Different Cardio-Selective ß-Blockers and the Prevention of Exaggerated Blood Pressure Response During Exercise: A Retrospective Cross-Sectional Study.

OBJECTIVE: The aim of this study was to analyze the role of various ß-blockers in managing exercise-induced blood pressure escalations, referred to as exaggerated blood pressure response (eBPR). Despite the importance of this phenomenon, there is limited data on the efficacy of ß-blockers in controlling eBPR. METHOD: Our retrospective cohort for this study comprised 2,803 individuals who underwent treadmill tests from January 2016 to February 2018. A further subgroup analysis of 1,258 patients receiving ß-blocker treatment was performed to evaluate the influence of different ß-blockers on eBPR. RESULTS: The results demonstrated that ß-blockers play a significant role in mitigating the occurrence of eBPR (P = 0.026), irrespective of the specific type of ß-blocker. Additionally, no significant variance was observed in the development of eBPR among the different ß-blocker groups (P = 0.532 for systolic blood pressure (BP); P = 0.068 for diastolic BP). This finding remained consistent even among the 992 hypertensive patients, where no notable association was found between the type of ß-blocker and the development of eBPR (P = 0.736 for systolic BP; P = 0.349 for diastolic BP). It is noteworthy that patients using ß-blockers had unique clinical and demographic attributes. CONCLUSION: Our study suggests that ß-blockers can potentially deter the development of eBPR during physical activity, a benefit that is consistent across all types of ß-blockers. The study sheds light on prospective randomized studies on the use of eBPR as a new treatment target.

The 6-minute walk test and fall risk in patients with heart failure: A cross-sectional study.

BACKGROUND: Given the increased risk of falls in patients with heart failure (HF), there is limited information in the literature about the possible relationship between fall risk and functional capacity. OBJECTIVE: To investigate the relationship between functional capacity and fall risk in patients with HF and to determine whether there are differences in clinical parameters between patients with and without fall risk. METHODS: The study included 64 patients with HF. The Activity-Specific Balance Confidence Scale (ABC) determined the fall risk. Functional capacity was assessed with the 6-minute walk test (6MWT). The Berg Balance Scale (BBS), the timed up-and-go test (TUG), and the five times sit-to-stand (5-STS) test were used to evaluate functional balance and mobility. Comorbidities and dyspnea perception were assessed with the Charlson Comorbidity Index (CCI) and modified Medical Research Council (mMRC), respectively. RESULTS: The 6MWT was associated with fall risk in logistic regression with an odds ratio of 0.979 (0.970-0.989, p < 0.001). Furthermore, the 6MWT had a discriminative value for increased fall risk in patients with HF, with a cutoff value of 248 m. Patients with increased fall risk had lower 6MWT distance, BBS, and gait speed, and higher CCI and mMRC, number of falls, duration of TUG and 5STS compared to patients with no increased fall risk (p < 0.05). CONCLUSIONS: The study results demonstrated that 6MWT may be a clinically useful tool in quickly identifying potential balance problems and increased fall risk by providing insight into fall risk/balance confidence in addition to assessing functional capacity.

Cryoballoon ablation of non-PV triggers in persistent atrial fibrillation.

Cryoballoon-based catheter ablation has emerged as an efficacious and safe therapeutic intervention for patients with paroxysmal atrial fibrillation (PAF). PAF is primarily associated with the triggers in the pulmonary vein (PV). However, persistent atrial fibrillation (PeAF) is a complex condition that involves changes in the atrial substrate and the presence of non-PV triggers. Therefore, a comprehensive treatment approach is necessary for patients with PeAF. Utilizing a 3D electroanatomical map, the radiofrequency-based ablation technique adeptly identifies and targets the atrial substrate and non-PV triggers. On the other hand, the cryoballoon-based AF ablation was initially designed for PV isolation. However, its single-shot feature makes it a great choice for electrophysiologists looking to address non-PV triggers. It is possible to target the left atrial appendage (LAA), superior vena cava (SVC), left atrial roof, and posterior wall using the apparatus's unique configuration and ablation abilities. This review focuses on the increasing literature regarding cryoballoon-based methods for non-PV trigger ablation. Specifically, it delves into the technical procedures used to isolate the LAA, SVC, and ablate the left atrial roof and posterior wall.

