The role of inflammatory parameters in the prediction of postoperative delirium in patients undergoing coronary artery bypass grafting.

OBJECTIVE: In this study, we aimed to evaluate the association of pre-operative and early postoperative inflammatory parameters with postoperative delirium in patients operated on for coronary artery bypass grafting. METHODS: The data of 1 279 cardiac surgery patients operated on between June 2014 and March 2020 were analysed retrospectively. Among these, 777 (61.2%) patients operated on for isolated coronary artery bypass grafting surgery with cardiopulmonary bypass were enrolled. Two groups were formed. The patients who developed postoperative delirium were placed in group 1 (n = 187) and the patients with uneventful postoperative follow up (n = 590) were enrolled in group 2. RESULTS: Pre- and early postoperative mean platelet volume, C-reactive protein level, erythrocyte sedimentation rate, platelet- to-lymphocyte ratio and neutrophil-to-lymphocyte ratio were elevated in group 1 (p = 0.0001). The APACHE II score and duration of hospital and intensive care unit stay were significantly elevated in group 1 (p < 0.05). An early-stage neurological event was observed in eight patients (4.3%) in group 1 and 12 patients (2%) in group 2, which was not statistically significantly different between the groups (p = 0.09). In-hospital mortality was observed in three patients (1.6%) in group 1 and five patients (0.8%) in group 2, which did not show a statistically significant difference (p > 0.05). In univariate and multivariate regression analysis, the pre-operative platelet-to-lymphocyte ratio (p = 0.013), mean platelet volume (p = 0.0001) and erythrocyte sedimentation rate (p = 0.002) were determined as independent risk factors for the occurrence of delirium in the early postoperative period. Also, the postoperative platelet-to-lymphocyte ratio (p = 0.0001), neutrophil-to-lymphocyte ratio (p = 0.0001) and erythrocyte sedimentation rate (p = 0.0001) were determined as independent risk factors for the occurrence of delirium in the early postoperative period. CONCLUSIONS: Pre- and early postoperative inflammatory parameters were observed to be predictors of postoperative delirium in patients operated on for coronary artery bypass grafting.

The use of ivabradine in a patient with idiopathic ventricular arrhythmia originating from the left ventricular summit.

Idiopathic ventricular arrhythmias (VA) are common and treatment options include anti-arrhythmic drugs (AAD) or catheter ablation. Patients presenting with idiopathic VA which is originating from the left ventricular summit (LVS) poses a particular challenge as the success for catheter ablation is low and AAD's may not be used long-term due to side effects. Ivabradine is an inhibitor of funny current (If) in cardiac pacemaker cells by blocking hyperpolarization-activated cyclic nucleotide-gated (HCN). In the present case, we reported the use of ivabradine in treatment of idiopathic VA which was originated from LVS and was resistant to multiple AAD's and catheter ablation.

Evaluation of Electrocardiographic Parameters and the Presence of Interatrial Block in Patients with Mad Honey Intoxication.

Mad honey intoxication (MHI) is a food-induced clinical condition that usually presents with cardiovascular symptoms and can lead to life-threatening arrhythmias if not diagnosed and treated early. No data exist in the literature on the presence of interatrial block (IAB) after food intoxication. In our study, we sought to investigate atrioventricular electrocardiography (ECG) parameters and determine the frequency of IAB in patients with MHI. In total, 76 patients diagnosed with MHI were included in our retrospective study. Twelve-lead ECGs were performed and participants were divided into two groups according to the presence of IAB in the reference ECG. The P maximum (Pmax), P minimum (Pmin), P dispersion (Pdisp), T peak to T end (Tp-Te) interval and QT dispersion (QTdisp) values were compared between the two groups. IAB was detected in 28 (35.5%) of 76 MHI patients included in the final analysis. Pmax duration (122 ± 8; p < 0.001) and PD (69 ± 11; p < 0.001) were significantly higher in the IAB ( +) group. During regression analysis, Pmax [odds ratio (OR) 1.158, 95% confidence interval (CI) 1.036-1.294; p = 0.010] and Pd (OR 1.086, 95% CI 1.001-1.017; p = 0.046) were independently associated with IAB. Pmax and Pd area under the receiver operating characteristic curve values for IAB prediction were 0.926 (95% CI 0.841-1,000; p < 0.001) and 0.872 (95% CI 0.765-0.974; p < 0.001), respectively. ECG changes are common in patients presenting with MHI. These patients need to be followed up clinically in terms of progression to arrhythmic events that may occur in the future.

