Pre-Procedural Right Atrial Diameter May Predict the Development of Typical Atrial Flutter in Patients Undergoing Catheter Ablation for Atrial Fibrillation.

BACKGROUND: Some patients undergoing catheter ablation for atrial fibrillation may develop typical atrial flutter on follow-up, and a second procedure for typical atrial flutter is often required in such patients. In this study, we aimed to define the variables associated with the development of typical atrial flutter after ablation. METHODS: One hundred fifty-nine patients who underwent catheter ablation for the first time due to atrial fibrillation and who did not have a previously documented atrial flutter were included in the study. Before ablation, baseline clinical features and echocardiographic parameters were recorded. At the 1st, 3rd, 6th, and 12th months after the procedure, and then annually, the patients were followed up for typical atrial flutter development. RESULTS: At a mean follow-up of 34.0 (14.0-50.0) months, typical atrial flutter developed in 21 (13.2%) patients. During the follow-up, right atrial diameter was greater in those who developed typical atrial flutter than those who did not [39.0 (38.0-43.0) vs. 36.0 (34.0-39.0) mm, P <.001]. A multiple Cox regression analysis showed that the right atrial diameter was the only independent predictor of typical atrial flutter development (hazard ratio = 1.12, 95% CI: 1.02-1.23, P =.021). A receiver operating characteristic analysis showed that the best cutoff for the right atrial diameter was 38.5 mm to predict typical atrial flutter development (area under the curve = 0.77, 95% CI: 0.67-0.86, sensitivity = 62%, specificity = 75%, P <.001). CONCLUSION: In patients undergoing catheter ablation for atrial fibrillation, a pre-procedural right atrial diameter measurement may predict typical atrial flutter development at follow-up. In particular, patients with a pre-procedural right atrial diameter ≥39 mm may be at a higher risk for developing typical atrial flutter in the future.

Hand-held echocardiography during complex electrophysiologic procedures.

Introduction: Complex electrophysiologic (EP) procedures are time consuming and open to complications. Accurate and rapid recognition of cardiac pathologies is essential before, during, and immediately after such procedures. In this study, we aimed to compare hand-held echocardiography (HHE) with standard echocardiography (SE) to determine whether HHE can be used as a practical and reliable diagnostic tool during such procedures. Methods: One hundred consecutive patients undergoing complex EP procedures and catheter ablation were included in the study. All patients were evaluated with SE or HHE in terms of main cardiac pathologies at the beginning and immediately after the procedure. The diagnostic accuracy and evaluation time of both methods were compared at the beginning and after the procedure. The agreement between both methods was calculated. Results: At the beginning and after the procedure, opening and evaluation times with HHE were significantly shorter than with SE (P<0.001 for all). There was significant agreement between the two methods in the diagnosis of cardiac pathologies (Agreement was 95% for minimal mild aortic regurgitation (AR), 99% for moderate/ severe AR, 93% for minimal/ mild mitral regurgitation (MR), 95% for moderate/ severe MR, 100% for pericardial effusion, and 100% for left ventricular thrombus at the beginning of the procedure). Conclusion: With the use of HHE during complex EP procedures, cardiac pathologies can be diagnosed with similar accuracy as SE. In addition, HHE has a significant advantage over SE in terms of time to diagnosis.

Genetic Polymorphism on Chromosome 4q25 (rs17570669) May Predict Recurrence After Successful Electrical Cardioversion in Patients with Persistent Atrial Fibrillation.