Association of vectorcardiographic T-wave area with clinical and echocardiographic outcomes in cardiac resynchronization therapy.

AIMS: Data on repolarization parameters in cardiac resynchronization therapy (CRT) are scarce. We investigated the association of baseline T-wave area, with both clinical and echocardiographic outcomes of CRT in a large, multi-centre cohort of CRT recipients. Also, we evaluated the association between the baseline T-wave area and QRS area. METHODS AND RESULTS: In this retrospective study, 1355 consecutive CRT recipients were evaluated. Pre-implantation T-wave and QRS area were calculated from vectorcardiograms. Echocardiographic response was defined as a reduction of ≥15% in left ventricular end-systolic volume between 3 and 12 months after implantation. The clinical outcome was a combination of all-cause mortality, heart transplantation, and left ventricular assist device implantation. Left ventricular end-systolic volume reduction was largest in patients with QRS area ≥ 109 µVs and T-wave area ≥ 66 µVs compared with QRS area ≥ 109 µVs and T-wave area < 66 µVs (P = 0.004), QRS area < 109 µVs and T-wave area ≥ 66 µVs (P < 0.001) and QRS area < 109 µVs and T-wave area < 66 µVs (P < 0.001). Event-free survival rate was higher in the subgroup of patients with QRS area ≥ 109 µVs and T-wave area ≥ 66 µVs (n = 616, P < 0.001) and QRS area ≥ 109 µVs and T-wave area < 66 µVs (n = 100, P < 0.001) than the other subgroups. In the multivariate analysis, T-wave area remained associated with echocardiographic response (P = 0.008), but not with the clinical outcome (P = 0.143), when QRS area was included in the model. CONCLUSION: Baseline T-wave area has a significant association with both clinical and echocardiographic outcomes after CRT. The association of T-wave area with echocardiographic response is independent from QRS area; the association with clinical outcome, however, is not.

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.

Functional substrate mapping characteristics during sinus rhythm predicts critical isthmus of reentrant atrial tachycardia.

BACKGROUND: Atrial tachycardia (AT) is a commonly encountered rhythm disorder in patients with underlying atrial scar. The role of atrial late activation mapping during sinus rhythm to predict the critical isthmus (CI) of AT has yet to be systematically evaluated. We aimed to investigate the relationship between the functional substrate mapping (FSM) characteristics and the CI of reentrant ATs in patients with underlying atrial low-voltage areas. METHODS: Patients with history of left AT who underwent catheter ablation with 3D mapping using high-density mapping were enrolled. Voltage map and isochronal late activation mapping were created during sinus/paced rhythm to detect deceleration zones (DZ). Electrograms with continuous-fragmented morphology were also tagged. After induction of AT, activation mapping was performed to detect CI of the tachycardia. Atrial tachyarrhythmia (ATa) recurrence was defined as detection of atrial fibrillation or AT (≥30 s) during the follow-up. RESULTS: Among 35 patients [mean age: 62 ± 9, gender: 25 (71.5%) female] with left AT, a total of 42 reentrant ATs induced. Voltage mapping during sinus rhythm revealed low-voltage area of 37.1 ± 23.8% of the left atrium. The mean value of bipolar voltage, EGM duration, and conduction velocity during sinus rhythm corresponding to CI of ATs were 0.18 ± 0.12 mV, 133 ± 47 ms, and 0.12 ± 0.09 m/s, respectively. Total number of DZs per chamber was 1.5 ± 0.6, which were located in the low-voltage zone (<0.5 mV) detected by high-density mapping. All CIs of reentry were colocalized with DZs detected during FSM. The positive predictive value of DZs to detect CI of inducible ATs is 80.4%. Freedom from ATa after the index procedure was 74.3% during a mean follow-up of 12.2 ± 7.5 months. CONCLUSION: Our findings demonstrated the utility of FSM during sinus rhythm to predict the CI of AT. DZs displayed continuous-fragmented signal morphology with slow conduction which may guide to tailor ablation strategy in case of underlying atrial scar.

