V1r + DIIq is a novel and accurate criterion to predict right vs. left paraseptal accessory pathways.

PURPOSE: The correct estimation of accessory pathway (AP) localization from surface ECG is critical before the procedure. Our study aimed to detect the predictive value of the V1r + DIIq criterion for differentiating right- from left-sided paraseptal APs. METHODS: We retrospectively included 58 patients with (Wolff-Parkinson-White) WPW syndrome and paraseptal APs who underwent successful catheter ablation (37 male, 21 female; mean age 34.4 ± 13.6 years). The V1r + DIIq criterion was calculated using the following formula: V1r + DIIq (mV) = initial r wave amplitude in V1 + q wave amplitude in DII. The combined criterion included V1r + DIIq <2.05 mV and/or no initial r wave in V1. RESULTS: Right-sided paraseptal APs were detected in 36 patients (62.1%), left-sided paraseptal APs were detected in 21 patients (36.2%), and AP from CS was detected in 1 patient (1.7%). The initial r wave amplitude in V1 (mV), q wave amplitude in DII (mV) and V1r + DIIq criterion (mV) were lower in patients with right-sided paraseptal APs (p < 0.001). The percentage of patients with no initial r wave in V1 (36.1% vs. 0%) and those meeting the combined criterion (91.7% vs. 4.5%) were increased in patients with right-sided paraseptal APs. The cutoff value of the V1r + DIIq criterion obtained by ROC curve analysis was 2.05 mV for predicting right-sided paraseptal APs (sensitivity: 86.1%, specificity: 95.5%). The area under the curve (AUC) was 0.943 (95% CI = 0.881-1.000) (p < 0.001). The sensitivity and specificity values were 36.1% and 100%, respectively, for the no initial r wave criterion and 91.7% and 95.5%, respectively, for the combined criterion. CONCLUSION: The V1r + DIIq criterion and the combined criterion represent novel and simple electrocardiographic criteria for accurately differentiating right- from left-sided paraseptal APs. This simple ECG measurement can improve the accuracy of detection of paraseptal AP localization and could be beneficial for decreasing ablation duration and radiation exposure.

Decreased left atrial global longitudinal strain predicts the risk of atrial fibrillation recurrence after cryoablation in paroxysmal atrial fibrillation.

PURPOSE: We aimed to investigate the association of atrial fibrillation (AF) recurrence with left atrial (LA) strain in nonvalvular paroxysmal AF patients after cryoablation. METHODS: We included 190 patients who underwent successful cryoablation due to paroxysmal AF. In addition to classical echocardiographic data, LA apical 2-chamber (A2C) strain, LA apical 4-chamber (A4C) strain, and LA global longitudinal strain (LA-GLS) values were calculated by speckle tracking echocardiography. Forty-eight-hour Holter monitoring was performed to all patients no later than 6 months after ablation. RESULTS: AF recurrence was detected in 42 patients (22.1%). End-systolic diameter, LA end-systolic diameter, LA-volume, LA-volume index, interatrial septum thickness, coronary sinus diameter, epicardial fat thickness (EFT), and septal E/E` ratio were significantly higher, LV-EF, IVRT, septal S and A` wave, lateral S wave, LA-A2C strain, LA-A4C strain, and LA-GLS were significantly lower in patients with AF recurrence. LA-GLS, LA-volume index, and EFT were found to be independent parameters for predicting AF recurrence. CONCLUSIONS: LA-GLS and LAVI should be included in routine evaluations to determine long-term AF recurrence preoperatively.

Effect of cryoballoon ablation parameters on recurrence in patients with paroxysmal atrial fibrillation.

