Heparin reversal with protamine sulfate is not required in atrial fibrillation ablation with suture hemostasis.

BACKGROUND: The utility of protamine sulfate for heparin reversal in catheter-based atrial fibrillation (AF) ablation is unclear when using the suture closure technique for vascular hemostasis. OBJECTIVE: This study sought to address if protamine sulfate use for heparin reversal reduces vascular access complications in AF catheter ablation when suture techniques are used for postprocedural vascular hemostasis. METHODS: This is a retrospective multicenter observational study of 294 consecutive patients who underwent catheter ablation for AF with subsequent vascular access hemostasis by means of a figure-of-eight suture or stopcock technique. A total of 156 patients received protamine for heparin reversal before sheath removal while 138 patients did not receive protamine. The two groups were compared for procedural activated clotting time (ACT), access site complications, and duration of hospital stay. RESULTS: Baseline demographic characteristics were comparable in both groups. Despite higher ACT before venous sheath removal in patients not receiving protamine (288.0 ± 44.3 vs 153.9 ± 32.0 seconds; P < .001), there was no significant difference in groin complications, postoperative thromboembolic events, or duration of hospital stay between the two groups. Suture failure requiring manual compression was rarely observed in this cohort (0.34%). CONCLUSION: With modern vascular access and sheath management techniques, for patients undergoing catheter ablation for AF, simple suture closure techniques can obviate the need for protamine administration to safely achieve hemostasis after removal of vascular sheaths.

Risk Stratification of Patients Presenting with Transient Loss of Consciousness.

Important goals in the initial evaluation of patients with transient loss of consciousness include determining whether the episode was syncope and choosing the venue for subsequent care. Patients who have high short-term risk of adverse outcomes need prompt hospitalization for diagnosis and/or treatment, whereas others may be safely referred for outpatient evaluation. This article summarizes the most important available risk assessment studies and points out key differences among the existing recommendations. Current risk stratification methods cannot replace critical assessment by an experienced physician, but they do provide much needed guidance and offer direction for future risk stratification consensus development.

Mechanical prosthetic valve disease is related with an increase in depression and anxiety disorder.

AIM: Patients with organic disease can present with psychiatric symptoms. We hypothesized that since patients with prosthetic heart valve require frequent hospital followup and are at higher risk for complications, the incidence of depression and anxiety is higher in these patients. METHODS: This cross-sectional study prospectively studied 98 consecutive patients with mechanical prosthetic heart valve. All patients fulfilled prosthetic heart valve evaluation form, Beck Depression Inventory (BDI) and Hamilton Anxiety Scale (HAS). Complete blood count, basic metabolic panel and echocardiogram results were collected for all the patients. RESULTS: Using the BDI, there were 26 patients (27%) with no depression, 20 (20%) with mild depression, 38 (39%) with moderate, 4 (4%) with severe and 10 (10%) patients with very severe depression. Avarege score was 18.3±11.4 on BDI and 19.1±11.1 on HAS. The depression level was positively associated with prothrombin time (p les than 0.001) and international normalized ratio (INR) level (p les than 0.001). Hamilton Anxiety Scale was significantly correlated with comorbidities (r: 0.344; p=0.002), blood transfusion (r: 0.370; p les than 0.001), obesity (r: 0.319; p=0.007) and Beck Depression Scale was correlated with comorbidities (r: 0.328; p=0.002), in patients with prosthetic heart valve disease. CONLUSION: Patients with prosthetic heart valve have higher prevalence of depression and higher scores of anxiety and depression. Early recognition and appropriate treatment of depression and anxiety may decrease the morbidity in prosthetic heart valve disease. Besides, use of new oral anticoagulant agents that do not need INR check, could decrease anxiety and depression in the future.

High levels of high-sensitivity C-reactive protein and uric acid can predict disease severity in patients with mitral regurgitation.

