Excessive supraventricular activity and risk of atrial fibrillation in patients with cryptogenic ischaemic stroke.

INTRODUCTION: Atrial fibrillation (AF) is one of the leading causes of ischaemic stroke. However, screening for AF is often time-consuming in clinical practice. Therefore, the determination of an appropriate marker to detect the presence of AF would improve the diagnostic process. OBJECTIVE: The aim of the current study was to evaluate the efficacy of prolonged and early inpatient event Holter monitoring in the detection of AF in patients with ESUS-related cryptogenic ischaemic stroke (CIS), and to determine the possible relationship between excessive supraventricular activity and AF detection. MATERIAL AND METHODS: All consecutive patients with documented cerebral or cerebellar infarction were included. The diagnostic work-up included brain neuroimaging (CT/MRI), ultrasound of the carotid and vertebral arteries, admission ECG followed by 24 hours of Holter monitoring, and transthoracic echocardiography. The 24-hour Holter ECG was analysed, and supraventricular ectopic activity (supraventricular extrasystoles, runs and pairs of supraventricular extrasystoles) was recorded in all patients. If these examinations did not reveal the cause of ischaemic stroke, the patients underwent subsequent prlonged 14-day event Holter recorder monitoring. RESULTS: We included 48 patients (mean age 69.9 ± 8.5 years, 60.4% men) who had been diagnosed with CIS. Of these 48 patients, atrial fibrillation was detected in seven (14.6%) during the prolonged 14-day Holter event monitoring. Patients with newly diagnosed atrial fibrillation had a higher burden of supraventricular ectopic activity. The number of supraventricular extrasystoles (SVES) per hour, as well as the number of SV pairs and SV runs, was significantly higher in patients with new onset AF (p < 0.022; p < 0.043; p < 0.022). CONCLUSIONS: In our study, we confirmed that prolonged ECG event Holter monitoring in patients with CIS-ESUS subtype led to a higher rate of AF detection. Likewise, frequent supraventricular ectopic activity predicted the development of AF.

Safety of cryoballoon ablation for the treatment of atrial fibrillation: First European results from the cryo AF Global Registry.

BACKGROUND: Cryoballoon ablation for the treatment of patients with atrial fibrillation (AF) has been utilized in Europe for >15 years. OBJECTIVES: Report patient and procedural characteristics that influence the safety of cryoablation for the treatment of AF. METHODS: Patients enrolled in the prospective, multicenter Cryo AF Global Registry were treated at 38 European centers. Freedom from a ≥30s episode of AF/atrial flutter (AFL)/atrial tachycardia (AT) at 12-months and serious complications were analyzed. Univariate and multivariable models identified baseline patient and procedural characteristics that predicted a procedure-related complication. RESULTS: Of the 1418 subjects who completed an index procedure, the cohort was 62 ± 11 years of age, 37.7% female, and 72.2% paroxysmal AF (PAF). The mean procedure, left atrial dwell, and fluoroscopy times were 81 ± 34, 54 ± 25, and 14 ± 13 min, respectively. Among the 766 patients with 12-month follow-up, freedom from a ≥30 s AF/AFL/AT recurrence was 83.3% (95% CI: 79.8%-86.3%) and 71.6% (95% CI: 64.6%-77.4%) in patients with PAF and persistent AF. The serious procedure- and device-related adverse event rates were 4.7% and 2.0%. No baseline patient characteristic independently predicted a procedure-related adverse event; however, prolonged procedure duration (OR = 1.01 [95% CI: 1.00-1.01]), use of general anesthesia (OR = 1.71 [95% CI: 1.01-2.92]), and delivery of a cavotricuspid isthmus line (OR = 3.04 [95% CI: 1.01-9.20]) were each independently associated with the occurrence of a serious procedural safety event (all p < .05). CONCLUSIONS: Cryoballoon ablation is safe and effective in real-world use across a broad cohort of patients with AF.

The prognostic value of high sensitive cardiac troponin I in patients receiving cardiac resynchronisation therapy.