OBJECTIVE: The aim of this research was to investigate the relationship between atrial fibrillation (AF) recurrence and second generation cryoballoon ablation (CBA) procedural parameters in patients with non-valvular paroxysmal AF (PAF). METHODS: A total of 131 patients with a PAF diagnosis who underwent second-generation CBA (59 male; mean age: 55.2±10.6 years) were enrolled. Recurrence was defined as the detection of AF on a 12-lead electrocardiography (ECG) recording, or an attack lasting at least 30 seconds observed on Holter ECG records. CBA procedural data and echocardiographic findings were recorded and compared. RESULTS: After 1 year of follow-up, AF recurrence was detected in 27 patients. Patients with recurrence were older and had higher rates of hypertension and diabetes (p<0.05 for both). Left atrial diameter, left atrial volume (LaV), left atrial volume index, and the averaged warming angle (calculated by combining lowest temperature point and balloon temperature at 20°C point) were significantly higher in the recurrence group. Balloon warming time was significantly longer in the non-recurrence group (p<0.001). In binary logistic regression analysis, the averaged warming angle (odds ratio [OR]: 1.559, 95% confidence interval [CI]: 1.342-1.811; p<0.001) and LaV (OR: 1.063, 95% CI: 1.028-1.100; p<0.001) were found to be independent parameters for predicting recurrence. The cutoff value of the warming angle obtained with ROC curve analysis was 50° for the prediction of recurrence (sensitivity: 94.3%, specificity: 88.5%, area under the curve: 0.909; p<0.001). The cutoff value of LaV obtained by ROC curve analysis was 53.5 for prediction of recurrence (sensitivity: 77.8%, specificity: 74.5%; p<0.001). CONCLUSION: Measurement of balloon warming angle during CBA and increased LaV may predict the AF recurrence.

Fibrosis Marker Soluble ST2 Predicts Atrial Fibrillation Recurrence after Cryoballoon Catheter Ablation of Nonvalvular Paroxysmal Atrial Fibrillation.

BACKGROUND AND OBJECTIVES: We aimed to investigate the relationship between the recurrence of atrial fibrillation (AF) and fibrosis marker soluble ST2 (sST2) in patients with nonvalvular paroxysmal AF (PAF). METHODS: We prospectively included 100 consecutive patients with PAF diagnosis and scheduled for cryoballoon catheter ablation for AF (47 males, 53 females; mean age 55.1±10.8 years). sST2 plasma levels were determined using the ASPECT-PLUS assay on ASPECT Reader device (Critical Diagnostics). The measurement range of these measurements was 12.5-250 ng/mL. Patients had regular follow-up visits with 12-lead electrocardiogram (ECG), medical history, and clinical evaluation. Twenty-four hours Holter ECG monitoring had been recorded 12 months after ablation. RESULTS: AF recurrence was detected in 22 patients after 1 year. Age, smoking history, diabetes mellitus,hypertension frequency, angiotensin converting enzyme inhibitor-angiotensin receptor blocker use, CHA2DS2VASc and HAS-BLED scores, serum sST2 level, left atrium (LA) end-diastolic diameter, LA volume and LA volume index were related to AF recurrence. In multivariable logistic regression analysis, sST2 was found to be only independent parameter for predicting AF recurrence (odds ratio, 1.085; p=0.001). Every 10-unit increase in sST2 was found to be associated with 2.103-fold increase in the risk of AF recurrence. The cut-off value of sST2 obtained by receiver operating characteristic curve analysis was 30.6 ng/mL for prediction of AF recurrence (sensitivity: 77.3%, specificity: 79.5%). The area under the curve was 0.831 (p<0.001). CONCLUSIONS: sST2, which is associated with atrial fibrosis, can be thought to be a useful marker for detection of patients with high-grade fibrosis who will get less benefit from cryoablation.

Association of P wave duration index with atrial fibrillation recurrence after cryoballoon catheter ablation.

