The relationship between the S-wave in lead 1 and recurrence of RVOT PVC ablation.

BACKGROUND: Radiofrequency catheter ablation (CA) is a common non-pharmacological treatment option for ventricular premature contractions (PVCs) originating from right ventricular outflow tract (RVOT). In this study, we aimed to investigate the relationship between recurrence after CA for RVOT-PVC and S-wave in lead 1 that was shown to be associated with RVOT depolarization. METHODOLOGY: A total of 104 patients who were referred to our clinic for CA for idiopathic RVOT-PVC between 2012 and 2015years were enrolled. All ECG parameters were measured before and after the ablation procedure. RESULTS: Ablation was successful in 100 patients (96,1%). These patients with successful ablation were followed for a mean duration of 1078days. 13 patients (13%) had recurrence. Univariate logistic regression analysis revealed age (odds ratio: 1.916, p:0,012), presence of post-procedural S1 (odds ratio:1.040 p:0,028), post-procedural S1 area (oddsratio:1.023 p:0,041), ΔS1 area (odds ratio:1.242 p:0,004) as predictors for recurrence. Multivariate logistic regression analysis detected age (odds ratio:1.053 p:0,032) and ΔS1 area (odds ratio:0.701 p:0,009) as predictors for recurrence. CONCLUSION: Radiofrequency CA for RVOT-PVC can be performed with high procedural success and low complication rates. Age and ΔS1 area might be helpful for prediction of recurrence after CA.

Real-life data regarding acute procedural success and 1-year clinical outcome of desolve bioresorbable scaffolds.

OBJECTIVES: We aimed to evaluate the peri-procedural success of DESolve bio-resorbable scaffolds (BRSs) and analyzed real-life data about major cardiac events during 1-year follow-up. BACKGROUND: There is little information about real-life data of DESolve BRS which is a novel stent technology offering various advantages over drug eluting stents and commonly used in daily cardiology practice. METHODS: We conducted this single-center and non-randomized cross-sectional study from June 2015 through August 2016 in Medipol University Department of Cardiology and included 117 patients undergoing single or multivessel percutaneous coronary interventions (PCI) with novolimus-eluting BRS devices (152 scaffolds) (Elixir Medical Corporation). Study end points were acute device and procedural success, scaffold thrombosis and major adverse cardiac event (MACE) rates of DESolve BRS. RESULTS: Device success was 96.7% and procedural success was 99.3%. We detected MACE rate as 0.9% while clinical-driven target lesion revascularization was performed in one patient. None of the patients experienced scaffold thrombosis or death. Peri-procedural complications were reported in three patients. CONCLUSIONS: High rates of successful scaffold implantations, low rates of peri-procedural complications, and major cardiac events in long-term suggest that DESolve scaffolds can safely and effectively be used in daily intervention practice by particularly experienced operators.

Native Electrocardiographic QRS Duration after Cardiac Resynchronization Therapy: The Impact on Clinical Outcomes and Prognosis.

BACKGROUND: We investigated whether reversed electrical remodeling (RER), defined as narrowing of the native electrocardiographic QRS duration after cardiac resynchronization therapy (CRT), might predict prognosis and improvement in echocardiographic outcomes. METHODS AND RESULTS: A total of 110 CRT recipients were retrospectively analyzed for the end points of death and hospitalization during 18 ± 3 months. Native QRS durations were recorded at baseline and 6 months after CRT (when pacing was switched off to obtain an electrocardiogram) to determine RER. CRT response and mitral regurgitation (MR) improvement were defined as ≥15% reduction in left ventricular end-systolic volume and absolute reduction in regurgitant volume (RegV) at 6 months, respectively. Overall, 48 patients (44%) had RER, which was associated with functional improvement (77% vs 34%; P < .001) and CRT response (81% vs 52%; P < .001) compared with those without RER. The change in the intrinsic QRS duration correlated with the reduction in RegV (r = 0.51; P < .001) and in tenting area (r = 0.34; P < .001). RER was a predictor of MR improvement (P = .023), survival (P = .043), and event-free survival (P = .028) according to multivariate analyses. CONCLUSIONS: Narrowing of the intrinsic QRS duration is associated with functional and echocardiographic CRT response, reduction in MR, and favorable prognosis after CRT.

