Cardioneuroablation for treatment of carotid sinus syndrome secondary to oropharyngeal squamous cell cancer.

Head and neck tumors can rarely cause carotid sinus syndrome and this often resolves by surgical intervention or palliative chemoradiotherapy. If these modalities are not an option or are ineffective, the most preferred treatment is permanent pacemaker therapy. Here, we present the first case of cardioneuroablation treatment performed in patient with oropharyngeal squamous cell cancer who developed recurrent asystole and syncope attacks due to compression of the carotid sinus on neck movement.

QTc shortening effect of ganglionated plexi ablation.

BACKGROUND: In previous studies, patients undergoing ablation of ganglionated plexi (GPA) for vagally mediated bradyarrhythmias were noted to have shortening of their corrected QT interval (QTc). AIMS: To compare the effects of GPA (group 1) to pulmonary vein isolation + GPA (group 2) on QTc. MATERIAL AND METHODS: We enrolled 39 patients, n = 25 in group 1 and n = 14 in group 2. QTc was calculated at baseline, at 24 h after ablation, and at 9-12 months in the follow-up. Recurrent syncope, asystole >2 s, and/or second- or third-degree AVB episodes were carefully documented as the primary outcome in group 1. Any atrial arrhythmia ≥30 seconds documented on 24-h Holter monitoring was defined as the primary outcome in group 2. RESULTS: The mean follow-up time was 14.9 ± 4 months. Acute success was achieved in all cases. In whole cohort, a significant shortening on QTcBazett, QTcFramingham, QTcFredericia, and QTcHodges was observed [416 vs 398ms (p = .002), 411vs 378 ms (p < .001), 412 vs 379ms (p < .001), and 420 vs 383ms (p < .001), respectively]. In the linear mixed model analysis, the longitudinal reduction tendency in the QTc level was more pronounced in group 1. Event-free survival was detected in 90.7% (59/65) of cases. DISCUSSION: Our results demonstrate a significant shortening of QTc in addition to high medium-term success rates after GPA. Pulmonary vein isolation + GPA was associated with lower QTc shortening effect which implies structural disease may change electrophysiological response to ablation. The most likely mechanism is the effect of GPA on the sympathetic system.

The anatomical basis behind the neuromodulation effects associated with pulmonary vein isolation.

The anatomical basis underlying the neuromodulation effects seen with pulmonary vein (PV) isolation (PVI) is not fully understood. Left atrial (LA) electro-anatomical maps of 38 patients who underwent catheter cardioneuroablation for vagally mediated bradycarrhythmias were studied. During the procedure, LA ganglionic plexi (GPs) were systematically identified and ablated. Design PVI lines were created on these maps by a blinded observer, and the degree of overlap between four GPs and individual PVs was assessed. Here, 1.7 ± 7 (35.5 ± 17.0%) of the total 31.6 ± 10 GP ablation sites per patient were found to overlap with the design PVI lines. The overlap was higher for the right-sided GPs, p < .001. The degree of GP-PV overlap varied: 1 PV in 5 (13.2%) patients, 2 PVs in 15 (39.2%), 3 PVs in 16 (42.1%), and all 4 PVs in 2 (5.3%). No patient had zero GP-PV overlap. A vagal response was most commonly observed during ablation at the left superior GP (89.5%), while a sympathetic response was observed most often during the right superior GP ablation (97.4%). Some degree of GP-PV antral overlap is the norm, and this is more pronounced for the right-sided PVs. There is significant individual variability in the degree of overlap which may explain why neuromodulation effects are not seen universally following PVI.

Elevated levels of short-term blood pressure variability: A marker for ascending aortic dilatation in hypertensive patients.