OBJECTIVE: Direct current electrical cardioversion (DCCV) is an effective rhythm-control option for patients with atrial fibrillation (AF). Despite initial success, a high recurrence rate remains a significant challenge. There is limited data on the genetic predictors of AF recurrence following successful DCCV. In this study, we aimed to evaluate whether 11 single nucleotide polymorphisms (SNPs) previously associated with AF are also linked to recurrence after DCCV in the Turkish population. METHODS: Seventy-five patients with persistent AF, who achieved stable sinus rhythm following DCCV, were included in the study. The patients were prospectively monitored for the onset of AF recurrence. Clinical characteristics and SNPs were analyzed and compared between patients who experienced recurrence and those who did not. RESULTS: The average age of the patients was 61.9 ± 11.5, and 33 (44%) were female. Over an average follow-up period of 17.0 (11.0-25.0) months, AF recurrence was observed in 38 patients (50.7%). A SNP in the PITX2 gene (rs17570669) (OR: 9.00, 95% Confidence Interval (CI): 1.28-63.02) and another in the ZFHX3 gene (rs2106261) (OR: 8.96, 95% CI: 1.03-77.66) were notably associated with AF recurrence in the additive model (P = 0.027 and 0.047, respectively). Multivariate Cox regression analysis revealed that the rs17570669 SNP was the sole independent predictor of AF recurrence (Hazard Ratio (HR): 3.59, 95% CI: 1.05-12.21, P = 0.040). CONCLUSION: The SNP in the paired-like homeodomain 2 (PITX2) gene (rs17570669) emerges as an independent predictor for AF recurrence after successful electrical cardioversion.

The Safety and Tolerability of Nebivolol in Hypertensive Patients with Coronary Artery Disease and Left Ventricular Ejection Fraction ≥ 40%: A Population-Based Cohort Study (Nebivolol-TR Study).

BACKGROUND: This study aimed to assess the safety and tolerability of nebivolol in hypertensive patients with coronary artery disease and left ventricular ejection fraction ≥ 40% in a Turkish cohort. METHODS: A total of 1015 hypertensive patients and coronary artery disease with left ventricular ejection fraction ≥ 40% were analyzed from 29 different centers in Turkey. Primary outcomes were the mean change in blood pressure and heart rate. Secondary outcomes were to assess the rate of reaching targeted blood pressure (<130/80 mmHg) and heart rate (<60 bpm) and the changes in the clinical symptoms (angina and dyspnea). Adverse clinical events and clinical outcomes including cardiovascular mortality, cardiovascular hospital admissions, or acute cardiac event were recorded. RESULTS: The mean age of the study population was 60.3 ± 11.5 years (male: 54.2%). During a mean follow-up of 6 months, the mean change in blood pressure was -11.2 ± 23.5/-5.1 ± 13.5 mmHg, and the resting heart rate was -12.1 ± 3.5 bpm. Target blood pressure and heart rate were achieved in 76.5% and 37.7% of patients. Angina and functional classifications were improved by at least 1 or more categories in 31% and 23.2% of patients. No serious adverse events related to nebivolol were reported. The most common cardiovascular side effect was symptomatic hypotension (4.2%). The discontinuation rate was 1.7%. Cardiovascular hospital admission rate was 5% and hospitalization due to heart failure was 1.9% during 6 months' follow-up. Cardiovascular mortality rate was 0.1%. CONCLUSION: Nebivolol was well tolerated and safe for achieving blood pressure and heart rate control in hypertensive patients with coronary artery disease and heart failure with preserved or mildly reduced ejection fraction.

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.

State-of-the-art look at premature ventricular complex diagnosis and management: Key messages for practitioners from the American College of Cardiology Electrophysiology Council.

Premature ventricular complexes (PVCs) are one of the most common arrhythmias seen in daily practice. Although PVCs are generally considered benign, they can lead to the development of cardiomyopathy and, rarely, can be associated with sudden cardiac death. Recently, the American College of Cardiology Electrophysiology Council published a state-of-the-art review on PVCs to provide diagnostic and therapeutic considerations for clinical practice. Presented are some important points about the diagnosis, approach, and treatment of PVCs.

What Have We Learned from the European Society of Cardiology 2019 Guidelines on Supraventricular Tachycardia.

Supraventricular tachycardias (SVTs) are common arrhythmic conditions in clinical practice. Increased knowledge and experience on SVTs and some unclear situations in clinical practice led the European Society of Cardiology (ESC) team to write a new guideline. In this review, we touch upon the important points in the new ESC 2019 SVT guidelines and present changing approaches and suggestions. By providing a general review on SVTs, we also mention the basic mechanism, epidemiology, and clinical presentation of SVTs, approaching narrow and wide QRS tachycardias, SVTs in special patient groups, and treatment of SVTs.

The association of exaggerated hypertensive response to exercise and beta-blockers use in hypertensives.

