Isolating the entire pulmonary venous component versus isolating the pulmonary veins for persistent atrial fibrillation: A propensity-matched analysis.

BACKGROUND: The outcomes of pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) are suboptimal. The entire pulmonary venous component (PV-Comp), consisting of the pulmonary veins, their antra, and the area between the antra, provides triggers and substrate for AF. PV-Comp isolation is an alternative strategy for persistent AF ablation. METHODS: Among 328 patients with persistent AF who underwent a first radiofrequency ablation procedure, 200 patients (PVI, n = 100; PV-Comp isolation, n = 100) were selected by propensity score matching. Both groups were followed up for 1 year. RESULTS: At 6- and 12-month follow-up, atrial tachyarrhythmia (AF/atrial tachycardia) recurred in 41 and 61 patients in PVI group and 22 (P = .006) and 33 patients (P < .001) in PV-Comp isolation group, respectively. PV-Comp isolation was associated with longer mean time to recurrence (PVI: 8 months, PV-Comp isolation: 10 months, log-rank P < .001) and a lower probability of recurrence (odds ratio [OR] = 0.32; 95% confidence of interval [CI] = 0.18-0.56, P < .001), with no increase in procedural complications (PVI: 5 of 100, PV-Comp isolation: 6 of 100, P = .76). Procedure duration was longer in PV-Comp isolation group (PVI: 186 ± 42 min, PV-Comp isolation: 238 ± 44 min, P < .001), as well as fluoroscopy time (PVI: 22 ± 16 min, PV-Comp isolation: 31 ± 21 min, P = .001). CONCLUSION: PV-Comp isolation for persistent AF reduced atrial tachyarrhythmia recurrence up to 1 year compared with PVI alone. While procedure and fluoroscopy time increased, there was no difference in procedural complications.

Seaweed Sargassum aquifolium extract ameliorates cardiotoxicity induced by doxorubicin in rats.

Doxorubicin (DOX) is a potent anticancer drug with adverse cardiotoxic effects. Alginates are multifunctional biopolymers and polyelectrolytes derived from the cell walls of brown seaweeds. They are nontoxic, biocompatible, and biodegradable, and hence, utilized in several biomedical and pharmaceutical applications. Here, we investigated the potential cardioprotective effect of thermally treated sodium alginate (TTSA), which was extracted and purified from the seaweed Sargassum aquifolium, in treating acute DOX cardiotoxicity and apoptotic pathways in rats. UV-visible spectroscopy, Fourier-transform infrared, and nuclear magnetic resonance (1H-NMR) spectroscopy techniques were used to characterize TTSA. CK-MB and AST levels in sera samples were determined. The expression levels of Erk-2 (MAPK-1) and iNOS genes were investigated by quantitative real-time polymerase chain reaction (qRT-PCR). The protein expression levels of Erk-2, anti-apoptotic p53, and caspase-3 were analyzed using western blotting and ELISA. For the in vivo studies, sixty rats were randomly divided equally into six groups and treated with DOX, followed by TTSA. We revealed that treatment with TTSA, which has low molecular weight and enhanced antioxidant properties, improved DOX-mediated cardiac dysfunction and alleviated DOX-induced myocardial apoptosis. Furthermore, TTSA exhibited a cardioprotective effect against DOX-induced cardiac toxicity, indicated by the increased expression of MAPK-1 (Erk2) and iNOS genes, which are implicated in the adaptive responses regulating DOX-induced myocardial damage. Moreover, TTSA significantly (p < 0.05) suppressed caspase-3 and upregulated anti-apoptotic protein p53 expression. TTSA also rebalanced the cardiomyocyte redox potential by significantly (p < 0.05) increasing the levels of endogenous antioxidant enzymes, including catalase and superoxide dismutase. Our findings suggest that TTSA, particularly at a dose of 400 mg/kg b.w., is a potential prophylactic supplement for treating acute DOX-linked cardiotoxicity.