Predicting Ventricular Arrhythmias in Cardiac Resynchronization Therapy: The Impact of Persistent Electrical Dyssynchrony.

BACKGROUND: Although response to cardiac resynchronization therapy (CRT) has been conventionally assessed with left ventricular volume reduction, ventricular arrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]) are of critical importance associated with unfavorable outcomes even in the "superresponders" to therapy. We evaluated the predictors of VT/VF and the association of residual dyssynchrony during follow-up. METHODS: Ninety-five patients receiving CRT were followed-up for 9 ± 3 months. Post-CRT dyssynchrony was defined as a prolonged QRS duration (QRSd) for persistent electrical dyssynchrony (ED), and a Yu index ≥ 33 ms for persistent mechanical dyssynchrony. The first VT/VF episode, including nonsustained VT detected on device interrogation and/or appropriate antitachycardia pacing or shock for VT/VF, were the end points of the study. RESULTS: Forty-five patients who reached the study end points had significantly lower mean ΔQRS (baseline QRSd - post-CRT QRSd) values than those without VT/VF (-20.8 ± 28.9 ms vs -6.6 ± 30.7 ms, P = 0.022). Both the baseline and post-CRT QRSds, along with the Yu index values, were not different in two groups. Patients with VT/VF were statistically more likely to have persistent ED (38% vs 9%, P = 0.021). Kaplan-Meier curves showed that a negative ΔQRS was associated with a higher incidence of VT/VF during follow-up (P = 0.016). A multivariate Cox model revealed that QRS prolongation was an independent predictor of VT/VF after CRT (P = 0.029). CONCLUSIONS: A negative ΔQRS, also called persistent ED, is associated with VT/VF. Narrowest possible QRSd might be a reliable goal of both implantation and optimization of devices to reduce arrhythmic events after CRT.

Adjusting the QRS Duration by Body Mass Index for Prediction of Response to Cardiac Resynchronization Therapy: Does One QRS Size Fit All?

BACKGROUND: QRS duration (QRSd) is known to be affected by body weight and length. We tested the hypothesis that adjusting the QRSd by body mass index (BMI) may provide individualization for patient selection and improve prediction of cardiac resynchronization therapy (CRT) response. METHODS: A total of 125 CRT recipients was analyzed to assess functional (≥1 grade reduction in NYHA class) and echocardiographic (≥15% reduction in LVESV) response to CRT at 6 months of implantation. Baseline QRSd was adjusted by BMI to create a QRS index (QRSd/BMI) and tested for prediction of CRT response in comparison to QRSd. RESULTS: Overall, 81 patients (65%) responded to CRT volumetrically. The mean QRS index was higher in CRT responders compared to nonresponders (6.2 ± 1.1 vs 5.2 ± 0.8 ms.m(2) /kg, P < 0.001). There was a positive linear correlation between the QRS index and the change in LVESV (r = 0.487, P < 0.001). Patients with a high QRS index (≥5.5 ms.m(2) /kg, derived from the ROC analysis, AUC = 0.787) compared to those with a prolonged QRSd (≥150 ms, AUC = 0.729) had a greater functional (72% vs 28%, P < 0.001) and echocardiographic (80% vs 44%, P < 0.001) improvement at 6 months. QRS index predicted CRT response at regression analysis. CONCLUSIONS: Indexing the QRSd by BMI improves patient selection for CRT by eliminating the influence of body weight and length on QRSd. QRS index is a novel indicator that provides promising results for prediction of CRT response.

Tako-tsubo cardiomyopathy following catheter ablation of atrial fibrillation.

Tako-tsubo cardiomyopathy is characterized by reversible left ventricular dysfunction following emotional or surgical stress. Unlike the well-known complications of catheter ablation (CA) of atrial fibrillation (AF), Tako-tsubo cardiomyopathy has been rarely reported so far. We report a case of acute reversible left heart failure following successful CA of paroxysmal AF in a patient with a history of panic disorder.