INTRODUCTION: Both high-sensitivity CRP (hs-CRP) and uric acid (UA) levels are known to be increased in heart failure patients and are associated with poorer functional capacity and adverse outcome. The role of these markers in patients with mitral regurgitation (MR) is less clear. The aim of this study was to assess the relationship between hs-CRP, UA and organic MR. We also assessed whether hs-CRP and UA levels are correlated with symptoms of MR, severity of MR, LV remodeling and outcome during follow-up. METHODS: A total of 200 consecutive patients (87 men [43.5%]; mean age 61.6±12.5 years) with moderate or severe isolated and organic MR were included in the study. All the patients were assessed clinically and were managed and treated with standard medical therapy according to evidence-based practice guidelines. Patients were categorized according to New York Heart Association (NYHA) functional class. We assessed and graded the severity of MR using a multiparametric approach. hs-CRP was measured with chemiluminescent immunometric assay using an IMMULITE® 1000 autoanalyzer (Siemens, Germany). Serum UA levels were analyzed using a Cobas® 6000 autoanalyzer (Roche Diagnostics, Mannheim, Germany). RESULTS: Mean UA levels increased significantly with NYHA class: 4.46±1.58 mg/dl for patients in NYHA class I, 5.91±1.69 mg/dl for class II, 6.31±2.16 mg/dl for class III and 8.86±3.17 mg/dl for class IV (p<0.001). Mean UA levels also increased significantly with increased severity of MR (moderate 5.62±1.9 mg/dl, moderate to severe 5.56±1.2 mg/dl, severe 7.38±3.4 mg/dl, p<0.001). There was a significant correlation between UA level and left ventricular end-diastolic diameter (r=0.40; p<0.001), left ventricular end-systolic diameter (r=0.297; p=0.001) and left ventricular ejection fraction (LVEF) (r=0.195, p=0.036), whereas hs-CRP was not correlated with these parameters. In multivariate Cox proportional hazards analysis LVEF, NYHA class and UA levels were the only independent predictors of death. CONCLUSION: UA and hs-CRP levels can help identify patients with asymptomatic moderate or severe mitral regurgitation. UA levels may be useful to assess the extent of left ventricular remodeling and in the optimal timing of mitral valve surgery in certain subsets of patients.

Risk of new-onset atrial fibrillation and stroke after radiofrequency ablation of isolated, typical atrial flutter.

BACKGROUND: Radiofrequency ablation (RFA) is considered a curative procedure for typical atrial flutter (AFL); however, patients remain at risk for developing new atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to determine the incidence and predictors of new-onset AF and stroke after RFA of isolated AFL in a multicenter cohort. METHODS: The study included 315 consecutive patients who underwent successful RFA of isolated, typical AFL from 2006 to 2013 at 4 community and teaching hospitals. Patients with any history of AF prior to RFA were excluded. RESULTS: During 2.5 ± 1.8 years of follow-up after RFA, 80 patients (25%) developed new AF. In multivariate analysis, after adjusting for baseline medical therapy, obstructive sleep apnea and left atrial enlargement were independently associated with the development of new AF. Presence of a cardiac implantable electronic device (CIED) was associated with a 3.6-fold (95% confidence interval 1.9-6.6, P <.0001) increase in the likelihood of AF detection. New AF was detected in 48% of patients with CIED and 35% of those who underwent Holter ECG vs 19% of those with clinical follow-up only (P <.0001). Anticoagulation was stopped in 58% patients an average of 3.3 ± 4.8 months after RFA. Stroke occurred in 3 patients (1%) during the follow-up period. CONCLUSION: New AF occurs in ≥25% of patients after RFA of isolated typical AFL, but stroke is relatively rare. Obstructive sleep apnea and left atrial enlargement are risk factors for AF. The presence of a CIED significantly enhances the likelihood of detecting new AF, demonstrating the importance of arrhythmia surveillance after RFA of AFL.

The degree of left atrial structural remodeling impacts left ventricular ejection fraction in patients with atrial fibrillation.

OBJECTIVES: The extent of left atrial (LA) wall structural remodeling (fibrosis) detected by late gadolinium enhancement-magnetic resonance imaging (LGE-MRI) is correlated with advanced atrial fibrillation (AF). The concomitant occurrence of AF and left ventricular (LV) dysfunction is not uncommon. We studied the effect of LA fibrosis, a confounder of both AF and LV dysfunction, on LV ejection fraction (EF). STUDY DESIGN: For the analysis, we identified and included 384 patients from our retrospective AF database who underwent LGE-MRI and transthoracic echocardiography prior to AF ablation. Based on the degree of LA fibrosis, patients were categorized into four stages as: Utah 1 (<5% LA fibrosis), Utah 2 (5-20% fibrosis), Utah 3 (20-35% fibrosis), and Utah 4 (>35% fibrosis). RESULTS: The average pre-ablation LVEF was 60.5%±8.5% (n=24) in Utah stage 1 patients, 55.7%±10.3% (n=240) in Utah stage 2 patients, 51.7±11.5% (n=90) in Utah stage 3 patients, and 48.9%±11.6% (n=30) in Utah stage 4 patients (p<0.001, one-way ANOVA). The percentage of LA fibrosis was significantly negatively correlated to LVEF pre-ablation in a univariate analysis (p<0.001). In a multivariate model accounting for age, gender, AF type, and comorbidities such as diabetes and hypertension, Utah stage remained a significant predictor of pre-ablation EF (p<0.001). CONCLUSION: Patients with extensive LA fibrosis appear to have depressed LV function pre-ablation, suggesting that structural remodeling in the LA may also be triggering and promoting remodeling within the ventricular myocardium.