Background: Ascending aortic aneurysms are one of the primary causes of mortality. However, not much is known about the etiologies of aortic aneurysm. Recently, in hypertensive (HT) patients, blood pressure variability (BPV) has been recommended as a remarkable risk factor for adverse cardiovascular outcomes. This study aimed to explore the association between short-term BPV and ascending aortic dilatation (AAD).Methods: In this study, a total of 53 HT patients with AAD (aortic size index [ASI] ≥21 mm/m2) and 126 HT patients with a normal ascending aortic diameter (ASI <21 mm/m2) were included. Baseline, echocardiographic, and 24-h ambulatory blood pressure (BP) monitoring results were compared between groups. Standard deviation (SD) and coefficient of variation (CV) of BP were used to determine short-term BPV.Results: Except for daytime SBP values, daytime, nighttime, and 24-h mean systolic (SBP) and diastolic (DBP) BP levels were similar between groups. Compared with the HT patients with normal AA, daytime SBP, daytime SD of SBP, 24-h SD of SBP, daytime CV of SBP, and 24-h CV of SBP were significantly higher in HT patients with AAD. Compared with the HT patients with normal AA, the frequency of nondipper pattern was higher and dipper pattern was lower in HT patients with AAD. In multivariate logistic regression analysis, the daytime CV of SBP, daytime SD of SBP, 24-h SD of SBP, daytime SBP, and left ventricular mass index were independently associated with AAD. In receiver operating characteristic curve analysis, the daytime CV of SBP levels of >12.95 had a sensitivity of 61% and a specificity of 59% (area under the curve, 0.659; 95% CI, 0.562-0.756; P= .01); moreover, daytime SD of SBP > 16.4 had sensitivity of 62% and specificity of 61% (AUC, 0.687; 95% CI, 0.591-0.782; P< .001).:Conclusion Increased short-term BPV is independently associated with AAD and may be recommended as a remarkable factor risk for AAD in HT patients.

Effects of permanent cardiac pacing on ventricular repolarization when compared to cardioneuroablation.

INTRODUCTION: The impact of cardioneuroablation (CNA) on ventricular repolarization by using corrected QT interval (QTc) measurements has been recently demonstrated. The effects of cardiac pacing (CP) on ventricular repolarization have not been studied in patients with vasovagal syncope (VVS). We sought to compare ventricular repolarization effects of CNA (group 1) with CP (group 2) in patients with VVS. METHODS: We enrolled 69 patients with age 38 ± 13 years (53.6% male), n = 47 in group 1 and n = 22 in group 2. Clinical diagnosis of cardioinhibitory type was supported by cardiac monitoring or tilt testing. QTc was calculated at baseline (time-1), at 24 h after ablation (time-2), and at 9-12 months (time-3) in the follow-up. RESULTS: In the group 1, from time-1 to time-2, a significant shortening in QTcFredericia (from 403 ± 27 to 382 ± 27 ms, p < 0.0001), QTcFramingham (from 402 ± 27 to 384 ± 27 ms, p < 0.0001), and QTcHodges (from 405 ± 26 to 388 ± 24 ms, p < 0.0001) was observed which remained lower than baseline in time-3 (373 ± 29, 376 ± 27, and 378 ± 27 ms, respectively). Although the difference between measurements in time-1 and time-2 was not statistically significant for QTcBazett, a significant shortening was detected between time-1 and time-3 (from 408 ± 30 to 394 ± 33, p = 0.005). In the group 2, there was no time-based changes on QTc measurements. In the linear mixed model analysis, the longitudinal reduction tendency in the QTcFredericia and QTcFramingham was more pronounced in group 1. CONCLUSIONS: Our results demonstrate that CNA reduces QTc levels through neuromodulation effect whereas CP has no effect on ventricular repolarization in patients with VVS.

Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation.

AIMS: Previous reports have suggested that cardioneuroablation (CNA) can be effective in reducing syncopal recurrences in patients with vasovagal syncope (VVS). This study assessed the efficacy of CNA in preventing a positive response to head-up tilt testing (HUT). METHODS AND RESULTS: This is a single-centre retrospective study reviewing prospectively collected data. Fifty-one consecutive patients with VVS were included in the study. After confirmation of >3 s asystole on HUT, all patients underwent CNA. Head-up tilt testing was repeated 1 month after CNA. The main outcome measures were recurrence of syncope episode and positive response on HUT. During a median follow-up period of 11 months (interquartile range 3-27 months), all but 3 (5.8%) of 51 patients were free of syncope. Repeated HUTs were negative in 44 (86.2%) patients. When patients with recurrent syncope were excluded, vasodepressor response was seen in three cases and cardioinhibitory response in one case, respectively. Cardioneuroablation caused significant and durable shortening of RR interval in all cases. This effect was significantly higher in patients without positive HUT responses. CONCLUSION: This pilot study shows that CNA can effectively prevent recurrent syncopal episodes in patients with refractory VVS. Head-up tilt testing seems as a valuable diagnostic tool not only to select suitable candidates and but also to evaluate success of CNA.

