Evaluation of the non-alcoholic fatty liver fibrosis score in predicting short-term outcomes and severe coronary artery disease in patients undergoing coronary computed tomography angiography.

Introduction: The correlation between non-alcoholic fatty liver disease (NAFLD) and cardiovascular disease is well established. Aim: The objective of this study was to assess the short-term associations of the non-alcoholic fatty liver disease fibrosis score (NFS) with various outcomes, including mortality, severe coronary artery disease, myocardial infarction, and the need for coronary angiography, among patients who underwent coronary computed tomographic angiography (CCTA). Material and methods: In this study, we assessed 499 patients who underwent 640-slice CCTA and evaluated their liver fibrosis using the NFS. The NFS takes into account factors such as age, body mass index, impaired fasting glycemia or diabetes mellitus, aspartate aminotransferase/alanine aminotransferase ratio, platelets, and albumin. Our primary focus was myocardial infarction, the need for coronary angiography, and death. Additionally, we examined the association between NFS and severe coronary artery disease. Results: Patients with a higher NFS had a greater number of coronary angiography procedures and higher Agatston score (p < 0.001), with NFS and Agatston score emerging as independent predictors of severe coronary artery disease and the primary endpoint. An NFS value above -0.92 could predict the primary endpoint with 61% sensitivity and 63% specificity, while an NFS value above -0.88 could predict severe coronary artery disease with 62% sensitivity and 65% specificity. To analyze primary endpoints, the Kaplan-Meier method was used for survival analysis, with NFS groups compared using the log-rank test. During the follow-up period, patients with higher NFS were exposed to primary outcomes at an earlier period (p = 0.009). Conclusions: NFS is an effective predictor of major cardiovascular events such as death, myocardial infarction, severe coronary artery disease, and the need for coronary angiography. These findings underscore the importance of NFS as a valuable tool for risk assessment and early intervention in patients with suspected or confirmed coronary artery disease.

Long-Term Observational Study of the Isolated Ostial Diagonal Stenosis in Patients with Chronic Coronary Syndrome.

OBJECTIVE: Isolated ostial diagonal stenoses are very rare lesions in which percutaneous intervention could cause significant vessel compromise, and the long-term results have been reported in a few studies. This study sought the characteristics and long-term follow-up of the patients with isolated osteal diagonal stenosis regarding percutaneous coronary intervention and presence of angina. METHODS: The study was an observational retrospective study conducted between January 2014 and December 2020. A total of 9769 patients who underwent coronary angiography were analyzed, and 87 patients had isolated diagonal stenosis. The patients were evaluated according to treatment modality and angina severity in long-term pattern. RESULTS: Median follow-up time was 36 months. A total of 54 (83.1%) patients were followed up with only medical treatment, and 11 (16.9%) patients underwent revascularization in addition to medical treatment. The degree of stenosis of the diagonal artery was significantly higher in the percutaneous coronary intervention group than medical group (P = 0.002) and the patients with wider reference diameter of diagonal artery complaint of more angina (P = 0.007). Class I angina was significantly higher in percutaneous coronary intervention group than medical and the patients with no angina were significantly higher in medical group than percutaneous coronary intervention group. CONCLUSION: Percutaneous coronary intervention was mainly performed for diagonal arteries with a higher degree of stenosis; however, the patients who underwent percutaneous coronary intervention had angina more than 50% rates. Furthermore, the patients with ongoing angina had a larger diameter of the diagonal artery regardless of the type of treatment.

Optical coherence tomography measurements in patients with systemic hypertension.

AIM: To evaluate the effect of systemic arterial hypertension (SAH) on retinal optical coherence tomography (OCT) parameters and investigate whether a correlation exists between ambulatory blood pressure monitoring (ABPM) and OCT measurements.Material-methods: 115 SAH patients (225 eyes) and 123 healthy control cases (234 eyes) were included. ABPM was performed on 89 of 115 SAH patients. All patients underwent detailed ophthalmologic examination including imaging with OCT. SAH patients were divided into two groups (dippers, non-dippers) according to their nocturnal blood pressure (BP) reduction, and OCT measurements were compared. RESULTS: Average and superior retinal nerve fiber layer (RNFL) quadrants were significantly thin in hypertensive cases (p:0.002, p < 0.001, respectively). Cup area, cup/disk (c/d) area, and c/d horizontal ratios were wider; the rim area was smaller in hypertensive cases (respectively: p:0.024, p:0.017, p:0.003, p < 0.001). Total macular volume (TMV), the thicknesses in 1-3 and 1-6 mm of the macula were less in hypertensives (p < 0.001). There was no significant difference between dippers and non-dippers in RNFL thickness, macula and optic nerve head (ONH) parameters. CONCLUSION: There were statistically significant differences between healthy cases and patients with SAH in terms of RNFL, macula thicknesses and ONH parameters.