Percutaneous Treatment of Severe Acute Mitral Regurgitation Early After Myocardial Infarction and a Short Review of the Literature.

Transcatheter edge-to-edge repair treatment is mainly used for patients with chronic heart failure concomitant severe mitral regurgitation. However, utilization of this system in the acute seting of myocardial infarction is still limited. In this case report authors aimed to show the effectiveness of the percutaneous treatment for severe acute mitral regurgitation early after myocardial infarction.

How accurate are manufacturers' recommendations in determining ineligibility for transfemoral transcatheter aortic valve implantation?

INTRODUCTION: Up to one-third of patients indicated for transcatheter aortic valve implantation (TAVI) may be unsuitable for transfemoral TAVI (TF-TAVI) according to manufacturers' recommendations and numerous professional societies. OBJECTIVE: This study aimed to investigate the predictive value of manufacturers' guidelines for major vascular access site complications using the Perclose ProGlide device. METHODS: Among 208 patients undergoing TF-TAVI, 144 patients (69.2%) were deemed eligible for TF-TAVI according to the manufacturer's instructions. A minimal lumen diameter (MLD) of the femoral artery below the manufacturer's specified limits and/or the presence of circumferential calcification were the reasons for ineligibility. Calcium score (CS), sheath-to-femoral artery ratio (SFAR) and MLD were estimated from computed tomography imaging. Vascular complications (VCs) (defined according to VARC-2 criteria) were retrospectively compared. RESULTS: Patients in the ineligible group had higher SFAR (1.13±0.15 vs. 0.88±0.107, p<0.001) and CS (1.66±0.99 vs. 1.24±0.73; p=0.003), and significantly lower MLD (7.72±1.03 vs. 6.31±0.96 mm; p<0.001) compared to the eligible group. Major (6.3% vs. 12.3%, p=0.13) and minor VCs (10.4% vs. 15.6%, p=0.29) were similar in the eligible and ineligible groups. The ineligible group had higher rates of rupture (0.7% vs. 6.3%; p=0.03). SFAR was the only independent predictor of major VCs (OR 469.1, 95% CI 4.95-44466.57, p=0.008). CONCLUSION: The TAVI team should not decide whether the patient is suitable for a femoral approach based solely on the manufacturer's criteria, and should incorporate additional factors that could be predictive of major VCs.

Subacute anterior wall myocardial infarction complicated by intramyocardial dissection.

Myocardial dissection is a rare but fatal complication of myocardial infarction requiring urgent surgical treatment to avoid complete rupture. We report a case of intramyocardial dissecting hematoma treated with supportive pharmacologic therapy for 9 months of follow-up without surgical intervention.

Vascular complications after transcatheter transfemoral aortic valve implantation: Modified sheath-to-femoral artery ratio as a new predictor.

OBJECTIVE: Vascular complications (VCs) contribute to increased morbidity and mortality in patients who have undergone transcatheter aortic valve implantation (TAVI); however, studies on their incidence and predictors show conflicting results. In this study, we sought to assess the incidence, impact, and predictors of VCs in transfemoral (TF) TAVI and also investigated the predictive role of manufacturer's size charts and a new predictor modified sheath-to-femoral artery ratio. METHODS: A total of 223 patients undergoing TF-TAVI were categorized into 2 groups. The patients were divided as eligible and ineligible according to the manufacturer's guidelines (MG), and the same patient cohort was dichotomized into eligible and ineligible on the basis of sheath-to-femoral artery ratio (SFAR) value of less than or greater than or equal to modified SFAR (md-SFAR). VCs (defined according to the Valve Academic Research Consortium II criteria) were retrospectively compared. RESULTS: According to the manufacturer's size charts, 65 patients were unsuitable; however, 35 patients were ineligible for TF-TAVI per the md-SFAR criteria. Although VCs occurred in 42 (18.8%) patients, 17 (27.7%) of those patients were classified as ineligible according to MG, whereas 14 (41.2%) were classified as ineligible in the md-SFAR group. In a multiple logistic regression analysis that included md-SFAR, MG, SFAR ≥1.05, peripheral artery disease, and minimum iliofemoral artery diameter, only md-SFAR was the independent predictor of VCs (odds ratio=3.71, 95% confidence interval=1.13-12.53, p=0.031). CONCLUSION: According to our results, md-SFAR might provide better patient selection to prevent VCs and improve outcomes in TF-TAVI procedures.