AIM: We aimed to investigate the relationship between the recurrence of AF and P wave duration index (PWDI) in patients with nonvalvular PAF. METHODS: We included 114 patients who underwent cryoballoon catheter ablation with the diagnosis of paroxysmal atrial fibrillation (PAF) (55 male, 59 female; mean age 55.5±10,9years). PWDI was calculated by dividing the Pwd by the PR interval in DII lead of 12­lead ECG. Patients had regular follow-up visits with 12-lead ECG, medical history and clinical evaluation. 24h Holter ECG monitoring had been recorded at least 12months after ablation. RESULTS: AF recurrence was detected in 24 patients after 1year. Patients were divided into two groups according to the AF recurrence. All parameters were compared between the two groups. Age, DM, HT frequency, ACEI-ARB use, CHA2DS2VASc and HAS-BLED score, HsCRP, LA diameter, LA volume, LA volume index, Pwd and PWDI were related to AF recurrence. In binary logistic regression analysis, PWDI (OR=1.143, p=0.001) and HT (OR=0.194, p=0.020) were found to be independent parameters for predicting AF recurrence. Every 0,01 unit increase in PWDI was found to be associated with 14.3% increase in the risk of AF recurrence. The cut-off value of PWDI obtained by ROC curve analysis was 59,9 for prediction of AF recurrence (sensitivity: 75.0%, specificity: 69.0%). The area under the curve (AUC) was 0.760 (p<0.001). CONCLUSION: Increased PWDI may help to identify those patients in whom electrical remodeling has already occurred and who will get less benefit from cryoablation.

Evaluation of the relationship between renal resistive index and extent and complexity of coronary artery disease in patients with acute coronary syndrome.

BACKGROUND: Despite advances in cardiovascular medicine, acute coronary syndrome (ACS) is still a major cause of morbidity and mortality worldwide. Synergy between percutaneous coronary intervention with TAXUS™ and Cardiac Surgery (SYNTAX) score is used to determine the extent and complexity of coronary artery disease (CAD). Renal resistive index (RRI), a renal Doppler ultrasound parameter, is used to detect renal haemodynamics. Although some risk factors for CAD, including hypertension and diabetes mellitus, were demonstrated to have an association with RRI; a direct relationship between the presence, extent, and complexity of CAD and RRI has not been investigated yet. AIM: In this study, we evaluated the relationship between RRI and SYNTAX score in patients with ACS. METHODS: This cross-sectional study enrolled 235 patients who were diagnosed with ACS and underwent coronary angiography at our tertiary clinic between February 2016 and August 2016. Regarding clinical presentation, 112 patients were diagnosed with non-ST-segment elevation ACS (NSTE-ACS) and 123 patients were diagnosed with ST-segment elevation ACS (STE-ACS). The patients' demographic, clinical, laboratory, echocardiographic data, SYNTAX scores and measurements of renal Doppler ultrasound parameters, including RRI, renal pulsatility index (RPI) and acceleration time (AT) were recorded. RESULTS: Among 235 patients, 112 (47.7%) were diagnosed with NSTE-ACS and 123 (52.3%) were diagnosed with STE-ACS. Mean SYNTAX score and RRI of patients with NSTE-ACS and STE-ACS were 15.4 and 0.69, 21.1 and 0.67, respectively. The SYNTAX score was associated with gender, height, plasma uric acid level, left atrial diameter, left ventricular (LV) end-systolic and end-diastolic diameter, RPI, and RRI in patients with NSTE-ACS, as well as with low-density lipoprotein-cholesterol, total cholesterol, ejection fraction, and LV end-systolic diameter in patients with STE-ACS (p < 0.05 for each variable). RRI was significantly associated with age, haemoglobin level, left atrial diameter, SYNTAX score, AT, and RPI in patients with NSTE-ACS, as well as with weight, body mass index, interventricular septum thickness at diastole, LV posterior wall thickness at diastole, LV ejection fraction, and RRI in patients with STE-ACS. Multivariate logistic regression analysis demonstrated that LV end-systolic diameter (ß = 0.385, 95% CI 1.065-2.029, p = 0.019), RRI (ß = 32.230, 95% CI 5343.15-2.E+24, p = 0.008), and RPI (ß = -7.439, 95% CI 0.000-0.231, p = 0.015) were independent predictors of moderate to high SYNTAX score in patients with NSTE-ACS. CONCLUSIONS: Non-invasively detected RRI is closely associated with the extent and complexity of CAD in patients with NSTE-ACS. However, there is a need for randomised, controlled studies involving wider populations.