Left atrial appendage 2D-strain assessed by transesophageal echocardiography is associated with thromboembolic risk in patients with atrial fibrillation.

OBJECTIVE: The aim of this study was to determine the relationship of left atrial appendage (LAA) mechanics assessed using 2-dimensional (2D)-strain analysis of the gray scale images obtained during transesophageal echocardiography (TEE) to the conventional LAA functional parameters, CHA2DS2-VASc score, and the presence of spontaneous echo contrast (SEC) and/or LAA thrombus in patients with non-valvular atrial fibrillation (AF). METHODS: The study included 126 patients with AF and 30 controls with a sinus rhythm who were referred for TEE. The global, medial, lateral and apical LAA longitudinal 2D-strain of all patients and the CHA2DS2-VASc score of AF patients were evaluated. RESULTS: The global, medial, lateral, and apical LAA longitudinal 2D-strain results of AF patients were significantly lower than those of the controls and revealed moderate but significant correlations with LAA flow velocity and LAA area change. Patients with a CHA2DS2-VASc score of 0 or 1 had the highest LAA 2D-strain values and the results revealed that the LAAemptying velocity and LAA lateral and medial 2D-strain values were independent correlates of CHA2DS2-VASc score. SEC was detected in 84 patients, of whom, 42 had dense SEC and 27 had thrombus in the LAA. Multivariate analysis indicated that LAA emptying velocity, LAA area change, and LAA medial 2D-strain were independently associated with the presence of dense SEC/thrombus. In ROC analysis, cut-off values for global, medial, apical, and lateral 2D-strain for the presence of dense SEC/ thrombus were 6.0% p=0.011), 8.0% (p=0.032), 6.0% (p=0.033), and 5.4% (p=0.004), respectively. CONCLUSION: Global and regional LAA mechanics were significantly related to conventional LAA functional parameters and to the presence of LAA-dense SEC/thrombus in patients with AF and may be useful as complementary data for estimating future thromboembolism.

Reprogramming the tachycardia parameters with long-detection strategy in patients with pre-existing implantable cardioverter-defibrillator.

Background: A long-detection interval (LDI) programming has been proved to reduce shock therapy in patients who underwent de novo implantable cardioverter defibrillator (ICD) implantation. We aimed to evaluate effectiveness and safety of this new strategy in old ICD recipients. Methods: We included 147 primary prevention patients with ischaemic and non-ischaemic aetiology. Conventional setting parameters (18 of 24 intervals to detect ventricular arrhythmias (VA's)) were reprogrammed with LDI strategy (30 of 40 intervals to detect VA's). One monitoring zone (between 360 and 330 ms) and two therapy zones were programmed, treating all rhythms of cycle length <330 ms that met the duration criterion of 30/40 intervals and were discriminated as ventricular tachycardia/ventricular fibrillation (VT/VF). The supraventricular tachycardia (SVT) discriminators were used in all patients. Results: At a median follow-up of 24 months, 12.9% (n = 19) of patients received shock therapies (± antitachycardia pacing (ATP)). Appropriate and inappropriate shocks occurred in 7.5 and 5.4% of patients during follow-up, respectively. Only one patient experienced an arrhythmic syncope during the follow-up period. There was no death related to LDI programming. The LDI programming helped to stop unnecessary in 10 patients (6.8%), who otherwise would have been treated in the conventional programming. Conclusions: LDI programming was found safe and effective. Hence, old ICD recipients will benefit from this strategy.

Bendopnea and Its Clinical Importance in Outpatient Patients with Pulmonary Arterial Hypertension.

