Long-term Outcomes of Cryoballoon-based Empirical Superior Vena Cava Isolation in Addition to Pulmonary Vein Isolation in Persistent Atrial Fibrillation.

BACKGROUND: Superior vena cava (SVC) is atrial fibrillation (AF)'s most common non-pulmonary vein (PV) foci. Studies reported conflictory results when SVC isolation (SVCi) was combined with PVi and long-term outcomes were lacking. Therefore, we aimed to evaluate the long-term efficacy and safety of empirical SVCi as an adjunct to cryoballoon-based PV isolation (PVi) in persistent AF ablation. METHODS: A total of 40 consecutive persistent AF patients (60.6 ± 8.2 years, 52.5% females) who underwent SVCi in addition to PVi compared with a propensity score matched cohort of 40 persistent AF patients (58.6 ± 8.7 years, 50% female) in whom PVi-only was performed. Second-generation cryoballoon (CB2) was used in all procedures. Atrial tachyarrhythmia (ATa) recurrence was defined as the detection of AF, atrial flutter, or atrial tachycardia (≥30 s) after a 3-month blanking period. RESULTS: Pulmonary veins and SVC were successfully isolated in all patients. At a mean of 46.7 ± 7.8 months follow-up, 22 (55%) patients in the PVi-only group, and 27 (67.5%) patients in the PVi + SVCi group were free of ATa after the index procedure (P =.359). Phrenic nerve injury (PNI) was detected in 2 (5%) patients in the PVi-only group (during right PVi) and 2 (5%) patients in the PVi + SVCi group (during SVCi) (P = 1.00). Cox regression analysis revealed that early recurrence was the only predictor of recurrence (hazard ratio 4.88, 95% confidence interval 1.59-14.96; P =.005). CONCLUSION: Long-term results of our small sample-sized study revealed that CB-based PVi + SVCi was associated with outcomes similar to the PVi-only strategy in patients with persistent AF. Although complication rates were similar between the groups, close follow-up of diaphragmatic movement is crucial to prevent PNI during SVCi.

A Challenging Case of Viral Pneumonia in the COVID-19 Pandemic Era.

Cytomegalovirus (CMV) is a DNA virus that can cause widespread, severe infection in immunocompromised patients. While CMV usually leads to a subclinical infection in immunocompetent individuals, it can rarely cause severe disease in this population. The SARS-CoV-2 virus is an RNA virus and part of the Coronaviridae family. SARS-CoV-2 led to the COVID-19 (coronavirus disease 2019) pandemic. Even though COVID-19 usually presents with signs and symptoms of upper respiratory tract infection in younger adults, viral pneumonia, cytopenia, and neurological symptoms become more apparent with increasing age. Herein, we describe an immunocompetent 73-year-old female patient in whom oxygen demand and pancytopenia developed during hospitalization for post-ablation inguinal access site infection. The thorax CT revealed viral pneumonia, but two subsequent SARS-CoV-2 polymerase chain reaction (PCR) tests and a viral respiratory multiplex PCR panel were negative. The CMV viral load was high in the blood sample, and the patient responded to valganciclovir treatment. Although SARS-CoV-2 should be evaluated in patients with viral pneumonia and cytopenia, other viral etiologies mimicking SARS-CoV-2 infection, such as CMV, should not be overlooked in the era of the COVID-19 pandemic.

Telmisartan-Induced Myotoxicity in Patients with Essential Hypertension.

Drug-related muscular adverse effects are relatively common among certain groups of drugs, such as statins and steroids. However, these adverse effects are less well-known for angiotensin receptor blockers (ARBs). It is proposed that telmisartan and irbesartan may cause myotoxicity via increased Peroxisome Proliferator-Activated Receptor gamma (PPAR-gamma) activity. Herein, we present two hypertensive patients in whom telmisartan-induced myotoxicity was observed. Therefore, physicians should be aware that telmisartan, along with some other ARBs, can also cause myopathy. Possible drug-drug interactions should be considered in cases of concomitant prescription of these agents with other myopathic drugs.