PURPOSE: An elevation in blood pressure (BP) during exercise is the normal physiological response, however an abnormally exaggerated rise in BP, in terms of hypertensive response to exercise (HRE), is seen as a prognostic factor for end-organ damage and mortality. HRE is more common in hypertensive (HT) patients and data are lacking on the effect of antihypertensive medication on HRE. In this study, we evaluated patients who underwent treadmill exercise testing (TET) to reveal the effect of antihypertensive medication on HRE. MATERIALS AND METHODS: A cohort of 2970 individuals underwent TET and data were evaluated for HRE development. HRE has been defined as a systolic BP>210 mmHg in males and >190 mmHg in females throughout the TET. To reveal the effects of antihypertensive medication on HRE, 992 HT patients were analyzed. RESULTS: HRE was observed in 11.4% (n = 113) of HT patients and 5.9% (n = 107) of non-HT individuals(p < .001). HRE was observed significantly more in males (57.6% vs. 67.3%;p = .033), and in patients with higher body mass index BMI (29.1 ± 4.5 vs. 30.3 ± 5.2;0.033). There was no significant association between medication and HRE development apart from beta-blockers. Also, gender (odds ratio:1.787; 95%CI:1.160-2.751;p = .008), BMI (odds ratio:1.070;95%CI:1.025-1.116;p = .002) and being under beta-blocker treatment (odds ratio:0.637;95%CI:0.428-0.949;p = .026) were found to be independent predictors of HRE in multivariate logistic regression analysis. CONCLUSION: HRE was associated with gender, BMI and beta-blocker use in hypertensive with male gender and higher BMI associated with higher HRE, while beta-blocker-based treatment, either mono- or combination therapy, associated with lower HRE.

Medical treatment of a symptomatic acute pulmonary vein stenosis following antral pulmonary vein isolation.

Pulmonary vein (PV) stenosis is a rare but serious complication of PV isolation. It usually develops 3-6 months after the procedure, but may rarely develop in the acute phase. We present a case of symptomatic PV stenosis within 48 hours after antral PV isolation. Following the initiation of medical treatment including a glucocorticoid, acute changes in the PV wall regressed and the patient's complaint of dyspnea at rest improved rapidly. In addition, long-term renin-angiotensin-aldosterone system (RAAS) blockers were given. The complaint did not recur during follow-up and PV stenosis was mild at 6 months.

Important tips reflected in our daily practice from the American College of Cardiology Electrophysiology Council report on premature ventricular contractions.

Premature ventricular contractions (PVCs) is one of the most common situations in the current cardiology practice. Although PVCs are generally benign in people without any structural heart disease, they may be associated with left ventricular dysfunction, cardiomyopathy, and, rarely, sudden death. Recently, there has been a considerable research in the pathophysiology of PVC, several clinical presentations in different situations, new proposals of successful diagnostic methods, and treatment modalities. Finally, the American College of Cardiology Electrophysiology Council has published a special report that deals with all the aspects of PVC. We reviewed the important points from this report that can be reflected in our daily practice.

Early hyperbaric oxygen therapy for cerebral air embolism during atrial fibrillation ablation.

Cerebral air embolism is a potentially life-threatening complication of left-sided ablation procedures. We present a 51-year-old woman with cerebral air embolism during atrial fibrillation cryoballoon ablation. Taking a deep breath while removing the dilatator was the most likely mechanism in our case. The patient was successfully treated with hyperbaric oxygen therapy at early stage and was discharged without any neurological sequelae.

Monocyte to High-Density Lipoprotein Ratio Predicts Contrast-Induced Nephropathy in Patients With Acute Coronary Syndrome.

Contrast-induced nephropathy (CIN) is associated with worse prognosis in patients with acute coronary syndrome (ACS). Early identification and intervention for patients with a high risk of CIN are very important to improve clinical outcomes. Inflammation plays important role in the development of CIN in the setting of ACS. The monocyte to high-density lipoprotein ratio (MHR) is a novel inflammatory marker. Bleeding is also associated with worse prognosis in such patients. We aimed to investigate whether the preprocedural MHR had a predictive role for CIN development in such patients. In addition, using the thrombolysis in myocardial infarction classification, we aimed to assess whether there was any relationship between bleeding and CIN. A total of 647 patients (496 males; age: 63.3 ± 12.7 years) with ACS who underwent percutaneous coronary intervention (PCI) were included in the study. Seventy patients (10.8%) had developed CIN. Age, diabetes mellitus, contrast volume, estimated glomerular filtration rate, and MHR were independent predictors for CIN. Preprocedural MHR may be used as a simple marker of CIN. It may help with the early identification of patients with ACS who underwent PCI who are at high risk of CIN thus allowing the planning of protective measures.

