Bipolar radiofrequency ablation between middle cardiac vein and left ventricular endocardium for intramural ventricular tachycardia originating from the left ventricular inferobasal septum.

Ventricular tachycardia ablation in the post-surgical patients is complicated by difficult epicardial access. Endocardial-only ablation may lead to failure which can be prevented by mapping and ablating inside the coronary venous system. Radiofrequency ablation inside the coronary venous system is dependent on anatomical and biophysical factors. Herein we report a ventricular tachycardia case necessitating bipolar ablation between the middle cardiac vein and the left ventricular endocardium.

Late elimination of challenging idiopathic ventricular arrhythmias originating from left ventricular summit by anatomical ablation.

Ablation of premature ventricular complexes (PVCs) originating from left ventricular outflow tract (LVOT)/left ventricular summit (LVS) is challenging with considerable rate of failure. Recently, in a novel approach to ablation of these arrythmias, application of radiofrequency energy to anatomically opposite sites of presumed origin of arrythmia, has been associated with moderate procedure success. Although late elimination of PVCs that are persistent following an ablation procedure has been previously reported, this observation has not been studied sufficiently. In this report, firstly, we present three cases of lately eliminated LVS PVCs, then, we discuss possible mechanism of this observation and conclude that after an initial failed attempt of anatomic ablation, operators may choose a period of watchful waiting before attempting a redo procedure.

Percutaneous transapical approach and transcatheter closure for ventricular tachycardia ablation.

In patients with mechanical aortic and mitral valve prosthesis, left ventricular endocardial ablation via retrograde transaortic or antegrade transmitral approach carry high risk of catheter entrapment and death. In such cases, ablation can be performed via ventricular transseptal or transapical approach. Transapical approach, with the ease of catheter maneuverability and better endocardial contact, may be performed surgically or percutaneously. In this case report, we describe a patient with both aortic and mitral mechanical prosthesis who underwent ventricular tachycardia ablation via percutaneous transapical endocardial approach with the use of closure device.

Extrathoracic subclavian-axillary vein location and morphological features over the first rib for pacemaker and defibrillator lead implantation.

BACKGROUND: We aimed to describe the variations of extrathoracic subclavian-axillary vein location and its morphology over the first rib by venography in order to facilitate venous puncture using fluoroscopic landmarks without contrast venography, and evaluate the success rate of punctures, which is made with our method. METHODS: Patients who had undergone de novo lead implantation with the help of prepuncture venography between 2011 and 2015 were enrolled. For detection of the segmental location of the axillary vein, the zones were defined (Zone 1: Posterior, Zone 2: Lateral, Zone 3: Medial) at the first rib by fluoroscopy. Additionally, patients, who underwent venous puncture with our method after January 2017, were evaluated in terms of puncture success. RESULTS: Four hundred thirty-three patients who had prepuncture contrast venography for defibrillator or pacemaker lead implantation in 2011-2015 were analyzed. The most common position of the axillary vein was found to be over zone 2 (91%) while the zone 1 location was 8.5% and the zone 3 was 0.5%. Venous valves were detected on the first rib in 98 patients. After January 2017, venous puncture using fluoroscopic landmarks was performed to 171 patients. The punctures were successfully performed over zone 2 with our method in 90.7% of the patients. CONCLUSIONS: The most common radioanatomic position of the extrathoracic subclavian-axillary vein was observed at zone 2 according to our method and the probability of presence of venous valve over the first rib is 22%. Additionally, the success rate of puncture using fluoroscopic landmarks over zone 2 was 90.7%.

Effect of radiofrequency on epicardial myocardium after ablation of ventricular arrhythmias from within coronary sinus.