Comparison of the relation of the ESC 2021 and ESC 2013 definitions of left bundle branch block with clinical and echocardiographic outcome in cardiac resynchronization therapy.

INTRODUCTION: We aimed to investigate the impact of the 2021 European Society of Cardiology (ESC) guideline changes in left bundle branch block (LBBB) definition on cardiac resynchronization therapy (CRT) patient selection and outcomes. METHODS: The MUG (Maastricht, Utrecht, Groningen) registry, consisting of consecutive patients implanted with a CRT device between 2001 and 2015 was studied. For this study, patients with baseline sinus rhythm and QRS duration ≥ 130ms were eligible. Patients were classified according to ESC 2013 and 2021 guideline LBBB definitions and QRS duration. Endpoints were heart transplantation, LVAD implantation or mortality (HTx/LVAD/mortality) and echocardiographic response (LVESV reduction ≥15%). RESULTS: The analyses included 1.202, typical CRT patients. The ESC 2021 definition resulted in considerably less LBBB diagnoses compared to the 2013 definition (31.6% vs. 80.9%, respectively). Applying the 2013 definition resulted in significant separation of the Kaplan-Meier curves of HTx/LVAD/mortality (p < .0001). A significantly higher echocardiographic response rate was found in the LBBB compared to the non-LBBB group using the 2013 definition. These differences in HTx/LVAD/mortality and echocardiographic response were not found when applying the 2021 definition. CONCLUSION: The ESC 2021 LBBB definition leads to a considerably lower percentage of patients with baseline LBBB then the ESC 2013 definition. This does not lead to better differentiation of CRT responders, nor does this lead to a stronger association with clinical outcomes after CRT. In fact, stratification according to the 2021 definition is not associated with a difference in clinical or echocardiographic outcome, implying that the guideline changes may negatively influence CRT implantation practice with a weakened recommendation in patients that will benefit from CRT.

Relationship between left atrial functions and ambulatory blood pressure variability in patients with heart failure and preserved ejection fraction.

Aim    The aim of this study was to investigate the relationship between left atrial (LA) abnormalities and ambulatory blood pressure variability (BPV) in heart failure with preserved ejection fraction (HFpEF) patients.Material and methods    In this single-center, prospective study, we included 187 patients with HFpEF. Eighteen patients with poor image quality were excluded from the study. BPV was evaluated using 24-h ambulatory blood pressure (BP) monitoring. The standard deviation of systolic BP (SBP-SD) was calculated to assess BPV. The patients were classified into two groups according to median SBP-SD (10.5 mm Hg).Results    Overall, 169 HFpEF patients (69.2% women, mean age 69.2±11 yrs) were evaluated. There were 98 patients (57.9%) with a SBP-SD greater than 10.5 mm Hg. Patients with higher SPB-SD had significantly higher left atrial stiffness (LASt) and lower LA reservoir strain (LASr) than those with low SPB-SD. LASt was correlated with 24 hr SBP-SD in both sinus rhythm (r= 0.35, p= 0.015) and atrial fibrillation patients (r= 0.32, p= 0.005). There were significant correlations between night-time SBP-SD and LASr (r=-0.23, p=0.045) in HFpEF with sinus rhythm. For all HFpEF patients, multiple regression analyses showed that 24-hr SBP-SD was correlated with LASt (coeff.=0.40, 95%CI= 0.52-5.25, P= 0.017).Conclusions    High BPV is associated with impaired LA function, especially for LASt and LASr. This study may provide insight for larger multicenter studies to evaluate the effects on outcomes in HFpEF.

Comparison of atrial fibrillation ablation using cryoballoon versus radiofrequency in patients with left common pulmonary veins: mid-term follow-up results.