Speckle tracking echocardiography in severe patient-prosthesis mismatch.

BACKGROUND: Although aortic valve replacement (AVR) when successfully performed boasts low mortality rates in selected patients, prosthesis-patient mismatch (PPM) can be found in the majority of these individuals. Limited research is available supporting the benefit of two-dimensional speckle tracking echocardiography (2D-STE) in patients with severe PPM. This study sought to assess myocardial strain using 2D-STE to determine the relationship between subclinical left ventricular (LV) dysfunction and aortic PPM in patients undergoing AVR with preserved LV ejection fraction. MATERIAL AND METHODS: We retrospectively examined all consecutive patients with isolated AVR who presented to our center from 2005 to 2018. The data of 1086 patients were analyzed. Severe PPM was defined as an indexed effective orifice area of 0.65 cm2/m2 or less. As a result of the detailed assessment, 54 patients meeting the eligibility criteria were included in the study. Baseline data were collected and compared between the two groups of patients with severe PPM (n = 27) and those with normofunctional aortic prosthesis valve as a control group (n = 27). All patients underwent baseline echocardiography. Global longitudinal strain (GLS) and global circumferential strain (GCS) were evaluated by 2D-STE. RESULTS: When compared with controls, patients with severe PPM had significantly decreased GLS (18.6 ± 2.9 vs. 21.4 ± 2.1; p < 0.01) and GCS (17.2 ± 3.6 vs. 21.7 ± 2.1; p < 0.01) values. CONCLUSION: In addition to standard clinical and echocardiographic parameters, GLS and GCS suggest subclinical dysfunction and have incremental value in patients with severe PPM.

The association of inflammatory markers and echocardiographic parameters in Behçet's disease.

Background: The main objective of the current study is to find out if any association exists between specific inflammatory markers such as homocysteine (Hcy) and pentraxin-3 (PTX-3) and cardiac involvement determined by means of echocardiographic parameters in patients with Behçet disease (BD).Methods: From January 2011 to January 2012, a total of 62 Behçet's patients were enrolled in the study. Thirty-two healthy subjects constituted the control group. The diagnosis of BD was made as proposed by International Study Group of BD.Results: The mean PTX-3, Hcy, and C-reactive protein levels were significantly higher in patients with BD compared to the control group. The electromechanical delay (EMD) times were found to be prolonged in patients with BD. Also, the aortic stiffness index (SI) and elastic modulus (Ep) were significantly higher, while the aortic dispensibility was significantly lower in patients with BD. The left atrial volume, left atrial volume index, E/A ratio, E/E' septal, IRight-EMD, PA'-ML, PA'-MS, PA'-TL, SI, and Ep were correlated with PTX-3 levels. In addition, the E/A, PA'-ML, PA'-MS, SI, and Ep displayed correlation with Hcy levels in patients having BD.Conclusion: Elevated levels of PTX-3 and Hcy were found to be correlated with cardiac involvement determined by means of echocardiographic parameters in patients with BD.

The predictive value of PRECISE-DAPT score for arrhythmic complications in patients with ST-elevation myocardial infarction.