BACKGROUND: Radiofrequency (RF) ablation of idiopathic ventricular arrhythmias (IVA) from the coronary venous system (CVS) has been increasingly performed, but real effect of ablation lesions from CVS on epicardial myocardium has not been studied. OBJECTIVE: To compare effects of RF delivered inside the distal CVS during ablation of IVAs originating from left ventricular summit (LVS) with IVAs ablated from right ventricular outflow tract (RVOT) using cardiac magnetic resonance imaging (CMRI). METHODS: Twenty consecutive patients with IVAs who underwent acutely successful RF ablation at initial appropriate sites, i.e., distal CVS (Group 1, n = 10) or RVOT (Group 2; n = 10) were enrolled. Detailed contrast-enhanced CMRI of each patient was performed 3 months later. Presence and location of scars, distance of CVS to epicardial ventricular myocardium were measured and analyzed. RESULTS: Group 1 consisted of 10 and Group 2 consisted of 10 patients. Three months after the ablation, only three patients in Group 1 had detectable late gadolinium enhancement (LGE) on CMRI while nine out of 10 patients in Group 2 had evident LGE on CMRI (P: 0.02). The mean distance of distal CVS to epicardial anterobasal myocardium was measured to be 8.8 ± 1.6 mm in Group 1. In three cases that had detectable scar on superior anterobasal LV epicardium, the mean distance was 7.4 ± 1.1 mm. CONCLUSIONS: RF delivery inside the CVS is less likely to produce detectable LGE on CMRI compared to RVOT. This may partially explain less than ideal long-term results after ablation of LVS IVAs from within the great cardiac vein/anterior interventricular vein.

[Implantation of a biventricular ICD in a patient with dextrocardia with situs inversus]. / Dekstrokardi ve situs inversus bulunan bir hastada biventriküler ICD yerlestirilmesi.

In order to reduce sudden cardiac death and heart failure symptoms, biventricular implantable cardioverter defibrillator (ICD) implantation is a treatment method commonly used in selected patients with cardiomyopathy. The frequency of dextrocardia in congenital heart defects is approximately 0.4/10000. In this group, the frequency of cardiomyopathy development is rare. In this case report we present a patient with dextrocardia undergoing implantation of biventricular ICD.

Taming the Tiger: Partial Input Block Results in a Stable, Organized Coronary Sinus Activation During Atrial Fibrillation.

In this manuscript, we present a case where coronary sinus activation was organized and stable despite the rhythm being atrial fibrillation. We discuss the possible mechanisms of this rare occurrence.

Peroxisome proliferator activated receptor (PPAR)-gamma concentrations in childhood obesity.

BACKGROUND: Peroxisome proliferator-activated receptors (PPARs) are nuclear proteins that regulate transcriptional responses to peroxisome proliferators. There has been limited research concerned with the childhood expression of these receptors. In this study, we aimed to evaluate PPAR-gamma (PPAR-γ) concentrations and their relationship to body mass index (BMI), ratio of waist and hip, blood pressure levels, insulin resistance and lipid profile in obese children and adolescents. SUBJECTS AND METHODS: Children aged 8-16 years old were included in the study; 44 obese children and 25 healthy children were taken into the study. Blood pressure and waist-hip circumference of obese patients were measured. Following a 12-hour nighttime fasting, venous blood samples were taken, including blood glucose, insulin, lipid profile, liver function tests and PPAR-γ concentrations, and all samples were analyzed at the same time. FINDINGS: PPAR-γ concentrations were 0.226 + 0.128 in obese children and 0.547 + 0.546 in the control group. PPAR-γ concentrations were lower in obese children and this difference was statistically significant (p = 0.008). PPAR-γ concentrations of control children were 2.42-fold higher than obese children. There was a negative correlation between PPAR-γ concentrations and waist circumference, and a positive correlation between birth weight and PPAR-γ concentrations in obese children. CONCLUSION: In our study we found that PPAR-γ concentrations were low in obese children. In adults, treatment modalities aimed at enhancing the activation of PPAR in obesity lead to a decrease in obesity, insulin resistance, dyslipidemia and cardiovascular disease and this gives hope that similar treatment modalities can be used for children.

Cardioneuroablation for carotid sinus syndrome mediated by complete atrioventricular block.

Carotid sinus syndrome (CSS) is a rare condition leading to recurrent syncope. Permanent pacemaker implantation is the mainstay treatment of cardioinhibitory CSS. In this report, we present a CSS patient with reproducible atrioventricular block during carotid massage, who was treated with cardioneuroablation.

Electrophysiological characteristics of epicardial atrial tachycardias and endocardial breakthrough site targeting for ablation: a single center experience.