BACKGROUND: Cardiac troponin I (cTnI) is a valuable prognostic biomarker in patients with chronic heart failure (CHF). However, the prognostic importance of cTnI in patients who received cardiac resynchronisation therapy (CRT) remains unknown. The aim of this prospective study was to determine the prognostic value of high-sensitive cTnI (hs-cTnI) in CHF patients receiving CRT. METHODS: We performed measurements of baseline hs-cTnI levels in CRT patients with ischaemic as well as nonischaemic aetiology of CHF, and we investigated their possible association with response to CRT and survival of patients. RESULTS: Ninety consecutive CRT patients (mean age 64 ± 9 years, 71 men) were included. According to the best cut-off value of hs-cTnI level to predict CRT response and all cause mortality, patients were divided into group 1 (hs-cTnI level ≥6.5 ng/l, n = 46) and group 2 (hs-cTnI level <6.5 ng/l, n = 44). During the follow-up period (1155 ± 406 days), 47% of patients were CRT responders (30% in group 1 and 64% in group 2, p = .002) and 31% of patients died from any cause (48% in group 1 and 14% in group 2, p = .001). Regression analysis showed that hs-cTnI level <6.5 ng/l was an independent predictor of CRT response (OR 3.49, p = .019) and that hs-cTnI level ≥6.5 ng/l was an independent predictor of all cause mortality (HR 3.01, p = .021). CONCLUSION: The hs-cTnI can be an useful biomarker with prognostic value in patients receiving CRT.

The effectiveness of CRT on improvement of survival of heart failure patients in real life clinical settings.

Objectives Prolongation of QRS (≥ 120 ms) in patients with heart failure (HF) is associated with higher all-cause mortality than in those with narrow QRS. The aim of our study was to compare the survival of patients with HF and wide QRS after cardiac resynchronization therapy (CRT) with survival of HF patients with narrow QRS and to assess factors predictive of non-response to CRT. Methods We enrolled 680 patients with advanced HF and optimal pharmacologic therapy. All patients were assigned according to duration of QRS complex and implanted device. We acquired two groups. A first group, patients with wide QRS and implanted CRT-D (CRT-D group, n = 354) and a second group, patients having narrow QRS and implanted single/dual chamber ICD (ICD group, n = 326). The primary outcome was death from any cause. The response to CRT was defined as an increase of EF at least by 5% and/or reduction of LVEDD at least by 10%. Results The primary outcome was reached by 84 (23.7%) patients in the CRT-D group and 69 (21.2%) patients in the ICD group. We did not find a statistically significant difference in survival rate between the CRT-D and ICD group [P = 0.44; hazard ratio (HR) 1.132]. Conclusion Survival of patients with HF and wide QRS after CRT implantation is comparable to those with HF and narrow QRS. Coronary artery disease and QRS width less than 145 ms increase risk of non-response to CRT 2.2 and 2.9 times, respectively.

A long-term evaluation of cryoballoon ablation in 205 atrial fibrillation patients: a single center experience.

BACKGROUND: Atrial fibrillation is the most prevalent cardiac arrhythmia with significant healthcare impact with regards to treatment costs, morbidity, and mortality. Many of the focal electrical activities that initiate and sustain atrial fibrillation have been found to reside within or near the pulmonary veins. Consequently, pulmonary vein isolation by catheter ablation has emerged as an effective method to eliminate the focal triggers associated with atrial fibrillation. METHODS: In this single-center study, 205 patients were ablated for atrial fibrillation using a cryoballoon catheter and followed-up long-term by retrospective chart examination to evaluate their post-procedural freedom from atrial fibrillation. RESULTS: Patients were followed for up to 6 years with a cohort median of 3 years of post-ablation evaluation. Overall, at 12, 24, and 36 months post-ablation, 71, 49, and 31% of evaluated patients were free of atrial fibrillation, respectively. We found the type of atrial fibrillation (paroxysmal vs. persistent) as an independent predictor for arrhythmia recurrence (HR 1.97; 95% CI: 1.24-3.13, P = 0.006). The cohort median atrial fibrillation-free survival time was 24 months (27 months for paroxysmal atrial fibrillation patients and 14 months for persistent atrial fibrillation patients). There were a total of 37 (18%) complications, 8 (3.9%) were categorized as major complications, all without permanent sequels. The most common complication was phrenic nerve palsy which occurred in 14 (6.8%) patients. CONCLUSION: Long-term outcomes in this study suggest that the pulmonary vein isolation using the cryoballoon technique is relatively an effective method especially in the treatment of paroxysmal atrial fibrillation.