PURPOSE: Bendopnea is a recently reported novel symptom in patients with heart failure (HF) defined as shortness of breath when bending forward. It has been demonstrated that bendopnea is associated with advanced symptoms and worse outcomes. The aim of this study was to assess the presence of bendopnea and its clinical importance with regards to functional status, hemodynamic and echocardiographic characteristics in outpatient pulmonary arterial hypertension (PAH) patients. METHODS: We conducted this prospective observational study of 53 patients who were admitted to our PAH clinic for routine control visits. We determined the presence of bendopnea and analyzed hemodynamic parameters, World Heart Organization (WHO) functional class, transcutaneous oxygen saturation, 6-minute walking distance (6-MWD), N-terminal pro-brain natriuretic peptide (NT-proBNP) and right ventricular (RV) function indicators in patients with and without bendopnea. RESULTS: Bendopnea was present 33.9% of the PAH patients. The mean age was higher in the patients with bendopnea than in those without bendopnea, but the difference was not significant (p = 0.201). The patients with bendopnea had a lower 6-MWD and higher NT-proBNP level (p < 0.001), and worse WHO functional class symptoms (p = 0.010). Mean right atrial pressure, pulmonary artery pressure, and pulmonary vascular resistance were higher in the patients with bendopnea. The patients with bendopnea had a more dilated RV end-diastolic diameter and lower tricuspid annular plane systolic excursion value (p < 0.001 and p = 0.001, respectively). CONCLUSIONS: Bendopnea was associated with worse functional capacity status, hemodynamic characteristics and RV function in our outpatient PAH patients.

Elevated levels of vitamin B12 in chronic stable heart failure: a marker for subclinical liver damage and impaired prognosis.

BACKGROUND: Elevated vitamin B12 is a sign for liver damage, but its significance in chronic stable heart failure (HF) is less known. The present study investigated the clinical correlates and prognostic significance of vitamin B12 levels in stable systolic HF. METHODS: A total of 129 consecutive patients with HF and 50 control subjects were enrolled. Data regarding demographics, clinical signs, therapeutic and conventional echocardiographic measurements were recorded for all patients. Right-sided HF was defined as the presence of at least one of the typical symptoms (ankle swelling) or specific signs (jugular venous distention or abdominojugular reflux) of right HF. Cox proportional hazards regression analyses were performed to determine the independent prognostic determinants of mortality. RESULTS: Baseline B12 levels in HF patients (n=129) with and without right sided HF were significantly higher compared to healthy controls (n=50): Median 311 pg/mL and 235 pg/mL vs 198 pg/mL, respectively (P=0.005). Folic acid levels were similar between the study groups. Age, ejection fraction, left atrial size, estimated glomerular filtration rate, and direct and indirect bilirubin levels were significantly correlated to serum B12 level in univariate analysis. In multivariate analysis, independent correlates of B12 were direct bilirubin (R=0.51, P<0.001) and age (R=0.19, P=0.028). Patients with HF were followed-up for a median period of 32 months. Median B12 levels were significantly higher in patients who subsequently died (n=35) compared to survivors, but folic acid was not different between the two groups. ROC analysis showed that B12 values ≥270 pg/mL had 80% sensitivity and 58% specificity for predicting all-cause mortality (area under the curve=0.672, 95% CI=0.562-0.781; P=0.003). However, in Cox regression analysis, only left atrial diameter, level of direct bilirubin, and the presence of abdominojugular reflux were independent predictors of death. CONCLUSION: Increased B12 in stable HF patients is associated with increased direct bilirubin due to right HF, indicating a cardiohepatic syndrome, but neither B12 nor folic acid are independently associated with mortality.

Predicting value of coupling interval variability in determining the origin of ventricular premature contractions with V3 transition.