The REDUCED (a RandomisED stUdy Comparing standard systemic anticoagulation thErapy to low Dose intracoronary anticoagulation therapy for elective percutaneous coronary intervention) trial. A novel pharmacologic regime for elective percutaneous coronary intervention.

AIM: This study tried to determine the efficacy and safety of low-dose intracoronary unfractionated heparin (UFH) in elective percutaneous coronary intervention (PCI). METHODS: Two-hundred patients who underwent elective PCI of an uncomplicated lesion were included into the study. The patients were assigned to either a control group (70-100 IU/kg intravenous UFH) or a low-dose intracoronary UFH (1,000 IU intracoronary UFH) group. RESULTS: At 30 days, the primary end point (composite of death, myocardial infarction, or urgent target vessel revascularization) was similar in both groups [intracoronary UFH group, 1.0%; control group, 2.0%; odds ratio; 0.49 (95% CI: 0.04 - 5.54), P = 0.56]. Post-procedural myocardial injury (according to CK-MB, P = 0.91; according to Tn I, P = 0.81) and bleeding events (based on TIMI criteria, P = 0.33; based on STEEPLE criteria, P = 0.20) were similar in the control and intracoronary groups. The primary end point at 6 months was also similar between the two groups (P = 0.33). Moreover, the health care cost at 30 days of follow-up was lower in the intracoronary group than in the control group (1,016 ± 54 $/patient vs 1,110 ± 102 $/patient, P < 0.001). CONCLUSION: This pilot study suggests that elective PCI could be safely performed with low-dose intracoronary UFH in the treatment of uncomplicated lesions and at a lower cost as compared to standard systemic anticoagulation.These results should be confirmed by further studies.

Predictive value of atrial electromechanical delay for atrial fibrillation recurrence.

BACKGROUND: We investigated the predictive value of atrial electromechanical delay (AEMD) for recurrence of atrial fibrillation (AF) at 1-month after cardioversion. METHODS: Seventy-seven patients with persistent AF were evaluated and finally 50 patients (12 men, 38 women) were included. All patients underwent transthoracic electrical DC cardioversion under amiodarone treatment. AEMD was measured as the time interval from the onset of the P wave on electrogram (ECG) to the beginning of late diastolic wave (Am) from the ventricular annulus and atrial walls on tissue Doppler imaging, in the apical 4-chamber view 24 h after cardiversion. P wave maximum-duration (Pmax), P wave minimum-duration (Pmin) and P wave dispersion-duration (Pdis) were calculated on the 12-lead ECG at 24-h postcardioversion. We followed the heart rate and rhythm by 12-lead ECG at 24-h, 1-week and 1-month. RESULTS: At 1-month follow-up after cardioversion, 28 (56%) patients were in sinus rhythm (SR), whereas 22 (44%) patients reverted to AF. The AEMD durations were longer in AF group than SR group (p < 0.001) and were signifi cantly correlated with Pmax and Pdis (p < 0.001 for both). For AF recurrence; duration of AF, left atrial (LA) diameter, maximum LA volume index, mitral A velocity and LA lateral AEMD were significant parameters in univariate-analysis, however LA lateral AEMD was the only significant parameter in multivariate-analysis (OR: 1.46; 95% CI 1.02-2.11; p = 0.03). CONCLUSIONS: Our results suggest that AEMD is associated with an increased risk of recurrence of AF within 1-month. These data may have implications for the identification of patients who are most likely to experience substantial benefit from cardiversion therapy for AF.