BACKGROUND: Despite being increasingly observed in daily practice, epicardial atrial tachycardias (Epi AT) have not been extensively characterized. In the present study, we retrospectively characterize electrophysiological properties, electroanatomic ablation targeting, and outcomes of this ablation strategy. METHODS: Patients who underwent scar-based macro-reentrant left atrial tachycardia mapping and ablation patients with at least one Epi AT, which had a complete endocardial map, were selected for the inclusion. Based on current electroanatomical knowledge, Epi ATs were classified based by utilization of following epicardial structures: Bachmann's bundle, septopulmonary bundle, vein of Marshall. Endocardial breakthrough (EB) sites were analyzed as well as entrainment parameters. EB site was targeted for initial ablation. RESULTS: Among seventy-eight patients undergoing scar-based macro-reentrant left atrial tachycardia ablation, fourteen (17.8%) patients met the inclusion criteria for Epi AT and were included in the study. Sixteen Epi ATs were mapped, four utilizing Bachmann's bundle, five utilizing septopulmonary bundle, and seven utilizing vein of Marshall. Fractionated, low amplitude signals were present at EB sites. Rf terminated the tachycardia in ten patients; activation changed in five patients and in one patient atrial fibrillation ensued. During the follow-up, there were three recurrences. CONCLUSIONS: Epicardial left atrial tachycardias are a distinct type of macro-reentrant tachycardias that can be characterized by activation and entrainment mapping, without need for epicardial access. Endocardial breakthrough site ablation reliably terminates these tachycardias with good long-term success.

Stepwise mapping and ablation algorithm in patients undergoing ablation of unstable, unmappable scar-based atrial tachycardias.

BACKGROUND: Scar based atrial tachycardia (AT)'s usually presents with a complex electrophysiological substrate. It is not uncommon that multiple instable ATs are present in a single patient. The aim of this study was to analyze clinical and electrophysiological characteristics of patients who had undergone ablation for instable ATs, and report outcomes of the stepwise substrate ablation procedure during the follow-up. METHODS: Patients scheduled to undergo AT ablation were screened for enrollment to the study. When instable ATs were diagnosed a stepwise mapping and ablation algorithm was applied to all patients. After the procedure, patients were clinically and electrocardiographically followed. RESULTS: Twenty-six patients were enrolled in the study. The mean number of ATs observed during the procedures is 3.1±0.7. At the end of the procedure, 18 (69.2%) patients had isolated posterior wall. Anterior mitral line ablation was successfully performed in 13 (50%), mitral isthmus line in 4 (15.4%), roof line in 4 (15.4%) patients. The mean follow-up was 13.5±5.4 months. During the follow-up period 6(23.1%) patients developed arrhythmia recurrence. CONCLUSIONS: A reasonable mid-term success can be expected in patients with instable ATs undergoing ablation according to the stepwise substrate modification algorithm, however due to extensive ablation it should be reserved for patients where conventional activation mapping cannot be performed.

Long-term follow-up of patients undergoing add-on pacing/sensing lead vs. ICD lead implantation for failed IS-1/DF-1 ICD leads: a single centre experience.

BACKGROUND: Intracardiac defibrillator/cardioverter (ICD) is a cornerstone device for prevention of sudden cardiac death. Lead failure (LF) is one of the most important long-term complications. In this study, we sought to investigate mid-to-long term clinical, device and lead characteristics of patients who have undergone pacing sensing lead (PSL) implantation for an ICD LF and compare them to the patients who have undergone a new ICD lead implantation. METHODS: In this retrospective, single centre, case-control study, we have screened all ICD patients presenting with LF. Patients with IS-1/DF-1 ICD leads with intact high-voltage conductor were included in the study group, while other patients were included in the control arm. Study group patients underwent PSL implantation, control group patients underwent ICD lead implantation. RESULTS: Thirty patients were included in each arm of the study. The mean duration of follow-up after intervention was similar in both groups (47.6 months ± 20.4 vs. 46.1 months ± 25.7, p = .808). The total failure rate was not different between two groups (p = .640). Rate of high-voltage conductor disfunction was also similar between two arms: 1 (3.3%) in PSL arm and 0 in control arm (p = .303). CONCLUSIONS: Addition of a PSL for IS-1/DF-1 ICD LF with normal high-voltage conductor measurements is a viable treatment option with similar long-term results to addition of a new ICD lead. This approach is potentially less costly, technically less demanding, and, in case of concomitant extraction procedure, associated with less acute complication risk.

Effect of hypertension on coronary remodeling patterns in angiographically normal or minimally atherosclerotic coronary arteries: an intravascular ultrasound study.