Why is pulmonary vein isolation not enough for vagal denervation in all cases?

Pulmonary vein isolation (PVI) may cause vagal response during radiofrequency application or increase on heart rate after ablation. All those responses are related to inadvertent ablation effect on ganglionated plexi. In the present case, we aimed to explain why vagal response effects of PVI are not same in all cases.

Ultrasound-guided combined pectoral nerve block and axillary venipuncture for the implantation of cardiac implantable electronic devices.

BACKGROUND: Combined ultrasound (US)-guided pectoral nerves (PECS) block and axillary vein (AV) puncture for cardiac implantable electronic devices can be effective to achieve optimal perioperative pain management and prevent access-related complications. METHODS: A total of 36 patients who underwent combined US-guided PECS block and AV puncture were included. All routinely recorded parameters, including clinical and demographic characteristics, periprocedural medical administrations, the time taken for both PECS block and AV puncture, procedure time, postprocedural pain score, and procedure-related complications, were collected and analyzed. RESULTS: In total, 54 leads were placed in 36 patients. The combined US-guided PECS block and AV puncture was performed successfully in 35 (97.2%) patients without the need for fluoroscopy or venography. AV access for each lead was achieved in a single attempt in 80.6% of cases. The time for both PECS block and AV puncture was 223.6 ± 52.1 s, including the time to apply incision site anesthesia. Additional sedatives and/or local anesthetics were required in two patients during procedure. Visual analog scale average of the patients in the 1st, 6th, and 24th h was 3.7 ± 1.14. 1.61 ± 1.29, and 0.08 ± 0.28, respectively. After the procedure, four patients (three of them woman) needed analgesics. There were no venous access-related complications. CONCLUSIONS: This new combined technique maintains both surgical and postoperative analgesia and prevents vascular access-related complications without significant increase on procedure time.

A simple discharge risk model for predicting 1-year mortality in hospitalised acute decompansated heart failure patients with reduced ejection fraction.

OBJECTIVE: The risk stratification for prognosis in heart failure is very important for optimal disease management and decision making. The aim of this study was to establish a simple discharge 1-year mortality prediction model by integrating data obtained from demographic characteristics, clinical evaluation, laboratory biomarkers and echocardiographic evaluation of hospitalised heart failure with reduced ejection fraction (HFrEF) patients with acute decompensation. METHODS AND RESULTS: A risk score model was developed based on ß-coefficient number of variables in a multivariable logistic regression model which was created with the use of data on clinical, laboratory, imaging and therapeutic findings of 670 patients (65.4% males, 65 ± 11 years) who was hospitalised with acute decompensated HFrEF. The mean left ventricular ejection fraction (LVEF) was 26 ± 9%. Independent predictors of mortality were: age ≥75 years, sodium <130 mEq/L, hepatomegaly at admission, unable to use beta-blocker at discharge and LVEF ≤20%. The 1-year mortality rate was 7.8% in the study population. The existence of each predictor was scored as 1 point and the discharge risk score identified patients into low (0-1 points), intermediate (2-3 points) and high (4-5 points) risk individuals with 3, 15.6 and 44.4% 1-year mortality rates, respectively. The model performance evaluated by concordance index was 0.74. CONCLUSIONS: This simple discharge risk score model for hospitalised acute decompensated HFrEF patients using easily determined demographic characteristics, clinical signs, echocardiographic and laboratory data is a valuable and an easy risk assessment tool to use at point-of-care.

Effect of Oral Nitrates on All-Cause Mortality and Hospitalization in Heart Failure Patients with Reduced Ejection Fraction: A Propensity-Matched Analysis.