Angio-Seal Used as a Bailout for Incomplete Hemostasis After Dual Perclose ProGlide Deployment in Transcatheter Aortic Valve Implantation.

BACKGROUND: The failure rate of vascular closure devices remains a significant cause of major vascular complications in contemporary transcatheter aortic valve implantation practice. METHODS: This research aimed to evaluate use of the Angio-Seal device in a bailout context in the setting of incomplete hemostasis following use of dual Perclose ProGlide devices in patients undergoing transfemoral transcatheter aortic valve implantation. A total of 185 patients undergoing transfemoral transcatheter aortic valve implantation with either dual Per-close ProGlide (n = 139) or a combination of dual Perclose ProGlide and Angio-Seal (n = 46) were retrospectively analyzed. The baseline, procedural characteristics, and all outcomes (defined according to Valve Academic Research Consortium-2 criteria) were compared. RESULTS: No significant differences were seen between the dual Perclose ProGlide vs dual Perclose ProGlide+Angio-Seal groups with regard to the in-hospital Valve Academic Research Consortium-2 primary end points of major vascular complications (n = 13 [9.4%] vs n = 2 [4.3%]; P = .36), minor vascular complications (n = 13 [9.4%] vs n = 8 [14.7%]; P = .14), major bleeding (n = 16 [11.5%] vs n = 2 [4.3%]; P = .25), and minor bleeding (n = 9 [6.5%] vs n = 5 [10.9%]; P = .34), with higher rates of hematoma in the dual Perclose ProGlide+Angio-Seal group (n = 4 [2.9%] vs n = 5 [10.9%]; P = .044). CONCLUSION: Finding from the current study suggest that adjunctive Angio-Seal deployment may be feasible and safe, especially in patients with incomplete hemostasis following dual Perclose ProGlide use, and can be an optimal "bailout" procedure.

Acute thrombus formation on an Amplatzer device during transcatheter closure of an atrial septal defect in a patient with homozygous factor V Leiden mutation.

A 32-year-old woman underwent transcatheter closure of a secundum type atrial septal defect with the Amplatzer device. The procedure was started under premedication with aspirin, clopidogrel, and heparin. During the procedure, a highly mobile thrombus attached to the left atrial disc of the device was detected by transesophageal echocardiography (TEE). The device and the associated thrombus were successfully withdrawn and the patient was started on a combination of heparin and tirofiban infusion. The procedure was successfully completed without any recurrent thrombus formation or residual shunt. Further investigation for thrombophilia revealed homozygous factor V Leiden mutation and the patient was started on a life-long warfarin therapy. Follow-up TEE showed proper device position with no recurrent thrombus and the follow-up was uneventful.

Long-term outcomes of Absorb bioresorbable vascular scaffold using predilation, sizing, and postdilation protocol in a real-world patient population.

OBJECTIVE: Bioresorbable vascular scaffolds (BVSs) have been a disappointment in the evolution of drug-eluting stents used in percutaneous coronary intervention because an excessive number of thrombotic complications have been reported. The aim of this study was to evaluate long-term clinical outcomes of the Absorb BVS in patients treated using a predilation, proper sizing, and post-dilation implantation technique. METHODS: The records of 110 patients who had a total of 150 Absorb BVSs implanted were retrospectively analyzed. The rate of major adverse cardiovascular events (MACEs), defined as the composite of cardiac death, target vessel myocardial infarction (MI), and target-lesion revascularization were studied using quantitative coronary angiography. RESULTS: Of the study population, 80% were male and the mean age was 60±11.3 years. The most common diagnosis was stable angina (84%). The median length of follow-up was 53 months (range: 46-59 months). The rate of predilation and postdilation was 100%, and 95%, respectively. The 4-year rate of MACEs was 20%: cardiac death in 3 patients (2.7%), target vessel MI in 9 (8.2%), and target lesion revascularization in 20 (18.2%). Definite device thrombosis occurred in 6 of 110 patients (5.5%). One case of very late scaffold thrombosis was observed at 47 months. A small BVS diameter (2.5 mm) was found to be the most powerful independent predictor of a MACE (p=0.05). CONCLUSION: The Absorb BVS was associated with an increased risk of adverse events, including late and very late device thrombosis, despite the use of a good implementation protocol.