Whether there is any particular role of hypertension in remodeling process has not been completely understood yet. The aim of this study was to assess the association between hypertension and remodeling patterns in normal or minimally atherosclerotic coronary arteries. Seventy-nine patients who were free of significant coronary atherosclerosis were divided into two groups according to the absence (n = 39) or presence (n = 40) of hypertension; and standard intravascular ultrasound examination was performed in 145 segments. To determine the remodeling pattern in early atherosclerotic process, patients were also analyzed according to the level of plaque burden at the lesion site after the analysis of remodeling patterns. Positive remodeling was more prevalent in the hypertensive group (52.5% vs. 12.8%; P < .001) whereas negative remodeling was more common in diabetic patients (53.6% vs. 27.4%; P = .03). Mean remodeling index was 1.04 for hypertensives and 0.96 for normotensives (P = .03). There were no correlations between remodeling patterns and other risk factors such as age, family history, and hypercholesterolemia. Early atherosclerotic lesions (< 30%) exhibited more negative remodeling characteristics while intermediate pattern was observed more frequently in patients with high plaque burden (P = .006 and .02, respectively). Positive remodeling showed no association in this context (P = .07). This study demonstrated that minimal atherosclerotic lesions in hypertensives had a tendency for compensatory arterial enlargement. Positive remodeling may result from local adaptive processes within vessel wall or hemodynamic effects of blood pressure itself.

Relationship between left atrial scar and P wave dispersion in patients undergoing atrial fibrillation catheter ablation.

BACKGROUND: Left atrial scar is an important entity in the atrial fibrillation substrate. P wave dispersion (PWD) is an indicator of slow and inhomogeneous conduction in the atria. In this study, we aim to investigate the relation between PWD and left atrial scars identified by electroanatomical mapping. METHODS: Patients who had an electroanatomical map obtained during sinus rhythm as well as at least one electrocardiogram in sinus rhythm prior to the procedure were included in the study. Left atrial scar (defined as <0.5 mV) area was calculated on the electroanatomical map. Maximum and minimum P wave duration and PWD were compared between patients with and without left atrial scar. RESULTS: A total of 224 patients were enrolled in the study. Of them, 47.9% of the patients were female. On the electroanatomical map, left atrial scar was identified in 103 patients, and no scar was present in 121 patients. PWD was significantly increased in patients with left atrial scar when compared to the no-scar group (46 ms ± 20 vs. 38 ms ± 15, respectively, p < 0.001). Similarly, PWD was significantly increased in patients with moderate-to-severe scar, when compared to patients with mild scar (50 ms ± 19 vs. 41 ms ± 19, respectively, p = 0.026). PWD was found not to be a good predictor of left atrial scar with an AUC of 0.625 for scar vs. no scar. CONCLUSION: PWD is significantly increased in patients with left atrial scar identified by electroanatomical mapping, however, the receiver operating characteristic analysis showed that PWD is not a good predictor of presence of left atrial scar.

Demographic, clinical and mutational characteristics of Turkish familial Mediterranean fever patients: results of a single center in Central Anatolia.

Clinical and genetic findings of familial Mediterranean fever (FMF) may be variable in different populations. Environmental factors may also affect phenotypic features of FMF. In this study, we investigated demographic, clinical and mutational features of FMF patients who were treated in a single reference hospital in Turkey. Two hundred and sixty patients (169 females, 91 males, mean age 30.44 +/- 10.29 years) were included in this study. All patients were evaluated regarding MEFV gene mutations. The mean age of disease onset was 17.21 +/- 8.66 years (range 2-40 years). The mean duration between the disease onset and diagnosis was 9.39 +/- 8.92 years. Seventy percent of patients had symptoms before 20 years of age (early onset FMF). Arthritis and erysipelas like erythema (ELE) were more common, and the mean duration between the disease onset and diagnosis was longer in early onset FMF patients. The frequency of attacks per year, and disease severity score (DSS) was higher in early onset patients. Homozygote mutation of M694V was detected in 37 (20.2%) and 4 (5.2%) patients in early onset FMF and adult onset FMF groups, respectively (p < 0.05). Histological diagnosis of amyloidosis was established in 7 patients (2.7%). The age of disease onset was earlier, and arthritis and ELE were more frequent, and DSS was higher in patients with M694V/M694V mutation. In conclusion, mean delay to diagnosis in our FMF population is quite high. Early and adult onset forms may differ regarding some clinical, molecular and prognostic characteristics. Disease activity was higher in patients with homozygote mutation of M694V.

Association between Demodex folliculorum and Metabolic Syndrome.