Early assessment of percutaneous coronary interventions for chronic total occlusions analyzed by novel echocardiographic techniques.

OBJECTIVE: Successful revascularization of chronic total occlusions has been associated with improved left ventricular systolic function, reduced anginal symptoms, increased exercise capacity, and increased survival. This study was conducted to determine the impact of revascularization in chronic total occlusion on left ventricular function using novel echocardiographic techniques. METHODS: A total of 129 patients with chronic total occlusion who underwent revascularization between April 2011 and November 2012 were included in this study. Echocardiographic assessments with two-dimensional speckle tracking echocardiography and real-time three-dimensional echocardiography were performed before the procedure and one month after the procedure. The left ventricular ejection fraction, left ventricular volumes, and three-dimensional systolic dyssynchrony index were quantified. RESULTS: An immediate procedural success was obtained in 118 patients (91.5%). There were no acute or subacute stent thromboses during follow-up. The mean left ventricular ejection fraction significantly increased (p<0.001), while the left ventricular end-diastolic and end-systolic volumes significantly decreased (p = 0.001 and p<0.001, respectively). The three-dimensional systolic dyssynchrony index also decreased significantly (p<0.001). The global longitudinal strain showed a significant increase after successful revascularization (p<0.001). An increase in the global longitudinal strain was correlated with an increase in the left ventricular ejection fraction (r = 0.27, p = 0.02). The patients with a left ventricular ejection fraction ≥50% displayed a greater improvement in the global longitudinal strain, and the patients with diabetes showed less improvement. CONCLUSIONS: Using novel echocardiographic techniques, our results showed that restoring the coronary blood flow in chronic total occlusion patients reduces the left ventricular volumes and improves the left ventricular ejection fraction and the global longitudinal strain of hibernating myocardium.

Electrocardiographic and echocardiographic evidence of myocardial impairment in patients with overt hypothyroidism.

OBJECTIVE: Our aim was to evaluate cardiac function and myocardial contractility in patients with overt hypothyroidism using two-dimensional speckle tracking echocardiography (2D-STE) strain imaging and real-time three-dimensional echocardiography (RT3DE) and compare the changes at one month after starting the treatment. We also compared the P wave dispersion (Pdis) in patients with and without hypothyroidism. SUBJECTS AND METHODS: Forty-one patients with overt hypothyroidism and forty age- and body mass index-matched healthy subjects underwent conventional echocardiography, RT3DE and 2D-STE for assessment of resting LV function. Electrocardiography (ECG) recordings were obtained and the P wave parameters were calculated. Measurements of RT3DE volumes and ejection fraction (EF) were performed. Global longitudinal strain (GLS) was calculated from 3 standard apical views using 2D-STE. RESULTS: Patients with overt hypothyroidism had significantly longer isovolumic contraction time (P<0.001), deceleration time (P<0.001) and isovolumic relaxation time (P<0.001). On RT3DE evaluation, none of the patients in both groups had LV systolic dysfunction with comparable LVEF and LV volumes. However, speckle tracking analysis showed that GLS was significantly reduced in the overt hypothyroidism group compared to control group (P<0.001). At one month follow-up after the treatment, GLS significantly improved in overt hypothyroidism group (P<0.001). Patients in the overt hypothyroidism group had increased Pdis compared to control group (P=0.02). CONCLUSIONS: Overt hypothyroidism may be related to impairment of LV longitudinal myocardial function, and 2D-STE is useful for the detection of early impairment. Successful treatment of overt hypothyroidism has a beneficial effect on cardiac functions. In addition, overt hypothyroidism has increased risk for atrial arrhythmias due to high Pdis value.

Improvement of left ventricular diastolic function and left atrial reverse remodeling after catheter ablation of premature ventricular complexes.