PURPOSE: We aimed to investigate the predictive value of coupling interval variability (ΔCI) in determining the origin of idiopathic outflow tract ventricular tachycardia (OTVT) with V3 transition. METHODS: We reviewed data from 126 patients who underwent catheter ablation of OTVT between 2015 and 2018 at our institution. We identified 32 patients of successful OTVT ablation with a precordial transition at V3 derivation. The ΔCI (maximum - minimum CI) was measured. RESULTS: CI variability was significantly smaller for right ventricular (RV) OT than left ventricular  (LV) OT premature ventricular contractions (PVCs) (p = 0.004). In multivariate analysis, including QRS duration, R-wave duration in lead V1, R-wave amplitude in V1, PVC burden, and ΔCI, ΔCI was the only independent predictor of PVC origin (OR 0.963, 95% CI, 0.939-0.988, p < 0.001). A CI variability ≥ 30 predicted a PVC from LVOT origin with a sensitivity of 83% and specificity of 89%. ΔCI was compared with other previously proposed ECG criteria used to differentiate LVOT from RVOT PVCs. ΔCI exhibited a greater area under the curve (AUC) (0.867) than the other ECG criteria. A ΔCI ≥ 30 ms exhibited a high sensitivity of 89% and a specificity of 83%. CONCLUSIONS: ΔCI is outperformed other ECG criteria to differentiate LVOT from RVOT PVCs, and this parameter may be useful for planning the ablation strategy.

Surface electrogram-guided left ventricular lead placement improves response to cardiac resynchronization therapy.

OBJECTIVE: Failure to select the optimal left ventricular (LV) segment for lead implantation is one of the most important causes of unresponsiveness to the cardiac resynchronization therapy (CRT). In our study, we aimed to investigate the echocardiographic and clinical benefits of LV lead implantation guided by an intraoperative 12-lead surface electrocardiogram (ECG) in patients with multiple target veins. METHODS: We included 80 [42 (62.5%) male] heart failure patients who successfully underwent CRT defibrillator (CRT-D) implantation. Patients were divided into two groups. In group 1, LV lead was positioned at the site with the shortest biventricular-paced (BiV-paced) QRS duration (QRSd), as intraprocedurally measured using surface ECG. In group 2 (control), we included patients who underwent the standard unguided CRT. ECG, echocardiogram, and functional status were evaluated before and 6 months after CRT implantation in all patients. RESULTS: In group 1, BiV-paced QRSd measurements were successfully performed in 112 of 120 coronary sinus branches during CRT and an LV lead was successfully placed at the optimal site in all patients. Compared with group 2, group 1 had a significantly higher rate (85% vs. 50%, p=0.02) of response (>15% reduction in LV end-systolic volume) to CRT as well as a shorter QRSd (p<0.001) and a greater QRS shortening (ΔQRS) associated with CRT compared with baseline (p<0.001). The mean New York Heart Association functional class was significantly improved in both groups, and no significant differences were found in clinical response to CRT (85% vs. 70%, p=0.181). CONCLUSION: Surface ECG can be used to guide LV lead placement in patients with multiple target veins for improving response to CRT. Thus, it is a safe, feasible, and economic approach for CRT-D implantation.

A simple discharge risk model for predicting 1-year mortality in hospitalised acute decompansated heart failure patients with reduced ejection fraction.

OBJECTIVE: The risk stratification for prognosis in heart failure is very important for optimal disease management and decision making. The aim of this study was to establish a simple discharge 1-year mortality prediction model by integrating data obtained from demographic characteristics, clinical evaluation, laboratory biomarkers and echocardiographic evaluation of hospitalised heart failure with reduced ejection fraction (HFrEF) patients with acute decompensation. METHODS AND RESULTS: A risk score model was developed based on ß-coefficient number of variables in a multivariable logistic regression model which was created with the use of data on clinical, laboratory, imaging and therapeutic findings of 670 patients (65.4% males, 65 ± 11 years) who was hospitalised with acute decompensated HFrEF. The mean left ventricular ejection fraction (LVEF) was 26 ± 9%. Independent predictors of mortality were: age ≥75 years, sodium <130 mEq/L, hepatomegaly at admission, unable to use beta-blocker at discharge and LVEF ≤20%. The 1-year mortality rate was 7.8% in the study population. The existence of each predictor was scored as 1 point and the discharge risk score identified patients into low (0-1 points), intermediate (2-3 points) and high (4-5 points) risk individuals with 3, 15.6 and 44.4% 1-year mortality rates, respectively. The model performance evaluated by concordance index was 0.74. CONCLUSIONS: This simple discharge risk score model for hospitalised acute decompensated HFrEF patients using easily determined demographic characteristics, clinical signs, echocardiographic and laboratory data is a valuable and an easy risk assessment tool to use at point-of-care.

Predictors of Long-Term Mortality and Frequent Re-Hospitalization in Patients with Acute Decompensated Heart Failure and Kidney Dysfunction Treated with Renin-Angiotensin System Blockers.