Real-World Data on the Incidence of Stroke, Myocardial Infarction, and Mortality Among Nonvalvular Atrial Fibrillation Patients in Türkiye: New Oral Anticoagulants-TURKey Study.

BACKGROUND: Atrial fibrillation (AF) is strongly associated with an increased risk of ischemic events. Anticoagulation focuses on reducing the risk of embolism. Guideline recommended CHA2DS2-VASc scoring system is most widely used; however, different scoring systems do exist. Thus, we sought to assess the impact of anticoagulant treatment and different scoring systems on the development of stroke, myocardial infarction, and all-cause mortality in patients with nonvalvular AF. METHODS: The present study was designed as a prospective cohort study. The enrollment of the patients was conducted between August 1, 2015, and January 1, 2016. The follow-up period was defined as the time from enrollment to the end of April 1, 2017, which also provided at least 12 months of prospective follow-up for each patient. RESULTS: A total of 1807 patients with AF were enrolled. During the follow-up, 2.7% (48) of patients had stroke, 0.8% (14) had myocardial infarction, and 7.5% (136) died. The anticoagulation and risk factors in AF (ATRIA) score had a better accuracy for the prediction of stroke compared to other scoring systems (0.729, 95% CI, 0.708-0.750, P <.05). Patients under low-dose rivaroxaban treatment had significantly worse survival (logrank P <.001). Age, CHA2DS2-VASc score, R2CHADS2 score, ATRIA score, chronic heart failure, prior stroke, and being under low-dose rivaroxaban treatment were independent predictors of clinical endpoint (P <.001). CONCLUSION: Low-dose rivaroxaban treatment was independently and strongly associated with the combined clinical endpoint. Furthermore, the ATRIA score proved to be a stronger predictor of stroke in the Turkish population.

Breast artery calcification as an opportunistic predictor of cardiovascular disease.

BACKGROUND: Atherosclerotic cardiovascular disease is still the leading cause of mortality for women. Breast cancer screening with mammography is recommended in all women aged over 40 years. AIMS: Whether breast artery calcification (BAC) is associated with cardiovascular disease is not clear. We aimed to evaluate the association between BAC and the presence of coronary atherosclerosis determined by CT. METHODS: All patients who underwent both mammography and coronary CT angiography between January 2010 and December 2016 were screened, and patients with a duration of less than 12 months between CT and mammography were included. RESULTS: A total of 320 women were included and BAC was detected in 47 (14.6%) patients. BAC was correlated with age and CT coronary calcium score. Both the frequency of critical coronary artery stenosis (34% vs 10.6%; p = 0.001) and CT coronary calcium score (5.5 vs 0; p = 0.001) was significantly higher in patients with BAC. The absence of BAC was a strong predictor of the absence of significant coronary artery disease (p = 0.001). BAC was independently associated with all-cause mortality after excluding patients with breast cancer (HR: 5.32; p = 0.013). CONCLUSION: Breast artery calcification is associated with coronary calcium score and significant coronary stenosis. A high BAC score is related to increased mortality.

Mechanistic vs. empirical ablation of atria during repeat ablation for atrial arrhythmias despite effective pulmonary vein isolation.

The management of atrial arrhythmia recurrence during repeat catheter ablation procedure is unclear despite persistent pulmonary vein isolation. It should be clarified whether an induced non-PV trigger-based (mechanistic) ablation approach more focusing on low-voltage zones is more effective compared to an empirical ablation of low-voltage zones via linear lesions during repeat ablation procedures. The operators should catch all triggers if possible rather than messing with the substrate.

Evaluation of atrial fibrosis in atrial fibrillation patients with three different methods.