Comparison of single-dose and repeated levosimendan infusion in patients with acute exacerbation of advanced heart failure.

BACKGROUND: Levosimendan (LS) is a novel inodilator that improves cardiac performance, central hemodynamics, and symptoms of patients with decompensated chronic heart failure. The aim of this study was to compare the effects of single and repeated LS infusion on left ventricular performance, biomarkers, and neurohormonal activation in patients with acute heart failure. MATERIAL AND METHODS: Twenty-nine consecutive patients with acute exacerbation of advanced heart failure were included in this study. LS was initiated as a bolus of 6 µg/kg followed by a continuous infusion of 0.1 µg/kg/min for 24 hours in both groups who received intravenous single and repeated (baseline and at 1 and 3 months) treatment. Physical examination, echocardiography, and biochemical tests (brain natriuretic peptide, tumour necrosis factor-alpha, interleukin-1beta, 2, and 6) were performed before treatment and on 3 day of the treatment. The last evaluation was performed at 6 month after the baseline treatment. RESULTS: Twenty male and 9 female patients with mean age of 60.2 ± 7.4 years were included in this study. A significant improvement in New York Heart Association functional status and myocardial performance index was detected only in the repeated LS treated patients at 6 month compared to the pretreatment status (p=0.03 and p<0.001; respectively). In addition, a significant decrease in brain natriuretic peptide (p<0.01) and plasma interleukin-6 (p=0.05) levels were also achieved only in patients who were given repeated LS. CONCLUSIONS: Our study showed that repeated LS treatment is more effective compared to the single dose LS treatment in improving clinical status, hemodynamic and laboratory parameters in patients with acute exacerbation of advanced heart failure.

Contrast-induced nephropathy in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention.

We assessed the relationship between contrast-induced nephropathy (CIN) and SYNTAX score (SS) and serum uric acid (SUA) levels in patients with ST elevation myocardial infarction (STEMI). A total of 835 STEMI patients in whom primary percutaneous coronary intervention was performed in our cardiology clinic were included in this study (615 male, 220 female; mean age 58.1 ± 12.2 years). The patients were divided into 2 groups (CIN and non-CIN). Contrast-induced nephropathy was observed in 9.6% (80) of patients; SS (13.9 ± 6.2/22.1 ± 5.8) and SUA (5.1 ± 0.9/6.2 ± 0.9) values in the CIN group were higher compared with the non-CIN group (P < .001, for all). All SS (95% confidence interval [CI] = 1.136-1.250, P = .001), SUA (95% CI = 1.877-3.236, P = .002), and diabetes (95% CI = 0.998-1.039, P = .026) were independent predictors of CIN in logistic regression analysis. Procedures that can prevent CIN may be beneficial in patients at high risk as identified by the SS and SUA levels.

Increased aortic stiffness predicts contrast-induced nephropathy in patients with stable coronary artery disease undergoing percutaneous coronary intervention.

Increased aortic stiffness (AS) has been shown to be an independent risk factor for cardiovascular disease in renal failure and was also found to be associated with even mild renal insufficiency. We investigated the relationship between contrast-induced nephropathy (CIN) and AS parameters such as pulse wave velocity (PWV) and augmentation index (AIx). Patients (n = 440) with stable coronary artery disease (CAD) treated with percutaneous coronary intervention (PCI) were included prospectively (mean age: 60.3 ± 10.3 years). The PWV and AIx were calculated using the single-point method. The PWV, age, diabetes, SYNTAX score, and contrast media dose were independent predictors for CIN (P < .05, for all). The cutoff value for PWV obtained by the receiver-operator characteristic curve analysis was 10.35 m/s for the prediction of CIN (95% confidence interval: 0.838-0.916, sensitivity: 82.1%, specificity: 77.9%, and P < .001). In conclusion, a greater AS pre-PCI may predict CIN development in patients with stable CAD.

