bpm, p = 0.027) were reduced after ARNI. ARNI switch associated with improvement in MLWHFQ scores (32.4 ± 7.1 ms vs. 22.6 ± 7.0 ms, p < 0.001) and reduction of NT-proBNP (2457 ± 1879 pg/ml to 1377 ± 874 pg/ml, p < 0.001). Pearson's correlation analysis revealed moderate correlations of MLWHFQ score with Tp-e (r = 0.543, p = 0.001) and Tp-e/QTc (r = 0.556, p = 0.001).Conclusions: Switching from ramipril to ARNI favourably alters QTc, Tp-e and Tp-e/QTc in HFREF. ARNI reduces symptoms of HFREF assessed by MLWHFQ and lowers NT-proBNP levels. Reduction in Tp-e and Tp-e/QTc correlate with clinical improvement in patients with HFrEF.

The Rate of Epistaxis Incidence in New-Generation Anticoagulants and Perioperative Approach in Otorhinolaryngological Practices.

Nose bleeding is a common situation seen in otorhinolaryngological practices. One of the greatest risk factors in nose bleeding is the use of anticoagulant medicine. With the medicine developed in recent years, the risk of nose bleeding due to the frequent use of anticoagulant and antiagregant is gradually increasing.The purpose of this study is to determine the effects of especially new-generation anticoagulants on nose bleeding. In addition, the use and complications of new-generation anticoagulants and antiagregants have been compiled in light of information obtained from the literature.Three hundred forty patients whose follow-up is conducted by the cardiology department and who use oral antithrombocytic medicine have been included in the study. It has been determined that 15% of these patients use new-generation oral anticoagulants (Rivaroksaban, apiksaban, dabigatran, danaparoid) and the other patients are treated with conventional antithrombocytic treatment (Aspirin, Warfarin, Enoksaparin sodium). The rate of nose bleeding in patients who use classical anticoagulants has been observed to be 28%. In 30 of these patients who had nose bleeding, while cauterization and buffering by otorhinolaryngology specialists, major intervention has not been necessary for any of the patients. While bleeding has been observed in 26% of the patients who use new-generation anticoagulants, bleeding that required operational intervention has taken place in 2 patients. Bleedings have been stopped surgically through a large number of cauterization and buffering.While the new-generation anticoagulants cause lower rate of bleeding, it has been observed that controlling these bleedings is more difficult.

P-wave dispersion: What we know till now?

P-wave dispersion is defined as the difference between the maximum and the minimum P-wave duration recorded from multiple different-surface ECG leads. It has been known that increased P-wave duration and P-wave dispersion reflect prolongation of intraatrial and interatrial conduction time and the inhomogeneous propagation of sinus impulses, which are well-known electrophysiologic characteristics in patients with atrial arrhythmias and especially paroxysmal atrial fibrillation. Extensive clinical evaluation of P-wave dispersion has been performed in the assessment of the risk for atrial fibrillation in patients without apparent heart disease, in hypertensives, in patients with coronary artery disease, in patients undergoing coronary artery bypass surgery, in patients with congenital heart diseases, as well as in other groups of patients suffering from various cardiac or non-cardiac diseases. In this paper, we aimed to summarize the measurement methods, current use in different clinical situations, strengths and limitations of the of P-wave dispersion.

Predictors of atrial fibrillation recurrence after atrial fibrillation ablation with cryoballoon.

BACKGROUND: Catheter ablation of atrial fibrillation is recommended for patients with symptomatic paroxysmal atrial fibrillation (PAF) despite anti-arrhythmic drugs (AADs). Radiofrequency ablation is widely accepted as an effective treatment for PAF. Cryoenergy by cryoballoon technique is an alternative to radiofrequency (RF) ablation. Cryoballoon ablation is safe, and has a similar success rate in comparison to RF ablation. AF recurrence with cryoballoon ablation is roughly 30%. The aim of this study is to determine the predictors of AF recurrence after cryoballoon ablation. METHODS AND RESULTS: Sixty one patients with symptomatic PAF despite AADs without structural heart disease were included. Cryoballoon ablation was performed in 60 patients (36 males, mean age: 54.6 ± 10.7, mean left atrium size: 3.74 ± 0.39 mm). Transthoracic echocardiography including tissue Doppler imaging was performed in all subjects during sinus rhythm at baseline and after the ablation. Intra-atrial and inter-atrial electromechanical delays, and PA-lateral were measured. All patients were scheduled for 24 h Holter recording at baseline and at 3, 6, 9 months follow-up. Venous samples were collected to measure CK-MB, Troponin-T (TnT), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels at baseline and 24 h after ablation. Median follow up was 10 (8-12) months. Forty eight (80%) patients were in sinus rhythm during the follow up. In receiver operating curve (ROC) analysis, intraleft atrial electromechanical delay and PA-lateral achieve an area under the curve (AUC) 0.97 (p < 0.001) and 0.69 (p < 0.001) for the ability to predict AF recurrence. A cut-off value for baseline intra left atrial electromechanical delay of 29.5 ms predicted AF recurrence with sensitivity of 85% and specifity of 98%. A cut-off value for PA-lateral of 125 ms predicted AF recurrence with sensitivity of 80% and specifity of 90%. In ROC analysis, age achieves an AUC 0.822 (p = 0.006) for the ability to predict AF recurrence. A cut-off value for age of 64 predicted AF recurrence with sensitivity of 71% and specifity of 90%. Early recurrence of AF (HR = 60, 95% CI 18.61-417.86, p < 0.001) predicted also late recurrence of AF. CONCLUSIONS: The increase in AF recurrence by increased intraleft atrial electromechanical delay, PA-lateral and older age show the importance of substrate in AF mechanism. Early recurrence was the strongest predictor of late recurrence of AF; therefore, existence of blanking period for cryoballoon ablation should be questioned.