BACKGROUND: The presence of atrial fibrosis has already been known as a risk factor for atrial fibrillation (AF) development. We aimed to evaluate atrial fibrosis with previously defined three different methods, which were cardiac magnetic resonance imaging (C-MRI), echocardiographic strain imaging, and biomarkers and show the relationship between these methods in patients with AF scheduled for cryoballoon ablation. METHODS: A total of 30 patients were enrolled. Atrial T1 relaxation durations were measured using C-MRI before the procedure of atrial fibrillation catheter ablation. Fibroblast growth factor-21 (FGF-21) and fibroblast growth factor-23 (FGF-23) levels were measured at serum derived from the femoral artery (Peripheral FGF 21 and 23) and left atrium blood samples (Central FGF 21 and 23) before catheter ablation. Preprocedural transthoracic echocardiography was performed. The median follow-up duration for atrial tachyarrhythmia (ATa) recurrence was 13 (12-18 months) months. RESULTS: The mean ages of the study group were 55.23 ± 12.37 years, and there were 17 (56.7%) female patients in study population. There were negative correlations between post contrast T1 relaxation durations of both posterior and posterosuperior atrium, and central FGF-23 (r: - 0.561; p = 0.003; r:-0.624; p = 0.001; Posterior T1 vs. central FGF-23 levels and Posterosuperior T1 vs central FGF-23 levels, respectively). The positive correlations were observed between postcontrast posterior T1 relaxation durations and left ventricle ejection fraction (r:0.671; p = 0.001); left atrial emptying fraction (r:0.482; p = 0.013); peak atrial longitudinal strain (r:0.605; p = 0.001), and peak atrial contraction strain (r:0.604; p = 0.001). Also negative correlation was observed between postcontrast posterior T1 relaxation durations, and left atrial volume index (r: - 0.467; p = 0.016).

CT dose management for neurologic events in patients with cardiac devices: Radiation exposure variation in patients with cardiac devices.

PURPOSE: To compare the inter-center cranial computed tomography (CT) acquisition rates, CT findings, CT related radiation dose, and variability of CT acquisition parameters for neurologic events among patients with implantable cardioverter-defibrillator (ICD) or left ventricular assist device (LVAD). METHODS: A total of 224 patients [ICD group (n = 155) and LVAD group (n = 69)] who had at least one cranial CT scan were enrolled from three medical centers. The variability and effect of the number, indication, and findings of cranial CT scans as well as CT acquisition parameters including tube potential, tube current, tube rotation time (TI), slice collimation (cSL), and spiral or sequential scanning techniques on CT dose index volume (CTDIvol), total dose length product (DLP) were analyzed. RESULTS: The mean DLP value of Center A and mean CTDIvol values of Center A and C were significantly lower than Center B (p < 0.001). The mean CTDIvol and DLP values in the ICD group were substantially lower than the LVAD group (p<0.001). The most potent parameters causing the changes in CTDIvol and DLP were kV, mAs values, and CT scanning technique as sequential or spiral according to multivariate linear regression analysis. CONCLUSION: Cranial CT acquisition parameters and radiation doses vary significantly between centers, which necessitates optimization of cranial CT protocols to overcome the cumulative radiation dose burden in patients with neurologic events.

Coronary (peri)-arteritis in patients with IgG4-related disease: A case series from the Central Anatolia Region of Turkey.

OBJECTIVE: Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized fibro-inflammatory disease which affects many systems, as well as the cardiovascular system. Identifying the coronary involvement like periaortitis, coronary periarteritis and pericarditis is important, as they often cause unfavorable outcomes. METHODS: Eighty-one patients with IgG4-RD were retrospectively evaluated for symptomatic coronary artery involvement from Hacettepe University Vasculitis Research Center (HUVAC) database. The demographic, laboratory, radiologic and clinical characteristics of the patients were assessed. RESULTS: Among 81 patients with IgG4-RD, 6 patients (M/F:5/1) had coronary artery involvement. The patients' median age was 57 and serum IgG4 levels were above normal except for one case. All patients with coronary arteritis revealed an increased coronary vessel wall thickening and stenotic lesions. The coronary aneurysm and pericarditis were observed in half of the patients. Immunosuppressive treatments were given to all the patients and most of them followed in stable condition. CONCLUSION: Coronary arteritis is a rare but notable manifestation of IgG4-RD. Although coronary periarteritis can cause significant morbidity and mortality, it seems better results can be achieved with early diagnosis and treatment.

Common ostium of inferior pulmonary veins: An extremely rare variant described by preprocedural computerized tomography angiography.

