A machine learning analysis of predictors of future hypertension in a young population.

BACKGROUND: Early diagnosis of hypertension (HT) is crucial for preventing end-organ damage. This study aims to identify the risk factors for future HT in young individuals through the application of machine learning (ML) models. METHODS: The study included individuals aged 18-40 years who had not been diagnosed with HT through ambulatory blood pressure monitoring (ABPM). These participants were monitored for hypertension diagnosis from the date of ABPM application until the date of data collection. Hypertension prediction was carried out using three distinct ML methods: Support Vector Machine, Random Forest, and Least Absolute Shrinkage and Selection Operator. The identification of variables significant for future HT was based on the outcomes of these models. RESULTS: This study comprised 516 patients, with a mean follow-up duration of 793.4±58.6 days. Following the integration of demographic data, laboratory results, and ABPM findings into the ML models, age, high-density lipoprotein cholesterol, triglycerides, and the standard deviation of systolic blood pressure (SDsis) were identified as predictors for future HT. A logistic regression with the selected variables (age, diabetes mellitus history, HDL, triglycerides, white blood cell count, and SDsis) using the full data set gave the following log odds 0.0737 (P<0.001), 0.7146 (P<0.001), -0.0160 (P=0.071), 0.0026 (P=0.002), 0.0857 (P=0.069), and 0.0850 (P=0.005), respectively. The corresponding probability values of age, diabetes mellitus history, HDL, triglycerides, white blood cell count, and SDsis were 0.5184, 0.6714, 0.4960, 0.5006, 0.5214, and 0.5212, respectively. This indicates a unit increase in all factors, except diabetes mellitus history, increases the probability of future HT by 50%. A history of diabetes, however, increases the probability of future HT by more than two thirds. The history of diabetes mellitus emerged as the most crucial predictor of future HT across all applied methods. CONCLUSIONS: ML methods appear to be valuable tools for predicting future HT. The widespread adoption of these methods and the refinement of more comprehensive models will lay the groundwork for future studies.

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.

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.

Procedural Characteristics, Safety, and Follow-up of Modified Right-Sided Approach for Cardioneuroablation.

BACKGROUND: Cardioneuroablation is one of the emerging therapies in vasovagal syncope. In this study, we present a simple method of cardioneuroablation performed via a rightsided approach, targeting anterior-right and right-inferior ganglionated plexi, along with procedural and follow-up data. METHODS: Patients who had underwent cardioneuroablation between March 2018 and September 2019 with vasovagal syncope in 2 clinics were enrolled in the study. All patients underwent radio-anatomically guided radiofrequency ablation targeting anterior-right ganglionated plexi and right-inferior ganglionated plexi. Syncope and symptom burden, 24-hour ambulatory electrocardiogram data at presentation, and at follow-up were assessed along with procedural data. RESULTS: A total of 23 patients underwent modified right-sided cardioneuroablation. Mean basal cycle length decreased significantly from 862.3 ± 174.5 ms at the beginning of the procedure 695.8 ± 152.1 ms following the final radiofrequency ablation (P < .001). Mean 24-hour ambulatory heart rate increased significantly from 66.4 ± 10.7 bpm at baseline to 80 ± 7.6 bpm at follow-up (P < .001). Only 1 patient had 1 episode of syncope following the procedure at the mean follow-up period of 10 ± 2.9 months. The same patient had recurrent presyncope. CONCLUSION: The right-sided cardioneuroablation approach was found to be an effective treatment for vasovagal syncope and may be regarded as a default initial cardioneuroablation technique.

Long-Term Results of Pulmonary Vein Isolation Plus Modified Posterior Wall Debulking Utilizing High-Power Short-Duration Strategy: An All-Comers Study in Real World.

BACKGROUND: High-power short-duration radiofrequency ablation has improved lesion durability in pulmonary vein isolation. In this study, we investigate long-term clinical out-comes of high-power short-duration pulmonary vein isolation and posterior wall debulk- ing as an initial treatment modality in all corner atrial fibrillation patients. METHODS: This is a single-center, retrospective, observational study including all patients who have undergone high-power short-duration pulmonary vein and posterior wall deb-ulking, regardless of atrial fibrillation type and/or duration. High-power short-duration power delivery protocol was defined as 45 W at all ablation sites. Clinical and electrocar-diographic follow-up were performed in all patients. RESULTS: One hundred forty-two patients were enrolled in this study. Paroxysmal atrial fibrillation was present in 88 (62%) of patients. The mean follow-up of this study was 36.9 months ± 12.2 months. During the follow-up period, 10 patients (11.4%) with a diag- nosis of paroxysmal atrial fibrillation had recurrence, while recurrence in patients with persistent and long-standing persistent atrial fibrillation was slightly higher (15 patients (28.1%) and 5 patients (50%), respectively). No major life-threatening complicationsoccurred. CONCLUSION: This study has demonstrated excellent arrhythmia-free outcomes in unselected, real world atrial fibrillation patients undergoing high-power short-duration pulmonary vein and debulking posterior wall isolations, however larger randomized trials are warranted.

