Atrial Fibrillation Ablation Success Rate - A Retrospective Multicenter Study.

Atrial fibrillation (AF) has become a major health and economic burden. Pulmonary veins isolation (PVI) based ablation for rhythm control of AF is well established. Furthermore, recent studies show its superiority over anti-arrhythmic therapy. However, most of these studies were performed in highly experienced centers, that may not necessarily reflect real world outcomes. We evaluated the outcome (success rate and complications) of 300 consecutive procedures, performed on 291 patients (during 2014-2015) of a major HMO. All had undergone PVI for AF by experienced electrophysiologists in 8 medical centers (85% RF technique). Data were retrospectively collected using computerized medical records. Variables included demographic and clinical characteristics, acute procedural success and complications, long term success rate based on multiple ECGs and Holter monitoring. The average age was 63 years, 61% were male, 79% had paroxysmal AF. Sinus rhythm at 2 years was considered success. The overall success rate of maintaining sinus rhythm at 2 years was 56%. Success rate correlated significantly with age and standard risk factors. Those patients in whom the index procedure was the first ablation, success rate was 78%. Sixty-one patients underwent a second ablation with success rate of 64%, 32 underwent a 3rd/4th procedure with success rate of 56%. The probability to be in sinus rhythm after 2 years regardless of the number of ablations was 78%. Thirty-five percent of the patients were still on anti-arrhythmic therapy at 2 years post procedure. Complication rate was 6.6% (2.5% serious), among them 2 deaths, 1 procedure related. PVI in a real-world large unselected population is a valid therapeutic option for AF with an overall 2-year success rate of 56%. In our group higher complication rate was observed compared to the reported rate in the literature. The use of cryo-ablation for PVI and further improvements in both technique and experience may improve both efficacy and safety profile.

Prospective, multi-center evaluation of a silicon carbide coated cobalt chromium bare metal stent for percutaneous coronary interventions: two-year results of the ENERGY Registry.

BACKGROUND: Novel bare metal stents with improved stent design may become a viable alternative to drug-eluting stents in certain patient groups, particularly, when long-term dual antiplatelet therapy should be avoided. PURPOSE: The ENERGY registry aimed to assess the safety and benefits of a cobalt-chromium thin strut bare metal stent with a passive coating in a large series of patients under real-world conditions. METHODS AND MATERIALS: This prospective registry recruited 1016 patients with 1074 lesions in 48 centers from April to November 2010. The primary endpoint was the rate of major adverse cardiac events (MACEs), a composite of cardiac death, myocardial infarction and clinically driven target lesion revascularization. RESULTS: More than half of the lesions (61.0%) were type A/B1 lesions, mean lesion length was 14.5±6.5mm and mean reference vessel diameter 3.2±0.5mm. MACE rates at 6, 12 and 24months were 4.9%, 8.1% and 9.4%, target lesion revascularization rates 2.8%, 4.9% and 5.4% and definite stent thrombosis rates 0.5%, 0.6% and 0.6%. Subgroups showed significant differences in baseline and procedural characteristics which did not translate into significantly different clinical outcomes. Specifically, MACE rates at 24months were 13.5% in diabetics, 8.6% in small stents and 9.6% in acute coronary syndrome patients. CONCLUSION: The population of ENERGY reflects real-world conditions with bare metal stents being mainly used in simple lesions. In this setting, percutaneous coronary intervention using a cobalt-chromium thin strut bare metal stent with a passive coating showed very good results up to 24months. (ClinicalTrials.gov:NCT01056120) SUMMARY FOR ANNOTATED TABLE OF CONTENTS: The ENERGY international registry evaluated the safety and benefits of a cobalt-chromium thin strut bare metal stent with passive coating in 1016 patients under real-world conditions until 2years. Results were encouraging with a low composite rate of cardiac death, myocardial infarction and clinically driven target lesion revascularization, even in the pre-defined high risk groups of diabetes, stents ≤2.75mm and acute coronary syndrome.

Preventive treatment of alveolar pulmonary edema of cardiogenic origin.