The common ostium of left and right inferior PVs is an extremely rare variant which was only reported in 16 cases undergoing catheter ablation. Thus, electrophysiologists should be careful about such an exremely rare PV variants for the safety and efficacy of ablation. Pre-procedural CTA is a valuable tool to decide on the ablation strategy in patients with such a very rare PV anomaly.

The prognostic role of cardiac troponin in hospitalized COVID-19 patients.

BACKGROUND AND AIMS: Myocardial injury defined by elevation of cardiac troponins (cTn) in the course of coronavirus disease 2019 (COVID-19) pandemic has been reported, though not fully characterized yet. Using the Turkish nationwide centralized COVID-19 database, we sought to determine whether cTn measured within 24 h of admission may help identify 30-day all-cause mortality in hospitalized patients. METHODS: This retrospective cohort study was conducted at all hospitals in Turkey between March 11, 2020, and June 22, 2020. All hospitalized COVID-19 patients (≥18 years) who had cTn measurements within 24 h of admission were included. The primary outcome was 30-day all-cause mortality. RESULTS: A total of 14,855 COVID-19 patients (median age 49 years and 54% male) from 81 provinces of Turkey were included. Of these, 2020 patients (13.6%) were transferred to intensive care unit, 1165 patients (7.8%) needed mechanical ventilation, and 882 patients (5.9%) died during hospitalization. The prevalence of cTn positivity was 6.9% (n = 1027) in the hospitalized patients. cTn positivity was 5% in those patients alive at 30-day, and 44% in those who died. In multivariable Cox proportional hazard regression model, age, lactate dehydrogenase, and cTn were the strongest predictors of 30-day mortality, irrespective of cTn definition as a continuous, ordinal variable, or dichotomic variables. CONCLUSIONS: A single measurement of cTn at admission in patients with COVID-19 is associated with 30-day all-cause mortality and may have an important prognostic role for optimizing risk stratification.

Real-life data of major and minor bleeding events with direct oral anticoagulants in the one-year follow-up period: The NOAC-TURK study.

OBJECTIVE: This study aimed to evaluate the safety of direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (NVAF) during daily clinical practice. METHODS: This was a prospective study conducted between January 01, 2016, and April 01, 2017, in patients aged ≥18 years with a diagnosis of NVAF. We performed the study in 9 clinical centers from different regions of Turkey, and the mean follow-up period was 12+2 months. We investigated major and minor bleeding events of DOAC. RESULTS: A total of 1807 patients with NVAF were enrolled. The mean age of the patients was 73.6±10.2 years, CHA2DS2-VASc score was 3.6±1.4, and HAS-BLED score was 2±1.2. The most frequently prescribed DOAC was dabigatran 110 mg bid in 409 (22.6%) patients. The patients on apixaban 2.5 mg bid were older (p<0.001). Patients on rivaroxaban 15 mg od also had a higher prevalence of chronic renal failure, 46 (16.7%) patients. A total of 205 (11.4%) bleeding events were observed; among these, 34 (1.9%) patients had major bleeding and 171 (9.4%) patients had minor bleeding. The major and minor bleeding events were 2/273 (0.7%) and 30/273 (10.9%) in patients receiving dabigatran 150 mg bid, 13/409 (3%) and 44/409 (10.7%) in patients receiving dabigatran 110 mg bid, 4/385 (1%) and 42/385 (10.9%) in patients receiving rivaroxaban 20 mg od, 8/276 (2.9%) and 27/276 (9.7%) in patients receiving rivaroxaban 15 mg od, 3/308 (0.9%) and 14/308 (4.5%) in patients receiving apixaban 5 mg bid, 4/156 (2.5%) and 14/156 (9%) in patients receiving apixaban 2.5 mg bid, respectively. The total bleeding events were 17 (5.6%) in patients receiving apixaban 5 mg, less than those receiving other DOACs. On multivariate analyses, rivaroxaban 20 mg od (p=0.002), ATRIA and HAS-BLED scores, and peripheral artery disease were independent indicators of bleeding. The most frequent location of major bleeding was the gastrointestinal system (GIS) [17 (0.9%) patients], and the most frequent location of minor bleeding was the gingiva [45 (2.5%) patients]. CONCLUSION: This study showed that similar results as the previous real-life study; however, we had some different results, such as the GIS tract bleeding was more frequent in patients receiving dabigatran 110 mg bid. The major and intracranial bleeding events were similar for different DOACs; and among DOACs, only rivaroxaban 20 mg od was associated with a high risk of bleeding.