Assessment of left ventricular mechanical dyssynchrony using real time three-dimensional echocardiography: a comparative study to Doppler tissue imaging.

PURPOSE: To assess left ventricular mechanical dyssynchrony (LVMD) using real time three-dimensional echocardiography (RT3DE) and comparing it with the different dyssynchrony indices derived from Doppler tissue imaging (DTI) for the same patient. METHODS: The study included 60 consecutive patients who were considered candidates for CRT, i.e., having ejection fraction ≤35%, NYHA class III or ambulatory class IV, QRS duration ≥120 msec, on optimal pharmacological therapy. Apical RT3DE full volumes were obtained and analyzed to generate the systolic dyssynchrony index (SDI-16), which is the standard deviation of the time to minimal systolic volume of the 16 segments of LV. Color-coded DTI was performed for the three standard apical views with estimation of the mechanical dyssynchrony index (12 Ts-SD), which is the standard deviation of the time to peak systolic velocity at 12 segments of LV. RESULTS: SDI-16 was 10.96 ± 3.9% (cutoff value: 8.3%), while Ts-SD was 38 ± 10.2 msec (cutoff value: 32.6 msec). The concordance rate for both indices was 75%; however, there was no correlation between both indices (r = 0.14, P = 0.3). SDI-16 showed good correlation with QRS duration (r = 0.45, P < 0.001) and inverse correlation with left ventricular ejection fraction (LVEF) calculated by RT3DE (r =-0.37, P = 0.004), while 12 Ts-SD index showed no correlation with QRS duration (r =-0.0082, P = 0.51) or 2D LVEF (r =-0.26, P = 0.84). CONCLUSIONS: RT3DE can quantify LVMD by providing the SDI-16 and it may prove to be more useful than DTI as it shows increasing dyssynchrony with increased QRS duration and decreased LVEF.

Original Article--Outcomes of Pacing in Egyptian Pediatric Population.

OBJECTIVES: Permanent pacemakers are widely used in the pediatric population due to congenital and surgically acquired rhythm disturbances. The diversity and complexity of congenital heart diseases make device management a highly individualized procedure in pediatric pacing. We are also faced with special problems in pediatric age group as growth, children's activity and infection susceptibility. This study aimed to present our institute's experience in pediatric and adolescent pacemaker implantation and long-term outcomes. METHODS: This cross-sectional observational study included 100 pediatric patients who visited our outpatient clinics at Ain Shams University Hospitals for regular follow up of their previously implanted permanent pacemakers. All patients were subjected to history taking, clinical examination, ECG recording, echocardiography and elaborate device programming. Data about device types, device components' longevity, subsequent procedures, complications were collected, with comparison between epicardial and endocardial pacemakers. RESULTS: Our study population ranged in age from 8 months to 18 years (mean 13.12 ± 5.04 years), 51 were males and 53 patients had congenital heart disease. Epicardial pacing represented 26% of our total population using only VVIR pacemakers, while endocardial pacing represented 74% of our population with 58.1% of them being VVIR pacemakers. First battery longevity was higher in endocardial batteries (108 months vs. 60 months, p value: 0.007). First lead longevity was also higher in endocardial leads (105 moths vs. 58 months, p value: 0.006). Complication rate was 25%; 8 patients had early complications (one insulation break in endocardial group). Late complications occurred in 17 patients (10 patients had lead fracture; 9 of them were endocardial, 2 insulation breaks in endocardial leads, 3 patients from epicardial group had lead failure of capture). In total, 16 patients had lead-related complications. There was no statistically significant difference between different lead models regarding lead-related complications. CONCLUSION: Pacemakers in children are generally safe, but still having high rates of lead-related complications. Lead failure of capture was more common in epicardial leads. These complications had no relation to the model of the leads. Endocardial pacemakers showed higher first lead and first battery longevity compared to epicardial pacemakers.

Clinical outcomes of catheter ablation of paroxysmal atrial fibrillation in very young population compared to older population: a prospective study.