Overview of Current Strategies Aiming at Improving Response to Cardiac Resynchronization Therapy.

Cardiac resynchronization therapy is a treatment modality developed in the early 2000s that targets the mechanical and electrical dyssynchrony in heart failure with reduced ejection fraction patients. Appropriate patient selection conditions specified in the guidelines include measurement of left ventricular systolic dysfunction, QRS width, and assessment of functional classification. Despite consistent and increasing evidence sup-porting the use of cardiac resynchronization therapy in eligible patients, proportion of patients with the device is still not at the desired level. In addition, studies conducted in recent years have shown that the cardiac resynchronization therapy response of patients is quite heterogeneous and in echocardiographic follow-up, it was observed that reverse remodeling was not at the supposed level in approximately one-third of the patients. In order to change this result, which is due to many reasons, solutions such as using assistive imaging methods, providing optimal patient selection, trying different pacing techniques and post-procedural programming strategies (AV-delay and VV-delay optimization) have been the subject of debate. In this article, we aim to review the mechanisms that have been revealed regarding the differences in cardiac resynchronization therapy response and new pacing techniques-especially conduction system pacing-that may be preferred to resolve poor cardiac resynchronization therapy response.

Electrocardiogram parameters for predicting future arrhythmia in patients with stable chronic obstructive pulmonary disease.

Introduction: Arrhythmia is one of the common comorbidities in chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate arrhythmia predictors by using ECG in non-hypoxemic patients with stable COPD in outpatient clinics. Materials and Methods: Fifty patients with COPD and 21 age-sex matched healthy controls were enrolled. Exclusion criteria were having history of exacerbation in the last two months, any cardiac symptoms, comorbidities, hypoxemia for COPD patients, and additionally, history of smoking for healthy controls. Twelve-lead ECGs were obtained from all patients. Result: Mean was 55 ± 4 year in all participants. Median Medical Research Council (MRC) score of COPD patients was 2 and median value of FEV1 was 49%. Median heart rate of COPD patients was 77/min with normal sinus rhythm, significantly faster than healthy controls. P-min, QTcmin, Tp-edisp, Tp-e/QT were significantly different from the control group. In patients with COPD, whilst significant correlations between pulmonary functions and Qtcmin, Qtc-max, p-min were found, there were no significant differences between groups of spirometric stages. Smoking and mMRC dyspnea scale were not correlated with ECG findings. Conclusions: This study showed that non-hypoxemic COPD patients with decreased pulmonary functions, without cardiac symptoms and comorbidities, could have risks for atrial, ventricular arrhythmias regardless of dyspnea, smoking.

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.

The combination of coronary sinus ostial atresia/abnormalities and a small persistent left superior vena cava-Opportunity for left ventricular lead implantation and unrecognized source of thromboembolic stroke.

BACKGROUND: Coronary sinus (CS) ostial atresia/abnormalities prevent access to the CS from the right atrium (RA) for left ventricular (LV) lead implantation. Some patients with CS ostial abnormalities also have a small persistent left superior vena cava (sPLSVC). OBJECTIVE: The purpose of this study was to describe CS ostial abnormalities and sPLSVC as an opportunity for LV lead implantation and unrecognized source of stroke. METHODS: Twenty patients with CS ostial abnormalities and sPLSVC were identified. Clinical information, imaging methods, LV lead implantation techniques, and complications were summarized. RESULTS: Forty percent had at least 1 previously unsuccessful LV lead placement. In 70%, sPLSVC was identified by catheter manipulation and contrast injection in the left brachiocephalic vein, and in 30% by levophase CS venography. In 30%, sPLSVC was associated with drainage from the CS into the left atrium (LA). When associated with CS ostial abnormalities, the sPLSVC diameter averaged 5.6 ± 3 mm. sPLSVC was used for successful LV lead implantation in 90% of cases. In 80%, the LV lead was implanted down sPLSVC, and in 20%, sPLSVC was used to access the CS from the RA. Presumably because of unrecognized drainage from the CS to the LA, 1 patient had a stroke during implantation via sPLSVC. CONCLUSION: When CS ostial abnormalities prevent access to the CS from the RA, sPLSVC can be used to successfully implant LV leads. In some, the CS partially drains into the LA and stroke can occur spontaneously or during lead intervention. It is important to distinguish sPLSVC associated with CS ostial abnormalities from isolated PLSVC.

Approach to recurrence of atrial fibrillation after catheter ablation.