OBJECTIVE: To investigate the predictive value of the PRECISE-DAPT score for the development of arrhythmias in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. METHOD: A total of 706 patients with a diagnosis of ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were enrolled to the study. The patients were divided into two groups according to the PRECISE-DAPT score (PRECISE-DAPT score ≥25 and PRECISE-DAPT score <25). The patients were compared in terms of in-hospital arrhythmia. RESULTS: High-degree atrioventricular block (second-degree Mobitz II or third-degree atrioventricular block) (17.2% vs. 4.9%; P < 0.001), ventricular tachycardia (11.2% vs. 4.6%; P = 0.005) and atrial fibrillation (13.8% vs. 3.1%; P < 0.001) rates were statistically higher in patients with higher PRECISE-DAPT score (≥25). There was no difference between the groups in terms of ventricular fibrillation (9.5% vs. 8.3%; P = 0.678). In multivariable logistic regression analysis; PRECISE-DAPT Score was independently associated with high-degree atrioventricular block (odds ratio: 6.38, P < 0.001) and atrial fibrillation (odds ratio: 4.33, P < 0.001). CONCLUSION: The PRECISE-DAPT score was associated with high-degree atrioventricular block and atrial fibrillation in patients with ST-segment elevation myocardial infarction underwent percutaneous coronary intervention.

Association of monocyte to high-density lipoprotein ratio with bare-metal stent restenosis in STEMI patients treated with primary PCI.

OBJECTIVE: Monocyte to high-density lipoprotein ratio (MHR) has recently been postulated as a novel parameter related to adverse cardiovascular outcomes. In this study, we aimed to investigate the correlation of MHR with stent restenosis (SR) rates after the primary percutaneous coronary intervention (PCI) and bare-metal stent (BMS) implantation. METHODS: In this study, patients who had undergone primary PCI for STEMI and had a control angiogram during follow-up were retrospectively recruited. Patients were categorized according to admission MHR tertiles, clinical and angiographic data were compared. In addition, predictors of SR were evaluated with logistic regression analysis. RESULTS: A total number of 448 patients (240 patients with SR and 208 patients without SR) were included in this study. Patients were categorized into three groups according to tertiles of admission MHR. During a follow-up period of median 12 months, the rate of SR was significantly higher in patients with higher MHR levels (45% in tertile 1, 54% in tertile 2 and 62% in tertile 3, p<0.01). In multivariate Cox regression analysis, male gender, stent length, admission NLR levels and MHR levels (HR 1.03, 95% CI 1.02-1.06, p<0.01) remained as the independent predictors of SR in the study population. CONCLUSION: Gender, stent length, higher MHR and NLR levels are correlated to SR after primary PCI.

Transient ST-segment elevation due to coronary slow flow during cryoballoon application.

This report is a description of a rare case of transient ST-segment elevation during cryoballoon application for paroxysmal atrial fibrillation (PAF). A 74-year-old male with symptomatic PAF was referred to the center for ablation. During cryoablation of the left superior pulmonary vein (188 seconds, -48°C), ST-segment elevation in the anterolateral leads was observed suddenly, though without any significant complaint. Upon the increase in the ST segment, the cryoapplication was immediately terminated. Coronary artery angiography was performed less than 5 minutes after balloon deflation and demonstrated coronary slow flow with a corrected Thrombolysis In Myocardial Infarction (TIMI) frame count of 48.4 (normal range: 21±3) in the left anterior descending artery (LAD). There was no significant flow-limiting lesion, coronary vasospasm, thromboembolus, or air embolus in any coronary vessel. The TIMI frame count for the right coronary artery and the circumflex artery was normal. The ST-segment elevation gradually returned to the baseline in 14 minutes without any intervention. A control TIMI frame count of the LAD was 22. A decision was made not to repeat the cryoapplication in this vein because there was both an entrance and an exit block. The other 3 pulmonary veins were then isolated uneventfully. The patient was discharged from the hospital the next day without symptoms or unusual electrocardiogram activity.

Catheter Ablation of Bradyarrhythmia: From the Beginning to the Future.

Enhanced parasympathetic tone may cause sinus bradycardia or pauses, transient or permanent atrioventricular block, with resultant vasovagal syncope. A substantial portion of these patients may be highly symptomatic and refractory to the conventional therapies and may require cardiac pacemaker implantation. Cardioneuroablation is a little known technique for management of patients with excessive vagal activation based on radiofrequency catheter ablation of main parasympathetic autonomic ganglia around the heart. Due to complicated inclusion criteria, ganglia detection methods, and ablation endpoints, routine usage of the procedure cannot be recommended at this time. In this comprehensive review, we aimed to discuss all aspects of cardioneuroablation procedure in bradyarrhythmias.