A patient with anomalous right coronary artery originating from the left anterior descending artery who underwent complex percutaneous coronary intervention: A case report.

An anomalous right coronary artery (RCA) arising from the left anterior descending artery (LAD) is an extremely rare coronary anomaly. A 71-year-old patient presented with severe exertional angina for 10 days. Coronary angiography revealed that an anomalous RCA originated from the proximal LAD. The anomalous RCA had also critical ostial stenosis and the LAD had a critical lesion before origin of RCA (95%) and chronic total occlusion (CTO) at DII branch level. Furthermore, extremely tortuous circumflex (Cx) artery had critical tandem lesions at the mid portion. Surgical treatment was offered, but the patient refused the surgery. We decided to perform percutaneous coronary intervention (PCI). The first stage of PCI was on Cx artery. Two floppy guide wires were placed into the Cx artery and a long drug-eluting stent (DES) could be placed. Secondly, the LAD CTO lesion could be crossed by Confianza pro 9 wire. After the predilatation, another DES was placed into the LAD CTO region. Then all other significant lesions were successfully treated with PCI in a single session. .

A silent and late embolization of atrial septal defect occluder device into the right pulmonary artery: a case report.

Percutaneous device closure of atrial septal defect (ASD) is an alternative treatment to surgery. The main advantages of the percutaneous approach include avoidance of surgery, short procedure time and hospital length, in addition to comparable rates of complications. However, percutaneous device closure is associated with infrequent early and late complications including device embolization, air embolism, cardiac tamponade and thrombotic complications. We report a rare complication of silent and late device embolization of the ASD occluder device into the right pulmonary artery, three months after implantation.

[The frequency of aspirin resistance by a modified thrombelastography method and its relationship with clinical and laboratory parameters in patients with stable coronary artery disease]. / Kararli koroner arter hastaligi olanlarda modifiye tromboelastogram yöntemi ile aspirin direnci sikligi ve klinik ve laboratuvar bulgularla iliskisi.

OBJECTIVES: Aspirin is the cornerstone of antiplatelet therapy in cardiovascular medicine. However, aspirin resistance has been demonstrated in 0.4% to 83.3% of aspirin-receiving patients. The aim of this study was to investigate the frequency of aspirin resistance using a modified thrombelastography (mTEG) method and related clinical and biochemical parameters in patients with stable coronary artery disease (CAD), who received 100 mg/day aspirin. STUDY DESIGN: The study included 168 patients (115 males, 53 females; mean age 60±8 years) with stable CAD, receiving aspirin at a dose of 100 mg/day. Aspirin responsiveness was determined using mTEG, where aspirin resistance was defined as arachidonic acid-induced whole blood platelet aggregation inhibition (PAI) of less than 50%. RESULTS: Aspirin resistance was detected in 27 patients (16.1%). Platelet aggregation inhibition showed negative correlations with hyperlipidemia, smoking, spironolactone use, systolic blood pressure, pulse pressure, and total cholesterol and fibrinogen levels. In multivariate regression analysis, only fibrinogen level (OR=1.063, p=0.010) and pulse pressure (OR=1.197, p=0.023) were found to be independent indicators of aspirin resistance and PAI. In ROC analysis, cut-off values of 50 mmHg for pulse pressure and 400 mg/dl for fibrinogen level predicted aspirin resistance with 88.9% and 74% sensitivity and 64.4% and 68% specificity, respectively. CONCLUSION: Our findings suggest that measurements of fibrinogen level and pulse pressure may be used as easy and reliable methods in predicting aspirin resistance.