Atrial fibrillation (AF) is the most commonly observed sustained rhythm disorder during adult ages. Since it has been shown that the ectopic beat initiating AF is usually caused by pulmonary veins, AF ablation has become the mainstay of therapy worldwide. Cryoballoon and radiofrequency ablation are the most commonly used methods in today's technologies. However, despite technological advances, the success of a single procedure in AF ablation is still limited and multiple procedures may be required for the majority of patients. In cases in which a redo ablation is required, pulmonary vein isolation is still the main target, but non-pulmonary vein targets should also be considered in AF episodes that continue despite multiple ablations. Many issues are still unclear as to which energy to choose in the first procedure, and what ablation strategy will be utilized when a redo ablation is required. The studies on this subject are very limited but, it still seems feasible and a rational approach to utilize a customized treatment strategy in each specific patient subgroup.

A case report of an acute reversible increase in pacing impedance of a ventricular epicardial lead after catheter ablation of ventricular tachycardia.

Pacemakers are lifesaving devices that are being implanted with various indications, such as sinus node disease, atrioventricular block, and cardiac resynchronization therapy. Impedance measurement is one of the integral tests by which electrical resistance in pacing lead is tested. In this paper, we report an interesting observation of sudden impedance rise after ventricular tachycardia ablation with transmural lesions, which subsequently normalized without any need for intervention. The clinical implication of our findings is that careful observation might be indicated instead of lead replacement in case of a sudden surge in epicardial lead impedance after endocardial ablation owing that the impedance surge might be reversible.

Triple gastrointestinal prophylactic therapy following high-power short-duration posterior left atrial wall ablation.

The purpose of this study is to investigate incidence of gastrointestinal symptoms and complications in patients who underwent high-power short-duration (HPSD), posterior left atrial wall isolation during atrial fibrillation ablation and thereafter have received gastrointestinal prophylactic regimen consisting of sucralfate, proton-pump inhibitor and colchicine. Patients were followed and assessed at baseline, up until 6th month following the procedures.Among 115 patients who were included, 5 patients (4.3%) reported gastrointestinal symptoms at follow-up. No complications were diagnosed during the follow-up. In conclusion, the HPSD along with prophylactic regimen has been associated with low incidence of gastrointestinal adverse events.

Assessment of Myocardial Perfusion by Angiographic Methods in Tortuous Coronary Arteries.

The relationship between coronary tortuosity (CorT) and tissue-level myocardial perfusion is not clear. We investigated tissue perfusion in myocardial territories supplied by tortuous coronary arteries. Among patients who had undergone coronary angiography, patients with reported CorT, those with ≥1 coronary artery were included in the study group (100 patients). The control group included patients with normal coronary arteries (100 patients). Thrombolysis In Myocardial Infarction frame count (TFC) and myocardial blush grade (MBG) were calculated for each coronary artery. Mean TFC was significantly higher in tortuous right coronary artery (RCA), left anterior descending (LAD) artery, and circumflex (Cx) artery compared to their non-tortuous counterparts (28.81 ± 6.463 vs 21.94 ± 3.328, P = .009; 43.28 ± 5.698 vs 36.17 ± 3.875, P = .006; 29.35 ± 4.111 vs 23.821 ± 2.639; P < .001, respectively). Mean MBG was also significantly lower in tortuous RCA, LAD, and Cx, compared to their normal counterparts (2.78 ± 0.417 vs 2.98 ± 0.155, P < .001; 2.74 ± 0.483 vs 2.97 ± 0.164, P < .001; 2.92 ± 0.277 vs 2.99 ± 0.110, P < .001, respectively). For each tortuous coronary artery, TFC was similar for every MBG category. Tortuous coronary arteries have higher TFC and lower MBG, suggesting impaired epicardial and microvascular coronary flow, when compared to normal coronary arteries.

Investigation of leukocyte RHO/ROCK gene expressions in patients with non-valvular atrial fibrillation.

Atrial fibrillation (AF) is an arrhythmia caused by disorganized electrical activity in the atria, and it is an important cause of mortality and morbidity. There is a limited data about Rho/Rho-kinase (ROCK) pathway contribute to AF development. The aim of the present study was to elucidate leukocyte RHO/ROCK gene expressions in patients with non-valvular AF (NVAF). A total of 37 NVAF patients and 47 age and sex-matched controls were included in this study. mRNA was extracted from leukocytes, and real-time polymerase chain reaction was used for gene expression analysis. A marked increase in ROCK1 and ROCK2 gene expressions in patients with NVAF was observed (P<0.0001). The present study detected significant elevations in RHOBTB2, RND3 (RHOE), RHOC, RHOG, RHOH, RAC3, RHOB, RHOD, RHOV, RHOBTB1, RND2, RND1 and RHOJ gene expressions (P<0.01). However, there were marked decreases in CDC42, RAC2, and RHOQ gene expressions in patients with NVAF. No significant modifications were seen in the other Rho GTPase proteins RHOA, RAC1, RHOF, RHOU and RHOBTB3. To the best of our knowledge, the present study is the first to provide data that gene expression of leukocyte RHO/ROCK may contribute to the NVAF pathogenesis through activated leukocytes, which promotes the immune or inflammatory cascade.

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.