BACKGROUND: Demodex folliculorum mite infestation is associated with many diseases such as rosacea, pityriasis found with acne vulgaris, and blepharitis. AIM: In this research, the aim of this study was to investigate an association between patients who have metabolic syndrome and presence of Demodex folliculorum. PATIENTS/METHODS: This research was planned prospectively as a case-control study. Fifty cases who have metabolic syndrome and 50 control subjects in good health were included. Metabolic syndrome was diagnosed according to the NCEP Adult Treatment Panel III criteria. Standard superficial skin biopsy was performed for the presence of Demodex folliculorum mite infestation. RESULTS: It was detected that number of Demodex affected from the glucose level and each increase in glucose level cause an increase on Demodex as 0.190 (P = .00, t = 4.746, B = 0.190, r = 0.57, Durbin-Watson = 1.801, confidence interval = 0.110 to 0.271 (for glucose)). CONCLUSION: In this study, the presence of Demodex folliculorum was found to be higher in the cases who have metabolic syndrome compared to the healthy group. These results show that in cases with metabolic syndrome, high blood sugar levels make them more susceptible to infestation of Demodex folliculorum.

Facilitation of radial artery cannulation by periradial subcutaneous administration of nitroglycerin.

PURPOSE: To determine whether subcutaneous administration of nitroglycerin mixed with local anesthetic agent results in effective vasodilation of the radial artery, and whether this technique improves access time and decreases complications. MATERIALS AND METHODS: This prospective study consisted of two consecutive investigations. In the first (n = 30), only local anesthetic agent (prilocaine 2%) was injected into one arm, and local anesthetic agent plus 500 microg nitroglycerin was injected into the other arm. Radial artery diameters before and after injections were measured by ultrasonography. In the second, 33 patients received local anesthetic agent (prilocaine 2%) plus 500 microg nitroglycerin (group A) and 30 received only local anesthetic agent (group B) to determine whether the addition of nitroglycerin would improve radial artery access time, duration of angiography, perception of arterial pulse (ie, pulse score), number of punctures before successful cannulation, and complication rates. RESULTS: In the first investigation, radial artery diameter increased significantly in the nitroglycerin-treated arm (2.3 mm +/- 0.4 vs 2.9 mm +/- 0.5; P = .05). In the second, there were no significant differences between groups with respect to age, sex, duration of angiography, and number of punctures before cannulation. However, the pulse score increased and radial artery access time improved significantly after addition of nitroglycerin (79% vs 10% [P < .001] and 75 sec +/- 47 vs 132 sec +/- 100 [P = .005], respectively). Radial artery spasm and thrombosis were less frequently observed in group A, albeit to an insignificant extent (P = .39 and P = .49, respectively). CONCLUSIONS: Subcutaneous administration of nitroglycerin significantly increased radial artery diameter, which can lead to facilitation of catheterization of the radial artery for arteriography and interventions.

Changing patterns of patient characteristics in the cath lab from 1998 to 2006: a single-centre retrospective analysis.

BACKGROUND: There are few data on the change in the profile of cath lab patients over long time intervals. METHODS: We retrospectively analysed our cath lab records, patient charts, in terms of demographic variables, clinical and laboratory characteristics in a thousand patients (499 patients in 1998 January-March, 501 patients in 2006 January-March). RESULTS: Mean age was significantly higher in the 2006 cohort (57.5 +/- 11 vs. 62.2 +/- 10.8, P < 0.001). Gender was similar in both cohorts (men 68.5% vs. women 69.9%, P = 0.65). Both hypertension and diabetes mellitus were more prevalent in the 2006 cohort (613% vs. 49.3 and 30.3 vs. 17.6 respectively, P < 0.001 for both). Smoking rates (past or active) did not differ between the cohorts. Rates of normal or near normal coronary angiograms were somewhat elevated in both cohorts (36.7% in 1998 and 39.1% in 2006). Rates of multivessel disease (2-3 vessel disease) tended to increase and rates of single-vessel disease tended to decrease from the 1998 cohort to the 2006 cohort (27.7% to 34.4% and 35.7% to 26.7%, P = 0.006). The number of percutaneous coronary interventions (PCI) performed increased with a borderline statistical significance in the 2006 cohort (32% vs. 38.5%, P = 0.053). CONCLUSIONS: Our data indicates that today interventional cardiologists face an older and more severely diseased cath lab patient population compared with a decade earlier. In comparison with 1998, more PCIs were performed.