PURPOSE: Cryoballoon (CB) and radiofrequency (RF) ablation techniques have similar outcomes for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). However, there is limited data about the impact of different ablation strategies in patients with left common pulmonary vein (LCPV). Our aim was to compare the safety and efficacy of RF and CB ablation in AF patients with LCPV. METHODS: One hundred and twenty-seven (n = 80 CB and n = 47 RF) AF patients with LCPV detected by preprocedural computerized tomography (CT) were included in the study. Ostial dimensions and trunk distance were measured in all patients. Atrial tachyarrhythmia (ATa) recurrence was defined as detection of AF, atrial flutter, or atrial tachycardia (≥ 30 s) after a 3-month blanking period. RESULTS: There was no significant difference in acute procedural success rates for PVI (97.5% in CB and 97.9% in RF, respectively, P = 0.953) and complication rates were similar between the groups (6 (7.5%) in CB and 4 (8.5%) in RF, respectively, P = 1.000). During a median follow-up of 20.7 (4.8-50.2) months for CB and 20.5 (6.2-36.0) months for RF, ATa recurrence was 35.0% and 38.2%, respectively (P = 0.777). Multivariate analysis did not reveal any of the morphologic parameters of LCPV as a significant predictor of ATa recurrence. CONCLUSIONS: Our findings demonstrated that both CB and RF ablation techniques have similar efficacy and safety in AF patients with LCPV during the mid-term follow-up.

Prognostic value of D-dimer/fibrinogen ratio on in-hospital outcomes of patients with heart failure and COVID-19.

Aim: In the present study, the relationship between D-dimer/fibrinogen ratio (DFR) and in-hospital outcomes was evaluated in patients with COVID-19 and a diagnosis of heart failure (HF). Materials & methods: In-hospital outcomes were compared in patients with high and low DFR values. Results: With regard to in-hospital outcomes, patients in the third tertile of DFR had a higher rate of mechanical ventilation, cardiogenic shock and death (p < 0.001). The length of ICU stay was longer in the third tertile group (p < 0.001). When evaluated together with infection markers, DFR was found to be an independent predictor of outcomes. Conclusion: DFR can be used as a prognostic marker in patients with COVID-19 with a diagnosis of HF, and perhaps more valuable than other infection markers.

Assessment of fragmented QRS formation and its relationship with left ventricular hypertrophy in nonhypertensive acromegaly patients

Background/aim: It is known that the presence of fragmented QRS (fQRS) on electrocardiography (ECG) is associated with cardiovascular events. The aim of this study was the evaluation of fQRS formation and its relationship with the left ventricular hypertrophy (LVH) parameters in acromegaly patients. Materials and methods: In total, 47 previously diagnosed with non-hypertensive acromegaly patients and 48 control subjects were included in the study. ECG and transthoracic echocardiography (TTE) were performed for each participant. Acromegaly patients were divided into two groups according to the fQRS formation on the ECG. Left ventricular wall thicknesses, and left atrial diameter (LAD), left ventricular mass (LVM), left ventricular mass index (LVMi), and relative wall thickness (RWT) were obtained. Results: In control group 5 (10.4%) and in acromegaly group 17 (36.2%) patients had fQRS on ECG (p = 0.003). LAD [36.0 (34.0­38.0) vs. 38.0 (35.0­41.0) mm, p < 0.001], LVM [155.27 ± 27.00 vs. 173.0 (153.0­235.0) g, p < 0.001], LVMi [83.12 ± 13.19 vs. 92.0 (83.0­118.0) g/m², p < 0.001] and RWT [0.39 ± 0.03 vs. 0.43 (0.41­0.45), p = 0.001] were significantly higher in patients with acromegaly. Disease duration was significantly higher (11.59 ± 1.3 vs. 8.2 ± 1.8 years, p < 0.001) in the fQRS (+) group. LAD [41.0 (39.0­42.5) vs. 37.0 (34.7­38.0) mm, p < 0.001], LVM [219.0 (160.5­254.5) vs. 164.0 (153.0­188.0) g, p = 0.017], LVMi [117.0 (92.5­128.5) vs. 86.0 (82.0­100.2) g/m², p = 0.013] and RWT [0.44 (0.42­0.49) vs. 0.43 (0.40­0.44), p = 0.037] were significantly higher in fQSR (+) acromegaly patients. In multivariate logistic regression analysis, disease duration (odds ratio: 10.05, 95% CI: 1.099­92.012, p = 0.041) and LAD (odds ratio: 2.19, 95% CI: 1.030­4.660, p = 0.042) were found to be the independent predictors of fQRS formation. Conclusion: The results of our study revealed that fQRS (+) acromegaly patients had increased LVH parameters compared to fQRS (-) patients.