BACKGROUND Assessment of risk for all-cause mortality and re-hospitalization is an important task during discharge of acute heart failure (AHF) patients, as they warrant different management strategies. Treatment with optimal medical therapy may change predictors for these 2 end-points in AHF patients with renal dysfunction. The aim of this study was to evaluate the predictors for long-term outcome in AHF patients with kidney dysfunction who were discharged on optimal medical therapy. MATERIAL AND METHODS The study was conducted retrospectively. The study group consisted of 225 AHF patients with moderate-to-severe kidney dysfunction, who were hospitalized at Kocaeli University Hospital Cardiology Clinic and who were prescribed beta-blockers and ACE-inhibitors or angiotensin II receptor blockers at discharge. Clinical, echocardiographic, and biochemical predictors of the composite of total mortality and frequent re-hospitalization (≥3 hospitalizations during the follow-up) were assessed using Cox regression and the predictors for each end-point were assessed by competing risk regression analysis. RESULTS Incidence of all-cause mortality was 45.3% and frequent readmissions were 49.8% in a median follow-up of 54 months. The associates of the composite end-point were age, NYHA class, respiration rate on admission, eGFR, hypoalbuminemia, mitral valve E/E' ratio, and ejection fraction. In competing risk regression analysis, right-sided HF, hypoalbuminemia, age, and uric acid appeared as independent associates of all-cause mortality, whereas NYHA class, NT-proBNP, mitral valve E/E' ratio, and uric acid were predictors for re-hospitalization. CONCLUSIONS Predictors for all-cause mortality in AHF with kidney dysfunction treated with optimal therapy are mainly related to advanced HF with right-sided dysfunction, whereas frequent re-hospitalization is associated with volume overload manifested by increased mitral E/E' ratio and NT-proBNP levels.

Improvement in left ventricular intrinsic dyssynchrony with cardiac resynchronization therapy.

OBJECTIVE: Cardiac resynchronization therapy (CRT) has been shown to induce a structural and electrical remodeling; the data on whether left ventricle (LV) reverse remodeling is associated with restitution of intrinsic contraction pattern are unknown. In this study, we investigated the presence of improvement in left ventricular intrinsic dyssynchrony in patients with CRT. METHODS: A total of 45 CRT recipients were prospectively studied. Dyssynchrony indexes including interventricular mechanical delay (IVMD) and tissue Doppler velocity opposing-wall delay (OWD) as well as QRS duration on 12-lead surface electrocardiogram were recorded before CRT device implantation. After 1 year, patients with chronic biventricular pacing were reprogramed to VVI 40 to allow the resumption of native conduction and contraction pattern. After 4-6 h of intrinsic rhythm, QRS duration and all echocardiographic measurements were recorded. Dyssynchrony was defined as IVMD >40 ms and OWD >65 ms. CRT response was defined by a ≥15% reduction in left ventricular end-systolic volume (LVESV) at a 12-month follow-up. RESULTS: Thirty-two patients (71%) showed response to CRT. The native QRS duration reduced significantly from 150±12 ms to 138±14 ms (p<0.001), and dyssynchrony indexes showed a significant improvement only in responders. The mean OWD reduced from 86±37 ms to 50±29 ms (p<0.001), and the mean IVMD decreased from 55±22 ms to 28±22 ms (p<0.001) in responders. The reduction in LVESV was significantly correlated with ΔOWD (r=0.47, p=0.001), ΔIVMD (r=0.45, p=0.001), and ΔQRS (r=0.34, p=0.022). CONCLUSION: Chronic CRT significantly improves LV native contraction pattern and causes reverse remodeling in dyssynchrony.

Effect of Oral Nitrates on All-Cause Mortality and Hospitalization in Heart Failure Patients with Reduced Ejection Fraction: A Propensity-Matched Analysis.