BACKGROUND: Data on procedural characteristics and clinical outcome of catheter ablation of atrial fibrillation (AF) in adults younger than 35 years has not been sufficiently addressed. The aim is to assess procedural characteristics and clinical outcome of catheter ablation of paroxysmal atrial fibrillation in young adults in comparison to older adults. RESULTS: Seventy-six consecutive patients with symptomatic paroxysmal AF underwent pulmonary vein isolation (PVI) at Ain Shams University Hospitals from 2013 till 2016. They were divided into the two groups, young population group (mean age 31.6 ± 4.2 years, 77% men) and older population group (mean age 49 ± 8.4 years, 74% men). Clinical data before and during the procedure were recorded. Follow-up was based on outpatient visits including 24 h Holter, ECG at 3, 6, and, 12 months post single ablation procedure. Recurrence was defined as any AF/atrial tachycardia episode > 30 s following a 3-month blanking period. Body mass index, CHA2DS2-VASc score, and left atrial volume were higher in the older population group [P values 0.019, < 0.001, and 0.001, respectively]. The presence of low-voltage areas was found only in 22% of the older population group and not in the younger group [P 0.02]. All patients were followed up for 1 year; 1-year arrhythmia-free survival after a single procedure was 83.3% (25/30) and 78.3% (36/46) in the older group [P 0.75]. No complications were recorded in both groups. Redo AF ablation were done for four patients in the old group and one patient in the young group. CONCLUSIONS: Catheter ablation of AF in very young adults is associated with higher 1-year success rates but comparable to success rates in older populations. AF ablation for PAF is effective in very young adults.

Reversal of premature ventricular complexes induced cardiomyopathy. Influence of concomitant structural heart disease.

BACKGROUND: We examined the effect of radiofrequency (RF) catheter ablation of premature ventricular complexes (PVCs) on left ventricle (LV) function recovery in patients with LV dysfunction, regardless the presence of structural heart disease (SHD). METHODS: Seventy seven patients with impaired LV ejection fraction (EF) (37.1±9.4), suspected to have PVCs cardiomyopathy (PVC-CM) (>10% PVCs burden), referred for RF ablation were enrolled, and divided into 2 groups according to the presence of SHD. SHD was ruled out by echocardiography, coronary angiography or MRI. CARTO 3 mapping system was used employing activation mapping in the majority of cases. Initial success was defined as complete elimination or residual PVCs≤10 beats/30min. Long term success was defined as reduction in PVCs burden >80% on follow-up holter. Echocardiography was done after 6 months. Improvement of EF >5% was considered significant. RESULTS: Forty two (55.8%) cases had SHD. PVCs burden was 28.4±9.8%. EF improved to 48.6±10.3. Initial success, overall success, post procedural PVCs burden and EF were comparable in both groups. EF improved in 47(75%) of successful cases with no significant differences between both groups. Post-MI Patients were the least category to improve. PVCs burden before and after ablation were the independent predictors of LVEF recovery by multivariate analysis. Cutoff values of >18%, <8% had 100% sensitivity and 85%, 87% specificity, respectively. CONCLUSIONS: PVCs elimination by RF ablation results in significant improvement even restoration of LV function regardless of PVC origin, or the presence of concomitant SHD. PVCs burden before and after ablation are the main predictors of LVEF recovery.

Epicardial fat thickness can predict severity and multivessel distribution in Egyptian patients with atherosclerotic coronary artery stenosis.

