The Extent of Left Atrial Low-Voltage Areas Included in Pulmonary Vein Isolation Is Associated With Freedom from Recurrent Atrial Arrhythmia.

BACKGROUND: The extent of left atrial (LA) baseline low-voltage areas (LVA-B), which may be a surrogate for fibrosis, is associated with recurrent atrial fibrillation (AF) after ablation. This study aimed to assess the relationship between the extent of LVA-B isolated by ablation (LVA-I) and AF recurrence. METHODS: The study cohort included 159 consecutive patients with drug-refractory AF who underwent an initial AF ablation with LA voltage mapping during sinus rhythm. The extent of LVA-B was quantified while excluding the pulmonary veins, LA appendage, and mitral valve area. LVA-I was quantified as the percentage of LVA-B encircled by pulmonary vein isolation. Surveillance and symptom-prompted electrocardiograms, Holter monitors, and event monitors were used to document atrial arrhythmia recurrence for a median follow-up of 712 days (1.95 years). RESULTS: Of 159 patients, 72% were men and 27% had persistent AF. The mean number of sampled bipolar voltage points was 119 ± 56. The mean LA surface area was 102.3 ± 37.3 cm2, and the mean LVA-B was 1.9 ± 3.8 cm2. The mean LVA-I was 51.05% ± 36.8% of LVA-B. In the multivariable Cox proportional hazards model adjusted for LA volume, CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age [≥ 75 years], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 years], Sex [Female] score), LVA-B, and AF type, LVA-I was inversely associated with recurrent atrial arrhythmia after the blanking period (hazard ratio, 0.42/percent LVA isolated; P = 0.037). CONCLUSIONS: The extent of LVA-I is independently associated with freedom from atrial arrhythmias after AF ablation, supporting ongoing efforts to target low LA voltage areas and other fibrosis indicators to improve ablation outcomes.

Pulmonary Embolism Secondary to Testosterone-Enhancing Herbal Supplement Use.

Decreased testosterone levels in men are often a normal sign of aging. Testosterone replacement therapy (TRT) is a well-established option for those with symptomatic hypogonadism related to low testosterone levels. Conversely, designer herbal supplements in the context of testosterone supplementation are poorly studied, yet remain popular among aging men who seek the well-known, often enhancing, effects of testosterone that involve muscle mass and sexual function/drive. In 2014, the Food and Drug Administration (FDA) issued a warning about the significant risk of venous clots secondary to testosterone product use. Testosterone-induced polycythemia is one of the proposed mechanisms for this increased clotting propensity. Increased thromboxane A2 receptor density on platelets and increased platelet aggregation have also been linked to testosterone treatment in men. Fenugreek extract is a common active ingredient in commercially available herbal supplements that are often marketed as testosterone enhancers. It is thought that certain fenugreek compounds inhibit aromatase and 5-alpha-reductase activity, leading to diminished testosterone breakdown. However, the efficacy and safety profile of this agent in its use for boosting testosterone levels are unclear. In this case report, we present a patient with new-onset, bilateral pulmonary embolism possibly associated with the daily use of fenugreek-containing testosterone supplements.

Association of left atrial function with incident atypical atrial flutter after atrial fibrillation ablation.

BACKGROUND: Symptomatic left atrial (LA) flutter (LAFL) is common after atrial fibrillation (AF) ablation. OBJECTIVE: The purpose of this study was to examine the association of baseline LA function with incident LAFL after AF ablation. METHODS: The source cohort included 216 patients with cardiac magnetic resonance (CMR) before initial AF ablation between 2010 and 2013. Patients who underwent cryoballoon or laser ablation, patients with AF during CMR, and those with suboptimal CMR, or missing follow-up data were excluded. Baseline LA volume and function were assessed by feature-tracking CMR analysis. RESULTS: The final cohort included 119 patients (mean age 58.9 ± 11 years; 76.5% men; 70.6% patients with paroxysmal AF). During a median follow-up of 421 days (interquartile range 235-751 days), 22 patients (18.5%) had incident LAFL. Baseline LA volume was similar between the 2 groups. In contrast, baseline reservoir, conduit, and contractile function of the LA were significantly impaired in patients with incident LAFL. Baseline global peak longitudinal atrial strain (PLAS) <22.65% predicted incident LAFL with 86% sensitivity and 68% specificity (C statistic 0.76). In a multivariable model adjusting for age, heart failure, and LA volume, PLAS (hazard ratio 0.9 per % increase in PLAS; P = .003) and LA linear lesions (hazard ratio 2.94; P = .020) were independently associated with incident LAFL. The coexistence of PLAS <22.65% and linear lesions was associated with 9-fold increased hazard of incident LAFL. CONCLUSION: Baseline LA function and linear lesions were independently associated with incident LAFL after AF ablation. Linear lesions should be limited to selected cases, especially in patients with impaired LA function.

[The prevalence of alternative herbal medicine and nutritional complementary product intake in patients admitted to out-patient cardiology departments]. / Kardiyoloji poliklinigine basvuran hastalarda bitkisel kökenli alternatif tedavilerin ve tamamlayici besin ürünlerinin tüketim prevalansi

OBJECTIVES: To detect the prevalence of alternative herbal medicine and nutritional complementary product intake in patients admitted to outpatient cardiology clinics and to determine demographic characteristics, comorbidities and medical properties of those patients. STUDY DESIGN: Patients admitted to outpatient cardiology clinics between June 2011 and March 2012 were given questionnaires involving age, gender, education, occupation, chronic illness, medication, herbs, nutritional complementary products, the index purpose and motivation for using herbs and nutritional complementary products. The data of those questionnaires were analyzed. RESULTS: A total of 454 questionnaires were collected. The mean age was 49±13 and 48% of the participants were female. Of those patients, 12% had diabetes, 34% had hypertension, 26% had coronary artery disease, 7% had heart failure, 58% had chronic illness, 49% had cardiovascular disease, and 57% had history of drug intake. Including vitamins and minerals, there were 75 (16%) patients taking alternative and complementary medicine. When vitamins and minerals were excluded, 56 (12%) patients were using at least one product, while 24 (5%) patients were using more than one. Garlic (n=33), flaxseed (n=13), ginger (n=12), omega 3 (n=12), and turmeric (n=11) were the most popular products. Of those 56 patients, 32% were using alternative medicine for hypertension and 23% for hyperlipidemia treatment, while 20% were using those products to be healthier in general. Alternative medicine was more prominent in females (p=0.04), and older patients (p=0.004). Education level, drug intake, and the presence of chronic illnesses, hypertension and cardiovascular disease were significantly higher in those patients. CONCLUSION: Alternative and complementary products were common in patients admitted to outpatient cardiology clinics. Female gender, advanced age, higher education level, drug intake, and having a chronic illness were predisposing factors.