Association of vitamin D deficiency with arterial stiffness in newly diagnosed hypertension.

OBJECTIVE: Vitamin D has beneficial effects on vascular endothelial function, blood pressure (BP) and arterial stiffness. Arterial stiffness increases in early-stage hypertensive patients and it is a strong predictor of cardiovascular morbidity and mortality. The purpose of this study was to assess the association between serum 25-hydroxyvitamin D (25-OH D) levels and arterial stiffness in patients with newly diagnosed hypertension. METHOD: Our study included 100 newly diagnosed hypertensive patients (63 male, 37 female and mean age: 51.7 ± 10.3 years) without cardiovascular disease, malignancy, chronic kidney disease and diabetes mellitus. Patients were divided into two groups: vitamin D deficiency group (<20 ng/ml) and normal vitamin D group (≥20 ng/ml). Twenty-four-hour, daytime and nighttime ambulatory BP readings were recorded. Mobil-O-Graph ARC solver algorithm was used to evaluate arterial stiffness parameters of pulse wave velocity (PWV) (m/s), augmentation index normalized with 75/min heart rate (Alx@75). RESULTS: Patients with vitamin D deficency had higher values of Alx@75 and PWV values (20.9 ± 9 vs. 16.8 ± 6.9, P = 0.018 and 8.37 ± 1.16 vs. 6.9 ± 0.9, P = 0.001, respectively) despite similar 24-hour ambulatory BP monitoring in both groups. Level of serum calcium was significantly higher in vitamin D deficiency group (9.5 ± 0.23 vs. 9.3 ± 0.12, P = 0.007). Nighttime SBP was higher in vitamin D deficiency group (133.2 ± 14.3 mmHg vs. 126.3 ± 17.2 mmHg; P = 0.03) and also, vitamin D deficiency group had non-dipping SBP pattern compared to normal Vitamin D group (P = 0.013). CONCLUSION: Vitamin D deficiency is associated with increased arterial stiffness in newly diagnosed hypertensive patients in terms of increased PWV and Alx@75 values.

Outcomes of the novolimus-eluting bioresorbable vascular scaffold in real world clinical practice.

BACKGROUND: Most of the current data regarding the use of bioresorbable scaffolds (BRS) come from everolimus-eluting stent platforms. Adverse events with the everolimus-eluting BRSs which are the most comprehensively characterized BRS, hampered the clinical use of other BRS. There is paucity of published data regarding long term use of novolimus-eluting BRS. METHODS: This study sought to evaluate the performance of novolimus-eluting BRS device at midterm follow-up in real world clinical practice. One hundred and forty-four patients (mean age 57.5±9.7 years, 78.5% male) treated with 206 scaffolds between October 2015 and December 2017 were enrolled. A device-oriented composite endpoint (DOCE) comprising cardiac death, target vessel myocardial infarction (TV-MI), clinically driven target lesion revascularization (TLR) and rate of scaffold thrombosis were investigated. RESULTS: During a mean follow-up of 33±9 months, DOCE occurred in 9 patients (6.3%) of which cardiac death occurred in 2 patients (1.4%), and clinically driven TLR in 7 patients (4.9%), TV-MI in one patient. Target vessel revascularization (TVR) was observed in nine patients. None of the patients experienced scaffold thrombosis. CONCLUSIONS: The use of novolimus-eluting BRS in this real-world population achieved good clinical outcomes.

Cystatin C and uncontrolled hypertension.