Comparison of acute and long-term outcomes of Evolution® and TightRail™ mechanical dilator sheaths during transvenous lead extraction.

BACKGROUND: Powered transvenous lead extraction (TLE) tools are commonly required to remove the leads with long implant duration due to fibrotic adhesions. However, comparative data are lacking among different types of TLE tools. AIM: To compare the efficacy and safety of two different rotational mechanical dilator sheaths in retrospectively analyzed patients who underwent TLE. METHODS AND RESULTS: A total of 566 lead extractions from 302 patients using TightRail™ (333 lead extractions from 169 patients) and Evolution® (233 lead extractions from 133 patients) mechanical dilator sheaths were performed between July 2009 and June 2018. Acute and long-term outcomes of study groups were compared. There is no statistically significant difference between Evolution® and TightRail™ groups in procedural success (93.9% vs. 94%), clinical success (99.2% vs. 98%), and major complications (3.8% vs. 1.2%), respectively (p > .05). In multivariate regression analysis, lead dwell time, the number of extracted leads, and baseline leukocyte count were found as independent predictors of procedural success (p < .05). During the median follow-up of 36.6 (0.2-118) months, all-cause mortality was observed in 73 patients (25.6% in the Evolution® vs. 23.1 in the TightRail™ group, p > .05). Chronic renal disease, heart failure, and coagulopathy were shown as independent predictors of all-cause mortality in multivariate regression analysis (p < .05). CONCLUSION: TLE using TightRail™ or Evoluation® mechanical dilator sheaths was a safe and effective therapeutic option. Both mechanical dilator sheaths showed similar efficacy, safety, and all-cause mortality at acute and long-term follow-up of patients who underwent TLE.

Genetic variants associated with atrial fibrillationand long-term recurrence after catheter ablation for atrialfibrillation in Turkish patients.

OBJECTIVE: Genome-wide association studies have revealed that single nucleotide polymorphisms (SNPs) are associated with atrial fibrillation (AF) and can predict AF recurrence after catheter ablation in different populations. However, there exists no such data for the Turkish population. We aimed to investigate whether 11 SNPs in the PITX2, ZFHX3, EPHX2, CAV1, TBX5, TGF-1, and SCN10A were related to AF and whether these SNPs can predict long-term atrial tachyarrhythmia (ATa) recurrence after pulmonary vein isolation (PVI) for AF in Turkish patients. METHODS: A total of 245 consecutive patients with non-valvular AF (44.9% men, mean age: 60.2±13.2 years, 65.3% paroxysmal AF) and 50 age- and sex-matched controls were included in this analysis. The clinical features and genetic variants were compared between the 2 groups. Of the 245 patients, 128 who underwent PVI with second-generation cryoballoon were further examined for long-term recurrence after the procedure. RESULTS: Four SNPs in PITX2 were significantly associated with AF (rs10033464_T: OR 3.29, 95%CI: 1.38-7.82, p=0.007; rs6838973_T: OR 3.06, 95% CI 1.36-6.87, p=0.007; rs3853445_C: OR 2.84, 95%CI: 1.27-6.36, p=0.011; rs17570669_T: OR 4.03, 95% CI: 1.71-9.51, p=0.001). Among these patients who underwent PVI, one locus in CAV1 (rs3807989_G: OR 4.50, 95% CI 1.04-19.31, p=0.043) and early recurrence (OR: 8.06, 95% CI: 2.12-30.55, p=0.002) predicted long-term AF recurrence after catheter ablation. CONCLUSION: Significant associations exists between 4 SNPs in PITX2 and AF (rs10033464, rs6838973, rs3853445, and rs17570669) in Turkish patients. In addition, 1 genetic variant in CAV1 (rs3807989) and early recurrence can predict long-term ATa recurrence after catheter ablation.