OBJECTIVE: To evaluate the efficacy of preventive treatment (PT) on alveolar pulmonary edema (APE) of cardiogenic origin using a monitor based on principles of internal thoracic impedance (ITI) measurements. METHODS: We conducted blinded clinical trials on patients with ST-elevation myocardial infarction (STEMI) and monitored whether the condition would progress to APE. ITI was measured non-invasively by the Edema Guard Monitor (EGM, model RS-207) every 30 min. The measurement threshold for the diagnosis of APE was fixed at > 12% decrease in ITI from baseline as described in our methodology. The patients were divided into one group that received standard treatment after the appearance of clinical signs of APE without considering the prediction of APE by EGM devise (Group 1), and another group of asymptomatic patients in whom development of APE was predicted by using only EGM measurements (Group 2). The latter participants' PT consisted of furosemide, intravenous nitroglycerine and supplemental oxygen. RESULTS: One-hundred and fifty patients with acute STEMI were enrolled into this study. Group 1 included 100 patients (53% males, age 64.1 ± 12.6 years). Treatment was started after the clinical appearance of overt signs of APE. Group 2 included 50 patients (54% males, age 65.2 ± 11.9 years) who received PT based on EGM measurements. Group 2 had significantly fewer cases of APE (n = 4, 8%) than Group 1 (n = 100, 100%) (P > 0.001). While APE was lethal in six (6%) Group 1 patients, PT resulted in prompt resolution of APE in all four (8%) Group 2 patients. CONCLUSION: ITI is a useful modality for early diagnosis and PT of pulmonary edema of cardiogenic origin.

Anti-oxidized low-density lipoprotein antibodies in chronic heart failure.

Oxidative stress may play a significant role in the pathogenesis of heart failure (HF). Antibodies to oxidized low-density lipoprotein (oxLDL Abs) reflect an immune response to LDL over a prolonged period and may represent long-term oxidative stress in HF. The oxLDL plasma level is a useful predictor of mortality in HF patients, and measurement of the oxLDL Abs level may allow better management of those patients. Antibodies to oxLDL also significantly correlate with the New York Heart Association score. Hypercholesterolemia, smoking, hypertension, and obesity are risk factors for atherosclerotic coronary heart disease (CHD) leading to HF, but these factors account for only one-half of all cases, and understanding of the pathologic process underlying HF remains incomplete. Nutrients with antioxidant properties can reduce the susceptibility of LDL to oxidation. Antioxidant therapy may be an adjunct to lipid-lowering, angiotensin converting enzyme inhibition and metformin (in diabetes) therapy for the greatest impact on CHD and HF. Observational data suggest a protective effect of antioxidant supplementation on the incidence of HD. This review summarizes the data on oxLDL Abs as a predictor of morbidity and mortality in HF patients.

Differential effects of coronary artery stenosis on myocardial function: the value of myocardial strain analysis for the detection of coronary artery disease.

BACKGROUND: Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this study was to assess the predictive value of two-dimensional longitudinal strain in the detection of longitudinal LV dysfunction and the identification of coronary artery disease (CAD) in patients hospitalized with angina. METHODS: Two-dimensional strain software was extended to allow the analysis of numerous longitudinal strain traces in the entire left ventricle and generate a histogram of peak systolic strain (PSS) values for the left ventricle and for each coronary territory. In each histogram, the value of the 10% worst strain values (PSS(10%)) was determined. Global strain, segmental PSS, and PSS(10%) were analyzed in 97 patients hospitalized with angina and had normal LV function, who underwent coronary angiography, and 51 patients with low probability of CAD. Echocardiography was performed 2.9 ± 2 days after admission. RESULTS: Sixty-nine patients had significant CAD on coronary angiography. Significant differences were observed in all strain parameters between patients with and without CAD. PSS(10%) showed the best accuracy in detecting CAD, with an area under the receiver operating characteristic curve of 0.85. The areas under the curve for global strain and segmental PSS were 0.80 and 0.76, respectively. The optimal cutoff for PSS(10%) was -13.9%, with sensitivity and specificity of 86% and 75%, respectively. PSS(10%) was better than segmental PSS in the detection of CAD in each coronary territory. CONCLUSIONS: In patients hospitalized with angina who have significant CAD on coronary angiography, longitudinal systolic function is impaired. Histogram analysis improved the accuracy of longitudinal strain analysis in detecting global and regional impaired function.