BACKGROUND: Hydralazine-nitrate combination is recommended for patients with heart failure with reduced ejection fraction (HFrEF)/systolic heart failure who are symptomatic despite guideline-directed medical therapy (GDMT). Use of nitrates alone for this indication is not well-established. This study aims to evaluate the effect of oral nitrates on all-cause mortality and hospitalization in HFrEF patients using GDMT. METHODS AND RESULTS: Nitrate prescription at discharge and its association with all-cause mortality and heart failure hospitalization were examined in a propensity-matched analysis of 648 HFrEF patients followed for a median of 56 months. A total of 269 (42%) patients died during that period. In Cox regression analysis, nitrate usage was associated with a slightly increased mortality risk compared with not using nitrates (hazard ratio 1.29; 95% confidence interval 1.01-1.65; P = .040), which continued modestly after the propensity-matched analysis (hazard ratio 1.26; 95% confidence interval 0.95-1.68; P = .102). In both prematch and propensity-matched analyses, nitrate use was not associated with risk of rehospitalization. No significant effect was detected on subgroups stratified by coronary artery disease, age, gender, and background medical therapy. CONCLUSIONS: In this study, oral nitrate use alone in addition to GDMT did not affect all-cause mortality and hospitalization risk in HFrEF patients during a long-term follow-up. There was even a modest tendency for increased risk of mortality.

Associations Between Neutrophil Gelatinase Associated Lipocalin, Neutrophil-to-Lymphocyte Ratio, Atrial Fibrillation and Renal Dysfunction in Chronic Heart Failure.

BACKGROUND Atrial fibrillation (AF) and renal dysfunction are two common comorbidities in patients with chronic heart failure with reduced ejection fraction (HFrEF). This study evaluated the effect of permanent AF on renal function in HFrEF and investigated the associations of atrial fibrillation, neutrophil gelatinase-associated lipocalin (NGAL), and neutrophil-to-lymphocyte ratio (NLR) with adverse clinical outcome. MATERIAL AND METHODS Serum NGAL levels measured by ELISA and NLR were compared between patients with sinus rhythm (HFrEF-SR, n=68), with permanent AF (HFrEF-AF, n=62), and a healthy control group (n=50). RESULTS Mean eGFR levels were significantly lower, and NLR and NGAL levels were significantly higher in the HFrEF patients than in the control patients but the difference between HFrEF-SR and HFrEF-AF was not statistically significant (NGAL: 95 ng/mL in HFrEF-SR, 113 ng/mL in HFrEF-AF and 84 ng/mL in the control group; p<0.001). Independent associates of baseline eGFR were age, hemoglobin, NLR, triiodothyronine, and pulmonary artery systolic pressure. In a mean 16 months follow-up, adverse clinical outcome defined as progression of kidney dysfunction and composite of all-cause mortality and re-hospitalization were not different between HFrEF-SR and HFrEF-AF patients. Although NGAL was associated with clinical endpoints in the univariate analysis, Cox regression analysis showed that independent predictors of increased events were the presence of signs right heart failure, C-reactive protein, NLR, triiodothyronine, and hemoglobin. In ROC analysis, a NLR >3 had a 68% sensitivity and 75% specificity to predict progression of kidney disease (AUC=0.72, 95% CI 0.58-0.85, p=0.001). CONCLUSIONS Presence of AF in patients with HFrEF was not an independent contributor of adverse clinical outcome (i.e., all-cause death, re-hospitalization) or progression of renal dysfunction. Renal dysfunction in HFrEF was associated with both NLR and NGAL levels, but systemic inflammation reflected by NLR seemed to be a more important determinant of progression of kidney dysfunction.

What is the lowest value of left ventricular baseline ejection fraction that predicts response to cardiac resynchronization therapy?

BACKGROUND: Cardiac resynchronization therapy (CRT) is an effective treatment option for patients with refractory heart failure. However, many patients do not respond to therapy. Although it has been thought that there was no relation between response to CRT and baseline ejection fraction (EF), the response rate of patients with different baseline LVEF to CRT has not been evaluated in severe left ventricular systolic dysfunction. We aimed to investigate any difference in response to CRT between the severe heart failure patients with different baseline LVEF. MATERIAL AND METHODS: In this study, 141 consecutive patients (mean age 59±13 years; 89 men) with severe heart failure and complete LBBB were included. Patients were divided into 3 groups according to their baseline LVEF: 5-15%, Group 1; 15-25%, Group 2, and 25-35%, Group 3. NYHA functional class, LVEF, LV volumes, and diameters were assessed at baseline and after 6 months of CRT. A response to CRT was defined as a decrease in LVSVi (left ventricular end-systolic volume index) ≥10% on echocardiography at 6 months. RESULTS: After 6 months, a significant increase of EF and a significant decrease of LVESVi and LVEDVi after 6 months of CRT were observed in all groups. Although the magnitude of improvement in EF was biggest in the first group, the percentage of decrease in LVESVi and LVEDVi was similar between the groups. The improvement in NYHA functional class was similar in all EF subgroups. At 6-month follow-up, 100 (71%) patients showed a reduction of >10% in LVESVi (mean reduction: -15.5±26.1 ml/m^2) and were therefore classified as responders to CRT. Response rate to CRT was similar in all groups. It was 67%, 75%, and 70% in Group 1, 2, and 3, respectively, at 6-month follow-up (p>0.05). There was no statistically significant relation between the response rate to CRT and baseline LVEF, showing that the CRT has beneficial effects even in patients with very low LVEF. CONCLUSIONS: It seems there is no lower limit for baseline LVEF to predict non-response to CRT in eligible patients according to current guidelines.