BACKGROUND: Hydralazine-nitrate combination is recommended for patients with heart failure with reduced ejection fraction (HFrEF)/systolic heart failure who are symptomatic despite guideline-directed medical therapy (GDMT). Use of nitrates alone for this indication is not well-established. This study aims to evaluate the effect of oral nitrates on all-cause mortality and hospitalization in HFrEF patients using GDMT. METHODS AND RESULTS: Nitrate prescription at discharge and its association with all-cause mortality and heart failure hospitalization were examined in a propensity-matched analysis of 648 HFrEF patients followed for a median of 56 months. A total of 269 (42%) patients died during that period. In Cox regression analysis, nitrate usage was associated with a slightly increased mortality risk compared with not using nitrates (hazard ratio 1.29; 95% confidence interval 1.01-1.65; P = .040), which continued modestly after the propensity-matched analysis (hazard ratio 1.26; 95% confidence interval 0.95-1.68; P = .102). In both prematch and propensity-matched analyses, nitrate use was not associated with risk of rehospitalization. No significant effect was detected on subgroups stratified by coronary artery disease, age, gender, and background medical therapy. CONCLUSIONS: In this study, oral nitrate use alone in addition to GDMT did not affect all-cause mortality and hospitalization risk in HFrEF patients during a long-term follow-up. There was even a modest tendency for increased risk of mortality.

Effectiveness of Handmade "Jacky-Like Catheter" As a Single Multipurpose Catheter in Transradial Coronary Angiography: A Randomized Comparison With Conventional Two-Catheter Strategy.

OBJECTIVE: To investigate safety and efficacy of specialized hand-modified "Jacky-Like" catheter (JLC) as a single dual-purpose catheter in transradial coronary angiography. METHODS: Patients over 18 years undergoing diagnostic CAG through right radial artery (RRA) were prospectively enrolled. Procedures were performed with a single JLC modified from a left Judkins (JL) 3.5 catheter or by using 2-catheter approach (2C). Procedures with coronary artery bypass grafts or ventricular angiographies were excluded from the study. Three hundred and eighty-seven transradial procedures were performed successfully. One hundred and ninety-four procedures were performed with 2C and 193 procedures with a JLC. Inability to use intended catheters, total fluoroscopic time in minutes, the consumption of contrast medium in milliliter, development of radial artery spasm (RAS), and radial artery occlusion (RAO) were evaluated. RESULTS: In the 2C group, angiography was successfully performed on the RCA of 191 patients (98.9%) and on LCA in 192 patients (99.4%). In the JLC group, angiography was successfully performed on the RCA and LCA of 193 (99.4%) and 174 (89.6%) patients, respectively. Utilization of supplemental catheters was significantly greater in the JLC group (21; 10.8%) versus the 2C group (3; 1.5% P = 0.001). Mean fluoroscopy time was shorter in the JLC group (2.0 ± 2.3 min vs. 2.3 ± 1.5 min; P = 0.043). Mean procedure time was also decreased with JLC but did not reach statistical significance (5.7 ± 3.1 min vs. 6.2 ± 2.5 min; P = 0.081). When additional time for reshaping the JLC was not taken into account, mean procedure time was significantly decreased in the JLC group (5.6 ± 2.9 min vs. 6.2 ± 2.4 min; P = 0.031). There was a trend toward lower incidence of consumption of contrast medium in the 2C group (49 ± 13 mL vs. 52 ± 18 mL; P = 0.061). RAS was observed more frequently in the 2C group (11.3% vs. 21.7%, P = 0.005). There was a trend toward high incidence of RAO in the 2C group (4.1 vs. 8.3% P = 0.064). CONCLUSION: In transradial procedures from RRA, a JLC catheter can be very effective when dedicated dual-purpose catheter is not available.

Associations Between Neutrophil Gelatinase Associated Lipocalin, Neutrophil-to-Lymphocyte Ratio, Atrial Fibrillation and Renal Dysfunction in Chronic Heart Failure.