Relation of hemoglobin level to no-reflow in patients with ST-segment elevation myocardial infarction undergoing primary coronary intervention.

INTRODUCTION: The primary goal in the management of acute ST segment elevation myocardial infarction (STEMI) is to open the occluded artery at an early stage. The development of no-reflow is multifactorial, and the etiology is not fully understood. There is accumulating evidence that anemia is related to a series of severe complications in cardiovascular disease (CVD) such as thromboembolic events, bleeding complications, uncontrolled hypertension, and inflammation characterized by elevated levels of inflammatory cytokines. AIM: We investigated the relationship between hemoglobin level and the no-reflow of infarct-related artery (IRA) in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). MATERIAL AND METHODS: A total of 3804 patients with acute STEMI who underwent PPCI were enrolled. The patients were divided into two groups according to thrombolysis in myocardial infarction (TIMI) flow grades after PPCI. Hematological parameters were measured on admission. Univariate and multivariate logistic regression analyses were conducted to assess the association between hemoglobin level and no-reflow. RESULTS: In the current study, 471 (12.4%) patients presented with no-reflow after PPCI. The patients in the no-reflow group had a significantly lower hemoglobin level (12.1 ±1.9 g/dl vs. 13.8 ±1.8 g/dl, p < 0.001). The multivariate logistic regression models revealed that hemoglobin level (OR = 0.564, 95% CI: 0.526-0.605; p < 0.001) was an independent predictor of development of no-reflow. The cutoff value for hemoglobin level was 11.5 g/dl with sensitivity of 83.0% and specificity of 80.0% (AUC = 0.844, 95% CI: 0.821-0.867; p < 0.001). CONCLUSIONS: Our results suggest that hemoglobin level showed a moderate diagnostic performance regarding the prediction of no-reflow in patients with STEMI undergoing PPCI.

Bradyarrhythmia development and permanent pacemaker implantation after cardiac surgery.

OBJECTIVE: Bradyarrhythmia is one of the complications that may develop after cardiac surgery. Only a few studies have previously dealt with this concern, and in our study, we investigated the factors affecting the development of atrioventricular block or sinus node dysfunction and the requirement of permanent pacemaker following cardiac surgery. METHODS: A total of 62 patients who developed the atrioventricular (AV) block or sinus node dysfunction and required a permanent pacemaker following cardiac surgery were included in the study. Among these, 31 patients were evaluated prospectively, and the information regarding 31 patients was evaluated retrospectively based on hospital records. Demographic, clinical, and surgical information was recorded. Patients were grouped according to the types of procedures, including the coronary artery bypass graft, valve surgery, congenital heart disease, and combinations of these. Patients were evaluated by standard 12-lead electrocardiogram and transthoracic echocardiography preoperatively. The postoperative development of bradyarrhythmia and requirement of permanent pacemaker were evaluated. RESULTS: The mean age of patients with preoperative conduction abnormality and wide QRS was statistically significantly higher than those without these disorders. The odds ratio for preoperative conduction abnormality risk in patients over 70 years of age was found as 4.429 (95% confidence interval, 1.40-13.93). There was no gender-related statistically significant difference in terms of left ventricular ejection fraction, left ventricular dilatation, interventricular septum thickness, the time interval from operation to the development of AV block, concomitant diseases, and complication rates. CONCLUSION: Preoperative conduction abnormality and wide QRS in patients over 70 years of age was determined as a risk factor.

Increased levels of red cell distribution width is correlated with presence of left atrial stasis in patients with non-valvular atrial fibrillation.