AIMS: Catheter ablation of premature ventricular complexes (PVC) improves left ventricular (LV) systolic performance in certain patients; however, the effect on diastolic function and left atrial (LA) remodeling is unclear. We assessed the effects of catheter ablation of PVCs on parameters of LV diastolic function and LA remodeling. METHODS: Forty-seven patients (age 65 ± 10 years, 46 men) who underwent catheter ablation for symptomatic PVCs were evaluated using two-dimensional echocardiography before and 6 ± 2 months after ablation. The measured diastolic indices included mitral inflow parameters (E wave, A wave, E/A ratio, and deceleration time (DT)), mitral lateral annulus early diastolic velocity (Ea), and E/Ea ratio. The LA volume was measured using modified biplane Simpson's method. We also compared the changes in the left atrial volumes and left atrial volume index (LAVI) after PVC ablation. RESULTS: After catheter ablation of PVCs, the mean LV ejection fraction (EF) increased significantly (49.9 ± 10.3 vs. 42.8 ± 11.8, p < 0.01). Significant improvement was also seen in A wave velocity (71.3 ± 17.1 vs. 59.5 ± 15.1 cm/s, p = 0.039), E/A ratio (1.42 ± 0.6 vs. 1.07 ± 0.5 ml, p = 0.034), Ea (8.9 ± 3.9 vs. 6.8 ± 2.9 cm/s, p = 0.04), and E/Ea ratio (15.4 ± 5.8 vs. 10.6 ± 3.4, p = 0.027), whereas mitral E and DT did not show significant change. LAVI decreased significantly after ablation (44.4 ± 14.8 vs. 36.7 ± 12.5, p < 0.001). Significant improvement in LAVI was also seen in patients with normal baseline LVEF (p = 0.04). CONCLUSION: Catheter ablation of PVCs improved LV diastolic function and resulted in left atrial reverse remodeling.

Efficacy and benefits of catheter ablation of ventricular premature complexes in patients younger and older than 65 years of age.

OBJECTIVES: Catheter ablation of ventricular premature complexes (VPC) improves clinical status and systolic performance of the left ventricle (LV) in a certain subset of patients; however, whether or not VPC ablation is equally effective in younger (<=65 years) and older (>65 years) patients remains unclear. We aimed to assess the clinical benefits of catheter ablation of VPCs in elderly patients. STUDY DESIGN: Fifty-one consecutive patients (66±10 years, 49 male) who underwent catheter ablation for symptomatic VPCs were included into the study. Twenty-seven patients were aged >65 years and 24 patients <=65 years. Frequency of VPCs per total heart beats by 24-hour Holter monitoring, LV ejection fraction (LVEF) and end-systolic diameters (LVEDD) were evaluated before and 6±3 months after ablation. RESULTS: The pre-ablation 24-hour VPC burden and VPC number were significantly higher in patients >65 years compared to those <=65 years (31±15.3 vs. 21.9±12.6, p=0.04 and 34493±21226 vs. 23554±13792, p=0.026, respectively). At the follow-up after catheter ablation, the mean VPC burden had decreased to 9.1±10.3% (p<0.001) in patients >65 years and to 3.8±7.1 (p<0.001) in patients <=65 years. Mean LVEF showed a significant increase in both groups after ablation (43.4±10.4 vs. 51.5±8.2, p=0.005 for age >65 years and 40.8±13.2 vs. 49.5±11.8, p=0.003 for age <=65 years). The improvement in LVEF was accompanied by a significant decrease in LVEDD (p=0.032 for age >65 years and p=0.047 for <=65 years). CONCLUSION: Catheter ablation is effective for treatment of frequent VPCs in all age groups.

Early assessment of percutaneous coronary interventions for chronic total occlusions analyzed by novel echocardiographic techniques

OBJECTIVE: Successful revascularization of chronic total occlusions has been associated with improved left ventricular systolic function, reduced anginal symptoms, increased exercise capacity, and increased survival. This study was conducted to determine the impact of revascularization in chronic total occlusion on left ventricular function using novel echocardiographic techniques. METHODS: A total of 129 patients with chronic total occlusion who underwent revascularization between April 2011 and November 2012 were included in this study. Echocardiographic assessments with two-dimensional speckle tracking echocardiography and real-time three-dimensional echocardiography were performed before the procedure and one month after the procedure. The left ventricular ejection fraction, left ventricular volumes, and three-dimensional systolic dyssynchrony index were quantified. RESULTS: An immediate procedural success was obtained in 118 patients (91.5%). There were no acute or subacute stent thromboses during follow-up. The mean left ventricular ejection fraction significantly increased (p<0.001), while the left ventricular end-diastolic and end-systolic volumes significantly decreased (p = 0.001 and p<0.001, respectively). The three-dimensional systolic dyssynchrony index also decreased significantly (p<0.001). The global longitudinal strain showed a significant increase after successful revascularization (p<0.001). An increase in the global longitudinal strain was correlated with an increase in the left ventricular ejection fraction (r = 0.27, p = 0.02). The patients with a left ventricular ejection fraction ≥50% displayed a greater improvement in the global longitudinal strain, and the patients with diabetes showed less improvement. CONCLUSIONS: Using novel echocardiographic techniques, our results showed that restoring the coronary blood flow in chronic total occlusion patients reduces the left ventricular volumes ...