Arrhythmogenic right ventricular cardiomyopathy in pregnancy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is predominantly a genetically determined heart muscle disorder that is characterized by fibro-fatty replacement of the right ventricular (RV) myocardium.(1)) The clinical spectrum of ARVC may represent from asymptomatic premature ventricular complexes to ventricular tachycardia (VT) and sudden cardiac death (SCD). It is a well-known leading cause of SCD in young adults.(2,3))There is no general consensus on the management of ARVC in pregnancy, and the preferred mode of delivery is uncertain. Herein, we report a case of ARVC diagnosed at 20 weeks of gestation following a sustained VT and treated with an implantable cardiac defibrillator (ICD). We also reviewed the current knowledge and approach to ARVC in pregnancy since the literature on this condition is based on case reports.

Clinical ventricular tachycardia and surgical epicardial ICD implantation in a patient with a Fontan operation for double-inlet left ventricle.

The Fontan operation is the primary surgical technique used for palliation of patients with single-ventricle physiology. Arrhythmias are frequently observed and associated with morbidity and mortality in Fontan patients. The frequency of arrhythmias after the Fontan procedure increases over time and it was reported to reach 50% in a 20-year follow up. Atrial tachyarrhythmias, especially atrial tachycardia and sinus bradycardia, are most frequently observed in these patients. Ventricular arrhythmias are rarely observed. Generally, medical therapy, catheter ablation, pacemaker or implantable cardioverter defibrillator (ICD) implantation are options in the treatment of these arrhythmias. It may be difficult to implant either a pacemaker or an ICD in patients on whom the Fontan procedure has been performed. In conditions where access to the right ventricle is from the venous system, it is anatomically impossible. Where there is no functional right ventricle, device implantation can be performed with alternative methods other than the conventional transvenous approach. In this report, we discuss a middle-aged woman with a Fontan operation performed 14 years earlier, who presented with ventricular tachycardia (VT) and in whom an epicardial ICD was implanted. The literature on this issue is also reviewed.

Expert panel on cost analysis of atrial fibrillation.

OBJECTIVE: To estimate total cost of atrial fibrillation (AF) management concerning acute coronary syndrome, heart failure, stroke and drug related adverse events with respect to clinical practice and available guidelines. METHODS: This cost analysis study was based on identification of total costs related to management of acute coronary syndrome, heart failure, stroke and the drug related adverse events in patients with AF based on standardized questionnaire forms filled by experts according to their daily clinical practice and also to ACCF/AHA/ESC guidelines. Total cost included cost items related to treatment, healthcare resources utilization, and diagnostic test and consultations. RESULTS: The yearly cost of acute coronary syndrome per patient was 5.478.43 TL according to expert's view reflecting real clinical practice whereas it was 11.319.44 TL when calculation was based on recommendations in the guidelines. The average total cost of heart failure was 4.523.74 TL according to expert's view whereas it was 2.925.86 TL based on guidelines. The average total cost of stroke was 5.719.25 TL according to expert's view but 7.931.18 TL based on guidelines. Among drug related adverse events, only those related to cardiac adverse events were estimated to be higher according to expert view as compared to guideline recommendations (288.65 vs. 150.99 TL). CONCLUSIONS: Reflecting the treatment algorithms in the management of AF and related adverse events, our findings seem to emphasize the extra burden on health economics posed by patients suffering from the uncontrolled disease.