BACKGROUND: Epicardial fat, in addition to its secretory function, may have an important role in predicting and stratifying cardiovascular risk. There is a paucity of data regarding correlation between epicardial fat thickness and coronary artery disease in Egypt. AIM OF THE STUDY: To study the relationship between epicardial fat thickness (EFT) measured by trans-thoracic echocardiography (TTE) and severity of coronary artery disease (CAD) and its distribution in Egyptian population. METHODS: Our study was a prospective observational case control study that was conducted upon 150 patients with stable CAD presented to the cardiology departments in Ain Shams University hospitals and Al-Zaitoun Specialized hospital from March to October, 2015. EFT was measured by TTE for all patients at the same day of performing invasive coronary angiography (CA). We studied the statistical correlation between EFT and presence of CAD, also we tried to find if EFT is related to severity of CAD (according to Gensini score) or its distribution. RESULTS: The study population was divided according to CA results to 2 groups; patients' group having atherosclerotic CAD consisting of 100 patients and control group consisting of 50 patients with normal coronaries. All the well- known risk factors of CAD (male sex, smoking, hypertension, diabetes, dyslipidemia, increased body mass index) were significantly more prevalent in the patients' group. Patients had significantly lower systolic and diastolic functions. EFT was significantly correlated to presence of CAD (P < 0.001) with a cut-off value of 5.5 mm. EFT was significantly correlated to severity of CAD assessed by Gensini score (P < 0.001). Also we found a significant positive correlation between EFT and number of vessels affected (P <  0.001). CONCLUSION: EFT is a good predictor of CAD severity and multivessel affection in Egyptian patients. It is also a potentially promising predictor for the presence of CAD.

Outflow tract ventricular premature beats ablation in the presence or absence of structural heart disease: Technical considerations and clinical outcomes.

BACKGROUND: Premature ventricular beats (PVBs) are early depolarization of the myocardium originating in the ventricle. In case of very frequent PVBs, patients are severely symptomatic with impaired quality of life and are at risk of pre-syncope, syncope, heart failure, and sudden cardiac death particularly in the presence of structural heart disease. Ventricular outflow tracts are the most common sites of origin of idiopathic PVBs especially in patients without structural heart disease. We examined the role of radiofrequency catheter ablation in suppression of monomorphic PVBs of outflow tract origin in the presence or absence of structural heart disease, and its impact on improvement of left ventricular (LV) systolic function. METHODS: Thirty-seven highly symptomatic patients with PVBs burden exceeding 10% were enrolled, provided that PVBs are monomorphic, originating in ventricular outflow tracts and regardless the presence or absence of structural heart disease. Patients were divided into 2 groups according to PVB site origin (RVOT vs. LVOT). 3D electro-anatomical mapping modalities were used in all patients employing activation mapping technique in the majority of cases. Acute success was considered when PVBs completely disappeared or when residual sporadic PVBs ≤ 1 beats/min or ≤10 beats/30 min after RF ablation. Patients were followed up for a mean period of 5.4 ± 1.2 months with long-term success defined as complete disappearance or marked reduction by more than 75% in the PVBs absolute number on 24 h holter monitoring. RESULTS: Mean age of the study group was 39.9 ± 12.97 years, including 22 (59.4%) males. PVBs originated in RVOT in 17 cases and in LVOT in the remaining 20 cases. Prevalence of structural heart disease and consequently shortness of breath was higher in LVOT group. Initial ECG localization matched EP localization in the majority (94%) of cases. R wave duration index was the only significant independent predictor for RVOT origin with cut off value of <0.3 (P = 0.0057) upon multivariate analysis. Acute success was encountered in 32 (86%) patients with all cases of failure in the LVOT group. Recurrence occurred in 5 (15%) cases without significant difference between both groups. All cases of recurrence had residual PVBs at the end of the procedure. 18 cases out of the study group showed significant improvement of their EF (>5%) at the end of the follow-up period with no significant differences between both groups (p = 0.09). A linear correlation was observed between PVBs burden at follow up and magnitude of improvement of LV EF, particularly in patients with resting LV dysfunction and increased LV internal dimensions. CONCLUSIONS: RF ablation is an effective and safe method for elimination of outflow tract PVBs irrespective of their origin and the presence or absence of structural heart disease. PVBs burden after ablation appears to be the main determinant for reversal of PVB induced myopathy particularly in those with increased LV internal dimensions.