Subclinical left ventricular dysfunction in women with polycystic ovary syndrome: an observational study.

OBJECTIVE: Cardiac involvement has been increasingly recognized in patients with polycystic ovary syndrome (PCOS). Identification of the earliest asymptomatic impairment of left ventricular (LV) performance may be important in preventing progression to overt heart failure. Our aim was to investigate LV function with different echocardiographic techniques in patients with PCOS. METHODS: Thirty patients with PCOS and 30 age and body mass index matched healthy subjects were enrolled to this cross-sectional observational study. All subjects underwent echocardiography for assessment of resting LV function as well as two-dimensional speckle tracking echocardiography (2D-STE) and real-time three-dimensional echocardiography (3D-Echo). Global longitudinal strain (GLS) was calculated from 3 standard apical views using 2D-STE. Student t-test, chi-square test, Pearson's, and Spearman's correlation analysis were used for statistical analysis. RESULTS: The early mitral inflow deceleration time (DT), isovolumetric relaxation time (IVRT) and E/Em ratio were increased in the PCOS group (p<0.05 for all). Waist-to-hip ratio, fasting insulin, homeostasis model assessment of insulin resistance (HOMA-IR) and low-density lipoprotein (LDL) levels were higher in PCOS group (p<0.05 for all). Significant correlation was observed between DT, IVRT and insulin value, HOMA-IR (p<0.05 for all). On 3D-Echo evaluation, none of the patients in both groups had LV systolic dysfunction with comparable LV ejection fraction and LV volumes. 2D-STE showed that GLS was significantly reduced in the PCOS group compared to control group (-16.78 ± 0.56% vs. -18.36 ± 1.04%, p<0.001). The GLS was found to be negatively correlated with waist-to-hip ratio and LDL values (p<0.05 for all). CONCLUSION: These results indicate that PCOS may be related to impaired LV systolic function detected by 2D-STE. In addition, PCOS may lead to diastolic dysfunction. Reduced GLS might be an early indicator of cardiac involvement in this patient population.

Short-term effect of percutaneous recanalization of chronic total occlusions on QT dispersion and heart rate variability parameters.

BACKGROUND: QT dispersion (QTd), which is a measure of inhomogeneity of myocardial repolarization, increases following impaired myocardial perfusion. Its prolongation may provide a suitable substrate for life-threatening ventricular arrhythmias. We investigated the changes in QTd and heart rate variability (HRV) parameters after successful coronary artery revascularization in a patient with chronic total occlusions (CTO). MATERIAL/METHODS: This study included 139 successfully revascularized CTO patients (118 men, 21 women, mean age 58.3±9.6 years). QTd was measured from a 12-lead electrocardiogram and was defined as the difference between maximum and minimum QT interval. HRV analyses of all subjects were obtained. Frequency domain (LF: HF) and time domain (SDNN, pNN50, and rMSSD) parameters were analyzed. QT intervals were also corrected for heart rate using Bazett's formula, and the corrected QT interval dispersion (QTcd) was then calculated. All measurements were made before and after percutaneous coronary intervention (PCI). RESULTS: Both QTd and QTcd showed significant improvement following successful revascularization of CTO (55.83±14.79 to 38.87±11.69; p<0.001 and 61.02±16.28 to 42.92±13.41; p<0.001). The revascularization of LAD (n=38), Cx (n=28) and RCA (n=73) resulted in decrease in HRV indices, including SDDN, rMSSD, and pNN50, but none of the variables reached statistical significance. CONCLUSIONS: Successful revascularization of CTO may result in improvement in regional heterogeneity of myocardial repolarization, evidenced as decreased QTcd after the PCI. The revascularization in CTO lesions does not seem to have a significant impact on HRV.

Polycystic ovary syndrome is associated with P-wave prolongation and increased P-wave dispersion.