OBJECTIVE: Red cell distribution width (RDW) and neutrophil to lymphocyte ratio (NLR) have been found to be associated with non-valvular atrial fibrillation (AF) and cardiovascular diseases. However, correlation of these parameters with presence of left atrial (LA) thrombus and/or spontaneous echo contrast (SEC) in patients with non-valvular AF has not been clarified. This study was an investigation of correlation of RDW, NLR, and clinical risk factors with LA thrombus and dense SEC in patients with non-valvular AF in the Turkish population. METHODS: The demographic, laboratory, and echocardiographic properties of 619 non-valvular AF patients who underwent transesophageal echocardiography (TEE) examination before direct current cardioversion (DCCV) or AF ablation treatment were retrospectively investigated. Complete blood count (CBC) and biochemical parameters were studied 6 to 12 hours before TEE examination. Left atrial stasis (LAS) markers were noted as presence of left atrial/left atrial appendage (LA/LAA) thrombus or dense spontaneous echo contrast (DSEC). RESULTS: Total of 325 (52%) patients with LAS were compared with 294 patients (48%) without LAS. In the LAS group, there were 274 (84%) patients with LA/LAA thrombus and 51 (16%) patients with DSEC. LAS (+) group, values for RDW (14.85±1.48 vs. 13.77±1.30; p<0.01), NLR (2.38 [1.58], vs. 2.10 [1.35]; p<0.01) and C-reactive protein (0.95 [0.61] vs. 0.88 [0.60] mg/L; p<0.01) were significantly higher than seen in LAS (-) group. In multivariate regression analysis, increased level of RDW, age, male gender, heart failure, duration of AF >6 months, and international normalized ratio <2 were independently correlated with presence of LAS. CONCLUSION: Our study indicated that increased level of RDW is independently correlated with higher risk for development of LAS in patients with non-valvular AF.

Renal sympathetic denervation assisted treatment of electrical storm due to polymorphic ventricular tachycardia in a patient with cathecolaminergic polymorphic ventricular tachycardia.

Electrical storm (ES) is not a rare clinical entity. Sympathetic hyperactivity may play critical role in development and continuation of ES. Some recent reports have demonstrated that catheter-based renal sympathetic denervation (RSD) may reduce sympathetic activation and have a potential role in reducing arrhythmic burden. A 46-year-old man was admitted to clinic with frequent implantable cardioverter defibrillator shocks and ES related to catecholaminergic polymorphic ventricular tachycardia (VT). Tachycardia was unresponsive to administration of beta-blockers, verapamil, and flecainide. Catheter ablation failed to suppress initial premature ventricular contractions. Based on aggravating effects of sympathetic system in clinical tachycardia, decision was made to perform RSD. After the procedure, sinus rhythm was achieved and no polymorphic VT was detected. Sustained monomorphic VT with right ventricular origin was successfully ablated via endocardial radiofrequency ablation. This new treatment modality may be a potential alternative method for patients in whom other ablative strategies have been unsuccessful.

Cardioneuroablation in the treatment of neurally mediated reflex syncope: a review of the current literature.

OBJECTIVE: An imbalance between parasympathetic and sympathetic tone is a main cause of neurally mediated reflex syncope (NMRS). These patients may be very symptomatic and the condition may require cardiac pacemaker implantation. Cardioneuroablation (CNA) is a relatively novel technique based on radiofrequency ablation of vagal ganglia that can be used in treatment of NMRS. The aim of this analysis was to compare potential role of CNA in patients with NMRS. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, literature search was conducted using the keywords "cardioneuroablation," "vagal denervation," "reflex syncope," "vagal ablation," and "ganglionic plexi ablation." Retrieved citations were first screened independently by 2 reviewers for inclusion and exclusion criteria. RESULTS: Freedom from syncope and freedom from prodrome were 100% and between 50% and 100%, respectively, in the studies. Ablation was performed via both atria in 3 studies; only left atrial approach was used in the remaining studies. There was no major complication related to the procedure reported. CONCLUSION: Focused or extensive vagal ganglia ablation may be a potential alternative to pacemaker implantation in a carefully selected patient population. In contrast to pharmacological therapy and pacemaker implantation, ganglia ablation is designed to get to the root of the problem: disturbances in the intrinsic cardiac autonomic nervous system. This novel technique should be evaluated in large-scale, randomized, controlled trials.