BACKGROUND Atrial fibrillation (AF) and renal dysfunction are two common comorbidities in patients with chronic heart failure with reduced ejection fraction (HFrEF). This study evaluated the effect of permanent AF on renal function in HFrEF and investigated the associations of atrial fibrillation, neutrophil gelatinase-associated lipocalin (NGAL), and neutrophil-to-lymphocyte ratio (NLR) with adverse clinical outcome. MATERIAL AND METHODS Serum NGAL levels measured by ELISA and NLR were compared between patients with sinus rhythm (HFrEF-SR, n=68), with permanent AF (HFrEF-AF, n=62), and a healthy control group (n=50). RESULTS Mean eGFR levels were significantly lower, and NLR and NGAL levels were significantly higher in the HFrEF patients than in the control patients but the difference between HFrEF-SR and HFrEF-AF was not statistically significant (NGAL: 95 ng/mL in HFrEF-SR, 113 ng/mL in HFrEF-AF and 84 ng/mL in the control group; p<0.001). Independent associates of baseline eGFR were age, hemoglobin, NLR, triiodothyronine, and pulmonary artery systolic pressure. In a mean 16 months follow-up, adverse clinical outcome defined as progression of kidney dysfunction and composite of all-cause mortality and re-hospitalization were not different between HFrEF-SR and HFrEF-AF patients. Although NGAL was associated with clinical endpoints in the univariate analysis, Cox regression analysis showed that independent predictors of increased events were the presence of signs right heart failure, C-reactive protein, NLR, triiodothyronine, and hemoglobin. In ROC analysis, a NLR >3 had a 68% sensitivity and 75% specificity to predict progression of kidney disease (AUC=0.72, 95% CI 0.58-0.85, p=0.001). CONCLUSIONS Presence of AF in patients with HFrEF was not an independent contributor of adverse clinical outcome (i.e., all-cause death, re-hospitalization) or progression of renal dysfunction. Renal dysfunction in HFrEF was associated with both NLR and NGAL levels, but systemic inflammation reflected by NLR seemed to be a more important determinant of progression of kidney dysfunction.

What is the lowest value of left ventricular baseline ejection fraction that predicts response to cardiac resynchronization therapy?

BACKGROUND: Cardiac resynchronization therapy (CRT) is an effective treatment option for patients with refractory heart failure. However, many patients do not respond to therapy. Although it has been thought that there was no relation between response to CRT and baseline ejection fraction (EF), the response rate of patients with different baseline LVEF to CRT has not been evaluated in severe left ventricular systolic dysfunction. We aimed to investigate any difference in response to CRT between the severe heart failure patients with different baseline LVEF. MATERIAL AND METHODS: In this study, 141 consecutive patients (mean age 59±13 years; 89 men) with severe heart failure and complete LBBB were included. Patients were divided into 3 groups according to their baseline LVEF: 5-15%, Group 1; 15-25%, Group 2, and 25-35%, Group 3. NYHA functional class, LVEF, LV volumes, and diameters were assessed at baseline and after 6 months of CRT. A response to CRT was defined as a decrease in LVSVi (left ventricular end-systolic volume index) ≥10% on echocardiography at 6 months. RESULTS: After 6 months, a significant increase of EF and a significant decrease of LVESVi and LVEDVi after 6 months of CRT were observed in all groups. Although the magnitude of improvement in EF was biggest in the first group, the percentage of decrease in LVESVi and LVEDVi was similar between the groups. The improvement in NYHA functional class was similar in all EF subgroups. At 6-month follow-up, 100 (71%) patients showed a reduction of >10% in LVESVi (mean reduction: -15.5±26.1 ml/m^2) and were therefore classified as responders to CRT. Response rate to CRT was similar in all groups. It was 67%, 75%, and 70% in Group 1, 2, and 3, respectively, at 6-month follow-up (p>0.05). There was no statistically significant relation between the response rate to CRT and baseline LVEF, showing that the CRT has beneficial effects even in patients with very low LVEF. CONCLUSIONS: It seems there is no lower limit for baseline LVEF to predict non-response to CRT in eligible patients according to current guidelines.

Arrhythmogenic right ventricular cardiomyopathy in pregnancy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is predominantly a genetically determined heart muscle disorder that is characterized by fibro-fatty replacement of the right ventricular (RV) myocardium.(1)) The clinical spectrum of ARVC may represent from asymptomatic premature ventricular complexes to ventricular tachycardia (VT) and sudden cardiac death (SCD). It is a well-known leading cause of SCD in young adults.(2,3))There is no general consensus on the management of ARVC in pregnancy, and the preferred mode of delivery is uncertain. Herein, we report a case of ARVC diagnosed at 20 weeks of gestation following a sustained VT and treated with an implantable cardiac defibrillator (ICD). We also reviewed the current knowledge and approach to ARVC in pregnancy since the literature on this condition is based on case reports.

Artificial Intelligence-Based Clinical Decision Support Systems in Cardiovascular Diseases.