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.

Transseptal access through atrial flow regulator device during ventricular tachycardia ablation.

Novel interventional therapies for heart failure patients are emerging like atrial flow regulator (AFR). Our case showed that endocardial ventricular tachycardia (VT) ablation could be performed safely by passing through the AFR device lumen without additional transseptal puncture in these patients.

Association of ECG characteristics with clinical and echocardiographic outcome to CRT in a non-LBBB patient population.

PURPOSE: Effectiveness of cardiac resynchronization therapy (CRT) in patients without left bundle branch block (non-LBBB) QRS morphology is limited. Additional selection criteria are needed to identify these patients. METHODS: Seven hundred ninety consecutive patients with non-LBBB morphology, who received a CRT-device in 3 university centers in the Netherlands, were selected. Pre-implantation 12-lead ECGs were evaluated on morphology, duration, and area of the QRS complex, as well as on PR interval, left ventricular activation time (LVAT), and the presence of fragmented QRS (fQRS). Association of these ECG features with the primary endpoint: a combination of left ventricular assist device (LVAD) implantation, cardiac transplantation and all-cause mortality, and secondary endpoint-echocardiographic reduction of left ventricular end-systolic volume (LVESV)-were evaluated. RESULTS: The primary endpoint occurred more often in non-LBBB patients with with PR interval ≥ 230ms, QRS area < 109µVs, and with fQRS. Multivariable regression analysis showed independent associations of QRS area (HR 2.33 [1.44, 3.77], p = 0.001) and PR interval (HR 2.03 [1.51, 2.74], p < 0.001) only. Mean LVESV reduction was significantly lower in patients with baseline RBBB, QRS duration < 150 ms, PR interval ≥ 230 ms, and in QRS area < 109 µVs. Multivariable regression analyses only showed significant associations between QRS area ≥ 109 µVs (OR 2.00 [1.09, 3.66] p = 0.025) and probability of echocardiographic response to CRT. CONCLUSIONS: In the heterogeneous non-LBBB patient population, QRS area and PR prolongation rather than traditional QRS duration and morphology are associated to both clinical and echocardiographic outcomes of CRT.

Long-Term Prognostic Value of Coronary Atherosclerotic Plaque Characteristics Assessed by Computerized Tomographic Angiography.

We aimed to present the long-term prognostic role of coronary computed tomography angiography (CTA) in a cohort of patients with coronary artery disease (CAD) and noncritical stenosis. A total of 1138 patients who underwent coronary CTA for suspected CAD were included in the study. For the categorization of the coronary atherosclerotic plaque (CAP), the coronary system was divided into 16 segments. For each segment, CAPs were categorized as calcified, noncalcified, and mixed. All-cause and cardiovascular (CV) mortality data were collected for prognostic evaluation. Coronary CTA analyses showed that 34.5% of patients had noncalcified CAP, 14.5% of patients had calcified CAP, and 11% of patients had mixed CAP. During a median of 141.5 months follow-up, CV and all-cause mortality was observed in 57 (5%) and 149 (13.1%) patients, respectively. In multivariable Cox regression analysis, calcified CAP morphology and the extent of involved segments were significant predictors of both CV and all-cause mortality. The presence of calcified CAP morphology and the higher number of diseased coronary segments via coronary CTA might help stratify patients at risk for adverse CV outcomes during long-term follow-up. Patients with these features at index coronary CTA may be evaluated more closely with aggressive preventive measures.