Thoracic aortic atherosclerosis in patients with aortic regurgitation.

OBJECTIVE: Hemodynamic forces are potential determinants of aortic atherosclerosis. Aortic regurgitation (AR) alters the flow pattern in the aorta. However, the association between AR and aortic atherosclerosis is not well known. METHODS: We assessed the presence, extent and distribution of atherosclerotic lesions in the aorta of 42 patients with chronic AR and compared them to 40 patients with similar risk factor profile for atherosclerosis and no valvular disease. RESULTS: There was no difference in the extent of atheroma in the ascending aorta and aortic arch between patients with and without AR. Descending aortic atheroma was evident in 25 patients with AR (60%) and 12 patients without AR (30%, p=0.01). AR was found to be the only predicting factor for the presence of aortic atherosclerosis in the descending aorta (odds ratio 4.1; 95% CI 1.2-14.3, p=0.03). CONCLUSIONS: There is an increased prevalence of descending aortic atherosclerosis in patients with significant AR.

High-molecular weight adiponectin is associated with coronary artery angiographic findings in Asian Indians.

Asian Indians (AIs) have a higher prevalence and a more aggressive form of coronary artery disease (CAD), and it has been suggested that hypoadiponectinemia may have a role in this accelerated CAD. The present study was undertaken to determine the extent and severity of angiographic findings in 2 groups of CAD patients matched for age and sex, AIs (n = 29) vs whites (n = 30), and to elucidate the potential relationship between adiponectin (total and high-molecular weight [HMW] form) and the severity and extent of coronary angiographic findings in both groups. Angiographic findings were assessed using the modified Gensini index; and 2 scores, scores 1 and 2, were used to assess the severity and extent. Both Gensini index scores 1 and 2 were higher in the AI group compared with the white group (144.4 +/- 87.1 vs 93.5 +/- 56.3 and 127.2 +/- 86.5 vs 80.1 +/- 39.3, respectively; P < .05). Adiponectin levels were similar in both groups. Total adiponectin and HMW adiponectin were positively associated with Gensini index score 1 (r = 0.62, P = .004 and r = 0.64, P = .003) and score 2 (r = 0.51, P = .021 and r = 0.54, P = .013), respectively, in AI men, whereas there was no significant association in white men. Thus, AIs had more severe CAD compared with whites; and in AI men with CAD, total adiponectin and HMW adiponectin were associated with the severity of angiographic scores.

Preliminary experiences using X-sizer catheter for mechanical thrombectomy of thrombus-containing lesions during acute coronary syndromes.

Thrombus-containing lesions are frequently observed in patients with acute coronary syndromes. These lesions are prone to increased procedural risks, including distal embolization and abrupt closure of the vessel. This preliminary report evaluates if thrombus removal using a new X-Sizer catheter could reduce thrombotic burden and optimize angioplasty results. Thrombectomy was attempted with the X-Sizer catheter in 11 patients (age, 59 +/- 10 years) undergoing coronary angioplasty with angiographic evidence of intracoronary thrombus. The device uses a helix cutter contained in a 4.5 or 5.5 Fr catheter tip connected to a closed vacuum aspiration system. Procedural outcomes using detailed angiographic analysis and clinical data were obtained from all treated patients. Seven patients (64%) had acute or recent myocardial infarction and four patients (36%) presented with unstable angina. The culprit lesion was located in right coronary, left anterior, vein graft, and circumflex-marginal in five, three, two, and one patient, respectively. The mean proximal reference diameter was 3.37 +/- 0.39 mm and % diameter stenosis was 90% +/- 15% prior to thrombectomy and decreased to 72% +/- 16% afterward and was 9% +/- 10% at the end of the procedure. The TIMI flow increased from 0.8 +/- 1.0 to 2.1 +/- 0.9 following thrombectomy and the final TIMI grade was 2.9 +/- 0.3. Stents were used in 9 of 11 patients. Procedural success was achieved in 10 of 11 patients (91%). No evidence of stent thrombosis was noted among treated patients in hospital and at 30-day follow-up. In this preliminary series of patients with angiographic evidence of thrombus, the use of X-Sizer thrombectomy seems to be feasible and relatively safe, permitting thrombus removal and improved intracoronary flow.