Predictors of new-onset atrial fibrillation in elderly patients with acute coronary syndrome undergoing percutaneous coronary intervention.

BACKGROUND: The development of atrial fibrillation (AF) during the course of acute coronary syndrome (ACS) is related to poor prognosis. Possible predictors of new-onset AF (NOAF) have not been adequately investigated in elderly patients with ACS undergoing percutaneous coronary intervention (PCI). We aimed to identify the factors associated with NOAF in such patients. METHODS: A total of 308 elderly patients with ACS undergoing PCI were enrolled in the study. Patients were divided into two groups: without NOAF [254 patients, 64.6% men, age: 73.5 (69.0-79.0) years] and with NOAF [54 patients, 70.4% men, age: 75.0 (68.7-81.2) years]. Clinical, angiographic, and laboratory features including neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-high-density lipoprotein ratio (MHR) were compared between the groups. RESULTS: The percentages of prior myocardial infarction (MI) (20.4 vs. 5.9%) and Killip III/ IV (24.1 vs. 7.1%), NLR [4.5 (2.6-7.2) vs. 3.2 (2.0-6.0)], and MHR [19.4 (15.7-26.5) vs. 12.9 (9.9-18.5)] were higher in patients with NOAF compared to the others (p = 0.020, < 0.001, 0.030, and < 0.001, respectively). In multivariate regression analysis, prior MI (OR 4.509, 95% CI 1.679-12.106, p = 0.003) and MHR (OR 1.102, 95% CI 1.054-1.152, p < 0.001) independently predicted NOAF. In addition, Killip III/IV was found to be an independent predictor of 6-month overall mortality (HR 2.949, 95% CI 1.218-7.136, p = 0.016). CONCLUSIONS: Prior MI and MHR are independent predictors of NOAF in elderly patients with ACS undergoing PCI. Killip III/IV predicts 6-month overall mortality in such patients.

High-dose bolus tirofiban versus low-dose bolus in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

OBJECTIVE: Aim of the present study was to determine effects of high-dose versus low-dose intravenous (IV) bolus tirofiban on angiographic measures, ST resolution, enzymatic infarct size, and clinical outcomes in patients with acute coronary syndrome (ACS) who were undergoing percutaneous coronary intervention (PCI) and received current pharmacoinvasive therapy. METHODS: Acute coronary syndrome patients (n=271, 85.6% male; mean age: 57.9±12.6 years) from between 2009 and 2015 who received IV tirofiban therapy following PCI were retrospectively analyzed. All patients had received maintenance tirofiban infusion (0.15 µg/kg/min) after bolus dose and 600 mg clopidogrel. Percentage of patients undergoing drug eluting stent implantation procedure was 33.5%. Tirofiban was administered to all patients in bailout situation or for thrombotic complication after PCI. RESULTS: High-dose IV bolus group (25 µg/kg; n=140) was associated with greater ST segment resolution (66% vs. 50%, p=0.013) and reduced peak troponin release [12.4 ng/dL (range: 6.5-21.5 ng/dL) vs. 16.4 ng/dL (range: 10.1-27.4 ng/dL), p=0.001] compared with low-dose bolus group (10 µg/kg, n=131). Cardiovascular event rates were similar between groups at in-hospital, 1-month, and 6-month follow-up (p=1.000, 1.000, and 0.287, respectively). Percentage of patients with post-procedural Thrombolysis in Myocardial Infarction (TIMI) grade III flow, major, and minor bleeding were similar (p=0.085, 1.000, and 0.965, respectively). CONCLUSION: Use of high-dose IV bolus tirofiban in addition to aspirin and high-dose clopidogrel improves ST segment resolution, reduces infarct size, and does not increase bleeding events in patients with ACS undergoing PCI compared with low-dose bolus. Angiographic measures and clinical endpoints were similar between groups.