Complications of circumferential pulmonary vein isolation using the cryoballoon technique: Incidence and predictors.

BACKGROUND: Cryoballoon ablation technique for the treatment of atrial fibrillation (AF) is a complex procedure consisting of several procedural steps associated with significant risk of complications. The aim of this single-centre study was to give detailed analysis of the complication rate and corresponding risk factors of pulmonary veins cryoisolation (PVI) procedures. METHODS AND RESULTS: A total of 158 consecutive patients (71.5% men, aged 57 ± 9 years, 73.3% paroxysmal atrial fibrillation) were enrolled. Out of 632 pulmonary veins, 96.7% were targeted and isolated by 2-7 applications of cryothermal energy guided with intracardiac echocardiography and fluoroscopy. The additional ablation of cavotricuspid isthmus was performed in 14.6% of procedures. In total, 29 complications were recorded in peri-procedural or early post-procedural period, 8 (5.1%) of them being evaluated as major. No case of permanent injury, disability or death was registered. Multivariate logistic regression showed the persistence of pre-ablation AF as the risk factor of major complications (OR=5.0; ± 95% CI: 1.14-21.97, P=0.033); lower body height was the significant risk factor of any complications (OR=0.95; ± 95% CI: 0.91-0.99, P=0.026) with rapid increase of complication risk with body height ≤ 162 cm. Embolic complications were significantly associated with the pre-ablation AF, while patients with low body height had a trend towards increased risk of phrenic nerve palsy. CONCLUSION: Our study confirmed that the cryoballoon pulmonary vein isolation can be safely performed with low incidence of life-threatening complications which may be further decreased if the mentioned risk factors are handled appropriately.

The link between angiotensin-converting enzyme genotype and pulmonary artery pressure in patients with COPD.

OBJECTIVE: The insertion (I)/deletion (D) polymorphism of the angiotensin-converting enzyme (ACE) gene has been associated with an increased risk of cardiovascular diseases. In patients with primary pulmonary hypertension, the homozygous ACE DD genotype is more prevalent than the non-DD genotype. However, the relationship of ACE gene polymorphism to secondary pulmonary hypertension remains unclear, and ethnicity may be one of the factors that can modulate the effects of ACE genotypes reported in different studies. We hypothesized that in patients with chronic obstructive pulmonary disease (COPD) the presence of the D allele in the ACE gene polymorphism is associated with increased pulmonary artery pressure (Ppa). PATIENTS AND METHODS: Bodyplethysmography was used to assess lung function in 66 consecutive patients with COPD; pulmonary artery pressures were determined using echocardiography. ACE gene I/D polymorphism was identified with the polymerase chain reaction. 118 healthy persons served as the control group. All patients and controls were Caucasian. Genotype II was identified in 15 patients with COPD, genotype ID in 31 and genotype DD in 20. In the control group, genotype II was identified in 19 persons, genotype ID in 68 and genotype DD in 31. The distribution of ACE gene polymorphism did not differ between patients and the control group. RESULTS: In patients with COPD, no differences were seen between the three genotype groups in mean age, smoking history, hemoglobin concentrations or ventilometric or blood gas variables. Both systolic and mean Ppa differed significantly between the II, ID and DD groups (Systolic Ppa: 24.4 +/- 2.2 versus 31.3 +/- 2.5 and 36.7 +/- 3.9 mm Hg, respectively, ANOVA, p < 0.05; Mean Ppa: 13.0 +/- 1.5 versus 17.5 +/- 1.4 and 21.2 +/- 2.8 mm Hg, respectively, ANOVA, p < 0.05). In multiple linear regression analysis, the I/D ACE gene polymorphism (p < 0.05), SaO2 (p < 0.05) and the duration of COPD (p < 0.02) were independent predictors of systolic and mean Ppa. CONCLUSION: The results of the study suggest that I/D ACE gene polymorphism is linked to pulmonary artery pressure in Caucasian patients with COPD.