Endocardial septal ablation for hypertrophic obstructive cardiomyopathy.

Septal reduction therapy (SRT) is the accepted therapeutic option for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). At this time, surgical septal myectomy is the gold standard method, but alcohol septal ablation is an acceptable alternative treatment for patients with suitable anatomy. Endocardial septal ablation (ESA) therapy is a little-known method of SRT. Presently described is case of successful ESA procedure performed for HOCM.

A Novel Deep Inspiration Maneuver for Difficult Transseptal Puncture.

Transseptal puncture (TSP) may not be possible in cases of an elastic, aneurysmal, or thickened interatrial septum (IAS). During deep inspiration (DI), the chest wall expands and the diaphragm descends. This makes intrapleural pressure to become more negative, which leads to movement of the IAS to the right side. The aim of this study was to verify prospectively the feasibility, safety, and outcome of DI associated with conventional TSP technique in patients with challenging IAS anatomy. From September 2012 to May 2016, 224 patients underwent TSP due to different indications. Patients were divided into 2 groups: 213 patients in whom the left atrium was successfully accessed in 3 attempts were grouped as conventional TSP group and 11 patients in whom left atrium access was failed after 3 conventional attempts were grouped as DI-TSP group. Conventional TSP was successful in 89.6% of patients with the first attempt. Second and third attempts were required in 4.1% and 1.4%, respectively. Septal puncture was achieved at the first attempt in 10 patients within a median of 1 second of DI maneuver (interquartile range, 1 to 3) and without any complications. Challenging IAS anatomy consisting of IAS aneurysm, a thick IAS, and an excessively mobile IAS were more frequent in the DI-TSP group (45% to 8%, 27% to 3%, and 21% to 5%, respectively, p <0.001). In conclusion, TSP by using the DI maneuver may be a reliable and safe method after failed conventional attempts. If there is any doubt about the correct location of the needle, additional imaging modalities have to be used.

Role of endocardial septal ablation in the treatment of hypertrophic obstructive cardiomyopathy.

Septal reduction therapy is accepted as a first therapeutic option for symptomatic drug-resistant hypertrophic obstructive cardiomyopathy (HOCM). Although, surgical septal myectomy is the gold standard method, alcohol septal ablation is a well-studied alternative approach in the patients with suitable anatomy. Endocardial septal ablation (ESA) therapy was relatively new defined modality and outcomes of the procedure were not clearly elucidated yet. We aimed to review the clinical aspects of ESA procedure and provide some historical background.

Association of contrast-induced nephropathy with bare metal stent restenosis in STEMI patients treated with primary PCI.

BACKGROUND: Contrast induced nephropathy (CIN) has been proven as a clinical condition related to adverse cardiovascular outcomes. However, relationship between CIN and stent restenosis (SR) remains unclear. In this study, we aimed to investigate the association of CIN with SR rates after primary percutaneous coronary intervention (PCI) and bare metal stent (BMS) implantation. METHODS: A total number of 3225 patients who had undergone primary PCI for STEMI were retrospectively recruited. The medical reports of subjects were searched to find whether the patients had a control coronary angiogram (CAG) and 587 patients with control CAG were included in the study. The laboratory parameters of 587 patients were recorded and patients who developed CIN after primary PCI were defined. Contrast induced nephropathy was defined as either a 25% increase in serum creatinine from baseline or 0.5 mg/dL increase in absolute value, within 72 h of intravenous contrast administration. RESULTS: The duration between primary PCI and control CAG was median 12 months [8-24 months]. The rate of SR was significantly higher in CIN (+) group compared to CIN (-) group (64% vs. 46%, p < 0.01). In multivariate Cox regression analysis, male gender, stent length, admission WBC levels and presence of CIN (HR 1.39, 95% CI 1.06-1.82, p < 0.01) remained as the independent predictors of SR in the study population. CONCLUSION: Gender, stent length, higher serum WBC levels and presence of CIN are independently correlated with SR in STEMI patients treated with BMS implantation.