Despite all the advancements in science, medical knowledge, healthcare, and the healthcare industry, cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide. The main reasons are the inadequacy of preventive health services and delays in diagnosis due to the increasing population, the failure of physicians to apply guide-based treatments, the lack of continuous patient follow-up, and the low compliance of patients with doctors' recommendations. Artificial intelligence (AI)-based clinical decision support systems (CDSSs) are systems that support complex decision-making processes by using AI techniques such as data analysis, foresight, and optimization. Artificial intelligence-based CDSSs play an important role in patient care by providing more accurate and personalized information to healthcare professionals in risk assessment, diagnosis, treatment optimization, and monitoring and early warning of CVD. These are just some examples, and the use of AI for CVD decision support systems is rapidly evolving. However, for these systems to be fully reliable and effective, they need to be trained with accurate data and carefully evaluated by medical professionals.

Digital Technologies in Heart Failure Management.

Heart Failure (HF) is an important public health problem in Turkey and in the world. Hospitalizations due to HF decompensation are associated with increased mortality. The use of digital technologies, especially wearable technologies, is increasing. As physicians, with the use of these devices, patients could be closely followed up and hospitalization, mortality are tried to be prevented by increased awareness of decomposition before clinical symptoms or at the beginning of symptoms. In this review, digital biomarkers, digital technologies, remote monitoring systems and the evidence supporting their use, artificial intelligence applications and the reasons limiting their use of digital technologies in clinical practice will be discussed.

Perspectives on the Use of Digital Health Technologies in Cardiology Among Specialists from an ESC Member Country: Results from a Survey.

OBJECTIVE: In this study, we aimed to identify the reasons for and perceived challenges associated with the use of digital health technologies (DHT) in cardiology. METHOD: We distributed an online survey to Turkish Society of Cardiology member cardiologists (n = 2789) between January 10 and March 3, 2022. RESULTS: A total of 308 subjects responded (27.6% females, 62.0% aged 30-44 years). Of these, 42.5% worked at university hospitals, and 44.8% at state hospitals. Smart devices were used by 44.2% (136/308) for personal health monitoring. Additionally, 40.3% (117/290) used social media to provide medical information to patients, while 64.6% (193/299) did so for communication with other physicians. The self-reported recommendation frequencies of wearables, cardiac implantable electronic device telemonitorization, mobile health applications, and teleconsultation/televisit technologies were lower than the proportion of respondents who found DHT beneficial for both patients and physicians. The most frequently mentioned barriers for physicians were increased work burden and responsibilities (78.8%, 193/245), lack of financial compensation (66.9%, 164/245), and lack of relevant training (66.5%, 163/245). For patients, low technological adaptability (81.6%, 200/245), low health literacy (80.4%, 197/245), and low affordability (79.6%, 195/245) were the most frequently mentioned barriers. Additionally, the cost of technologies (69.4%, 170/245), concerns regarding data privacy and security (57.6%, 141/245), and data storage challenges (48.2%, 118/245) were the most significant technical impediments. CONCLUSION: The findings suggest that although the majority of physicians believe DHT to be beneficial for both themselves and their patients, the frequency of recommendations to patients remains low. A large-scale joint effort is required to address these issues and facilitate the integration of DHT into clinical practice.

Ultrasound guided percutaneous cephalic venipuncture for implantation of cardiac implantable electronic devices.

BACKGROUND: Preoperative ultrasound (US) for cephalic cut-down is related to shorter procedure time and higher success rate. This study aimed to assess efficiency of US-guided percutaneous cephalic vein (CV) puncture for placement of cardiac implantable electronic devices (CIEDs). METHODS: Patients undergoing a procedure including both US-guided pectoral nerve block (PECS) and percutaneous CV puncture were retrospectively investigated. Patient medical history and demographic data was collected. Clinical features of the procedures and intra- and post-operative complications occurring were collected from patient records. Clinical data included target vessel features, and the time taken for the following: CV puncture; CV and PECS puncture; total procedure. RESULTS: In total 34 patients had CV puncture with US-guided PECS block was attempted in all patients and the procedure was successful in 27 of 34 (79.4%) patients. The total number of CV puncture attempts was 62 for 34 leads (mean attempts per lead = 1.82). The mean ± standard deviation time for CV puncture was 137.5 ± 27.4 s. There were no venous access-related complications. CONCLUSION: US-guided CV puncture appears feasible and safe with an acceptable success rate. In case of failure of the US-guided axillary or subclavian vein approach, it may be preferred as an alternative to the cephalic cut-down procedure, where the success rate is relatively lower and the risk of bleeding is higher.