[Pulmonary vein isolation with the cryoballoon technique in atrial fibrillation treatment: single centre experience]. / Atriyum fibrilasyonu tedavisinde kriyobalon teknigi ile pulmoner ven izolasyonu: Tek merkez deneyimi.

OBJECTIVES: Pulmonary vein (PV) isolation with cryothermal energy is a recently introduced technique in patients with atrial fibrillation (AF). It may reduce procedural times and serious complications associated with radiofrequency (RF) ablation. We aimed to present the baseline characteristics and follow-up data of our study population undergoing cryoballoon AF ablation. STUDY DESIGN: A total of 236 patients (126 male, 110 female; mean age 54.6±10.45; range 16 to 78 years) underwent PV isolation with 28 mm cryoballoon due to symptomatic AF. These patients failed with at least one previous antiarrhythmic drug. The postprocedure in the first 3 months was defined as blanking period. Median follow-up time was 14 (3-24) months. Procedural success, complicaitons, and follow-up results were defined according to Heart Rhythm Society guidelines. RESULTS: Acute procedural success rate (>=3 PV isolation) was 99.5%. Mean procedural and fluoroscopy times were 72.5±5.3 (50-90) min and 14±3.5 (12-24) min. Major complications were observed in 3 patients (1.2%). At the median 14 month follow-up, 80.6% of paroxysmal AF patients and 49.2% of persistant AF patients were free from AF recurrence. RF ablation was performed in 10 patients with recurrence. Smoking, body mass index, non-paroxysmal AF type, AF duration (years), left atrial size, and early recurrence were the predictors of recurrence in multivariate regression analysis. CONCLUSION: This study represents the first experience with cryoballoon ablation for AF in Turkey. The efficacy and safety of cryoballoon AF ablation technique was shown due to the acceptable success and low complication rates in paroxysmal AF patients. Particularly, patients with early recurrence should be closely followed-up.

Are the conventional cutoff values adequate to define hypertension in young women?

BACKGROUND: Women have lower systolic blood pressure (SBP) levels than men during early adulthood. Diastolic blood pressure (DBP) tends to be just marginally lower in women than men regardless of age. OBJECTIVE: Aims of this study were (i) to determine 95th percentile value of SBP, DBP, and mean arterial blood pressure in healthy women, and (ii) to evaluate the effects of basal demographic and anthropometric features on blood pressure. METHODS: Six hundred and fifty-four consecutive participants (18-35 years old) were initially enrolled in the study but among them 54 (8.2%) cases were excluded. Demographic features, relevant personal and family history data about hypertension, smoking habits, and use of medications were interviewed using a questionnaire. Blood pressure, height, weight, and waist circumference of every case were measured. RESULTS: Of the 600 patients (mean age, 24.6±4.0 years), 124 (20.7%) were currently smokers, 20 (3.3%) had history of hypertension during pregnancy, and 291 (48.5%) had family history of hypertension in women (mean age, 61.0±9.51 years). Reference ranges of 5th and 95th percentile values for SBP were determined as 74 and 115 mmHg, for mean arterial blood pressure as 57 and 85 mmHg, for DBP as 45 and 72 mmHg, respectively. CONCLUSION: In conclusion, cutoff values of hypertension in healthy women, which were determined by our study, are lower than the standard cutoff values for definition of hypertension in adults. However, clinical importance of these findings should be investigated in further studies involving larger population with prospective follow-up.

[Incomplete pacemaker lead fracture revealed by superficial maneuvers]. / Yüzeyel manevralarla belirgin hale gelen kismi kalp pili elektrot kirigi.

A 75-year-old man presented to our department with a complaint of recurrent syncope episodes seven years after dual chamber pacemaker implantation due to complete atrioventricular block. His electrocardiogram obtained on presentation showed a normal dual-chamber pacemaker rhythm. The chest X-ray and pacemaker interrogation did not show any lead fracture or dysfunction. Twenty-four hour Holter monitoring revealed periods of failure to pacing. Superficial maneuvers over the skin resulted in an excessive increase in the ventricular lead impedance and pacing failure. The clinical course of the patient was uneventful after implantation of a new electrode to the right ventricular apex.

Asymptomatic right atrial myxoma originating from the inferior vena cava and right atrium junction in a patient with breast ductal adenocarcinoma.

We present asymptomatic right atrial myxoma in a patient with breast ductal adenocarcinoma. A 58-year-old female was referred to our clinic for the evaluation of the potential cardiotoxic side effects of anthracycline-based chemotherapy. She had a 10-month history of modified radical mastectomy for ductal adenocarcinoma of the breast, followed by adjuvant chemotherapy. To evaluate potential side effects of anthracycline-based regimen, transthoracic echocardiography was performed, which showed a highly mobile, cystic, and heterogeneous mass, 20 x 25 mm in size, located in the right atrium. Transesophageal echocardiography confirmed the highly mobile mass originating from the inferior vena cava and extending to the right atrium. Surgery was planned. Upon exposure, the tumor had a broad base, with attachment to the lower dorsal free wall, interatrial septum of the right atrial cavity, and upper border of the inferior vena cava. The tumor was completely excised and histopathologic diagnosis was myxoma. Localization of right atrial myxoma at the junction of the inferior vena cava and right atrium is a rare condition, and its coexistence with breast carcinoma has only been reported once.