BACKGROUND: The polycystic ovary syndrome (PCOS) is associated with various cardiac manifestations including cardiac arrhythmias. P-wave dispersion (Pdis) is an appealing marker for predicting the risk of developing atrial arrhythmias. The purpose of this study was to evaluate P-wave durations and Pdis in patients with PCOS. METHODS: Forty adult patients with PCOS and 46 age- and sex-matched healthy individuals were included in this study. P-wave maximum duration (Pmax) and P-wave minimum duration (Pmin) were calculated on the 12-lead electrocardiogram, and the difference between the Pmax and the Pmin was defined as Pdis. All individuals also underwent transthoracic echocardiographic evaluation. RESULTS: Pmax and Pdis were significantly higher in patients with PCOS compared with controls (p = 0.007, p < 0.001, respectively). There was no difference in Pmin duration between both the groups (p = 0.2). Waist-to-hip ratio, insulin and homeostasis model assessment of insulin resistance (HOMA-IR) were higher in the PCOS group. Early mitral inflow deceleration time (DT) (p < 0.001) and isovolumetric relaxation time (p = 0.003) were longer in PCOS group. Waist-to-hip ratio, DT, E/A ratio and diastolic blood pressure correlated with Pdis. CONCLUSIONS: Patients with PCOS have prolonged Pmax and Pdis. The increase in those parameters may be an indicator for identification of patients at increased risk of atrial fibrillation.

A novel echocardiographic predictor of atrial fibrillation recurrence: L-wave.

Diastolic dysfunction leads to atrial fibrillation (AF) by increasing left atrial pressure and also increases recurrence rate after cardioversion. So, L-wave, which is associated with severe diastolic dysfunction, could predict recurrent AF after cardioversion. The aim of this study was to investigate predictive value of L-wave for AF recurrence at first month after electrical cardioversion. A total of 127 patients with persistent AF were evaluated for this study and finally 73 patients were included according to the study criteria. Echocardiographic examinations were performed for all patients before and at 24th hour after electrical cardioversion. Heart rates and rhythms were followed with electrocardiography monitor and 12-lead ECG at first week and first month. Seventy patients achieved sinus rhythm (SR) after cardioversion and 3 patients who did not go into SR excluded from the study. Patients were divided into 2 groups according to having (group 1) or not having (group 2) L-wave on echocardiography. Twenty-two patients (6 men, 16 women) had L-wave and 48 patients (19 men, 29 women) did not have L-wave. Duration of AF was longer in group 1 as compared to group 2 (P = 0.03). Mean heart rate was lower in group 1 than in group 2 (P < 0.001). Duration of AF and presence of L-wave were significant parameters for AF recurrence in univariate analysis, however, presence of L-wave was the only significant parameter for AF recurrence in multivariate analysis. Ten patients in group 1 (45.5%) and 7 patients (14.6%) in group 2 (P = 0.005) had AF recurrence at the end of first month after cardioversion. L-wave did predict AF recurrence with 59% sensitivity, 77% specificity, 45% positive predictive value, and 85% negative predictive value at 1 month. Echocardiographic L-wave could predict the AF recurrence.

Incidence of appropriate shock in implantable cardioverter-defibrillator patients with improved ejection fraction.

BACKGROUND: Heart failure with recovered ejection fraction (EF) is a recently described clinical entity. There is insufficient information on the management of implantable-cardioverter defibrillator (ICD) patients with improved EF at generator replacement. METHODS AND RESULTS: We examined the incidence of appropriate shocks in 91 consecutive patients with ICDs for primary prevention of sudden death who underwent generator replacement. Improved EF was defined as both EF >35% at generator replacement and increase in EF by ≥10% since original implantation. Patients were 70 ± 11 years old, and 76% had ischemic cardiomyopathy. At generator replacement, 25 patients (27%) had improved EF (0.49 ± 0.08 vs 0.31 ± 0.07 at baseline; P < .0001). Over 6.2 ± 2.2 years of follow-up after original implantation, 9 patients (36%) with improved EF versus 19 (29%) with unchanged EF had appropriate ICD shocks (P = .51). Incidence of appropriate ICD shocks was similar between the two groups before (P = .90) and after (P = .97) generator replacement. Of the 9 improved EF patients with appropriate shock, 4 had shocks before generator replacement, 2 had shocks before and after generator replacement, and 3 patients, who never had shocks before, had their first shock after generator replacement. CONCLUSIONS: Some ICD patients whose EF improves to >35% at generator replacement remain at risk for appropriate ICD shocks.