OBJECTIVE: Increased serum level of cystatin C, a sensitive biomarker for renal function, seems to predict adverse cardiovascular events. We investigated the predictive value of serum cystatin C for controlling hypertension in an observational study. METHODS: We screened 1037 adults residing in both rural and urban communities. They were grouped based on their diagnosis and control of hypertension. RESULTS: Serum cystatin C levels in patients with uncontrolled hypertension were higher than those in patients with controlled hypertension (0.98±0.23 mg/L vs. 0.89±0.19 mg/L, p=0.001). However, serum creatinine levels were similar between these groups (0.72±0.20 mg/dL vs. 0.70±0.18 mg/dL, p=0.89). Serum cystatin C levels increased the probability of uncontrolled hypertension independent from confounding factors (odds ratio, 1.48; 95% confidence interval, 1.09-5.64; p=0.03). CONCLUSION: Subtle kidney dysfunction may be detected using serum cystatin C concentrations among patients with poor blood pressure control and normal serum creatinine levels.

Long-term comparison of everolimus- vs. novolimus-eluting bioresorbable vascular scaffolds in real world patients.

INTRODUCTION: Elevated risk of adverse events in comparison to metallic stents resulted in withdrawal of everolimus-eluting bioresorbable scaffolds (eBVS), known as the most intensively studied BVS. There is a paucity of data comparing the two different BVS. AIM: To evaluate the long-term clinical outcomes of the novolimus-eluting bioresorbable vascular scaffold (nBVS) compared with eBVS. MATERIAL AND METHODS: Consecutive patients treated with nBVS or eBVS in our center were screened. The primary outcome was the 3-year rate of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, target vessel myocardial infarction (TV-MI), and target-lesion revascularization (TLR). RESULTS: After matching, 98 patients treated with 135 eBVS were compared with 98 patients treated with 136 nBVS. Baseline characteristics, clinical presentation, and lesion characteristics were comparable in both groups. The 3-year MACE rate was higher in the eBVS group (17.3% vs. 6.1%; p log-rank = 0.02). The occurrence of TLR (16.3% vs. 5.1%; p log-rank = 0.02) and TV-MI (8.2% vs. 0 %; p log-rank = 0.004) was also higher in the eBVS group except for cardiac deaths (1% vs. 2%; p log-rank = 0.98, eBVS vs. nBVS, respectively). Of note, definite device thrombosis rate was markedly increased in the eBVS group (5.1% vs. 0%; p log-rank = 0.03). CONCLUSIONS: The present study revealed that the 3-year event risk was lower for nBVS compared to eBVS. More evidence is needed to evaluate long-term performance of novolimus-eluting biovascular platforms.

Relationship between histopathological features of aspirated thrombi and long-term left ventricular function in patients with ST-segment elevation myocardial infarction.

OBJECTIVE: This study was an investigation of the severity of inflammation (SOI) in aspirated material and thrombus age to examine any association with pre-discharge and long-term left ventricular (LV) function after ST-elevation myocardial infarction (STEMI). METHODS: The study group comprised 25 patients with STEMI from whom an occlusive thrombus was aspirated from the infarct-related artery with a 7-F catheter. The SOI in the aspirate was determined according to the mean leukocyte count in 5 high-power magnification fields and graded as mild in the presence of ≤100 leukocytes per field or significant if there were >100 leukocytes per field. The thrombi were categorized as fresh or lytic/organized (L/O) using predefined criteria. Echocardiographic assessment was performed prior to discharge and at 1 year. Adverse left ventricular remodeling (LVR) was defined as a 20% increase in LV end-diastolic volume in comparison with baseline values. RESULTS: LVR was observed in 8 patients. The mean leukocyte count of the aspirate (127.5±86.0 vs 227.2±120.7; p=0.026) and frequency of significant inflammation (35% vs 75% p=0.046) were significantly higher in the group with LVR. The serum high-sensitivity C-reactive protein (hsCRP) level was significantly correlated with the leukocyte count of the aspirate (r=0.532; p=0.006). An L/O thrombus was related to better pre-discharge and long-term LV volumes and ejection fraction values compared with a fresh thrombus. CONCLUSION: A significant increase in the leukocyte count in the aspirate and a fresh thrombus might predict long-term LV functional deterioration irrespective of the clinical and procedure-related characteristics. In addition, serum markers of inflammation, like hsCRP, might also reflect the intensity of the local inflammatory response at the site of occlusion.