Stereotactic body radioablation therapy as an immediate and early term antiarrhythmic palliative therapeutic choice in patients with refractory ventricular tachycardia.

BACKGROUND: Stereotactic body radioablation therapy (SBRT) has recently been introduced with the ability to provide ablative energy noninvasively to arrhythmogenic substrate while reducing damage to normal cardiac tissue nearby and minimizing patients' procedural risk. There is still debate regarding whether SBRT has a predominant effect in the early or late period after the procedure. We sought to assess the time course of SBRT's efficacy as well as the value of using a blanking period following a SBRT session. METHODS: Eight patients (mean age 58 ± 14 years) underwent eight SBRT sessions for refractory ventricular tachycardia (VT). SBRT was given using a linear accelerator device with a total dose of 25 Gy to the targeted area. RESULTS: During a median follow-up of 8 months, all patients demonstrated VT recurrences; however, implantable cardioverter-defibrillator (ICD) and anti-tachycardia pacing therapies were significantly reduced with SBRT (8.46 to 0.83/per month, p = 0.047; 18.50 to 3.29/per month, p = 0.036, respectively). While analyzing the temporal SBRT outcomes, the 2 weeks to 3 months period demonstrated the most favorable outcomes. After 6 months, one patient was ICD therapy-free and the remaining patients demonstrated VT episodes. CONCLUSIONS: Our findings showed that the SBRT was associated with a marked reduction in the burden of VT and ICD interventions especially during first 3 months. Although SBRT does not seem to succeed complete termination of VT in long-term period, our findings support the strategy that SBRT can be utilized for immediate antiarrhythmic palliation in critically ill patients with otherwise untreatable refractory VT and electrical storm.

The relation between apical thrombus formation and systemic immune-inflammation index in patients with acute anterior myocardial infarction.

Left ventricular (LV) apical thrombus formation is a well described and clinically important complication of acute myocardial infarction (MI) with a substantial risk of thromboembolism. Alterations in the inflammatory status may contribute to this complication. The aim of this study was to evaluate the predictive role of the systemic immune-inflammation index (SII) in identifying high risk patients who will develop an apical thrombus formation during the acute phase of anterior transmural infarction. Consecutive 1753 patients (mean age: 61.5 ±â€…9.6 years; male: 63.8 %) with first acute anterior MI who underwent primary percutaneous coronary intervention were assessed. Patients were divided into 2 groups according to the presence of apical thrombus. SII was calculated using the following equation: neutrophil (N) × platelet (P) ÷ lymphocyte (L). LV apical thrombus was detected on transthoracic echocardiogram in 99 patients (5.6%). Patients with an apical thrombus had lower LV ejection fraction, prolonged time from symptoms to treatment, higher rate of post-percutaneous coronary intervention thrombolysis in myocardial infarction flow ≤1 and significantly higher mean high-sensitivity C-reactive protein, and SII values and lower lymphocyte than those without an apical thrombus. Admission SII level was found to be a significant predictor for early LV apical thrombus formation complicating a first-ever anterior MI. This simple calculated tool may be used to identify high-risk patients for LV thrombus and individualization of targeted therapy.

Assessment of the relationship between semaphorin4D level and recurrence after catheter ablation in paroxysmal atrial fibrillation.

OBJECTIVE: Semaphorin4D (Sema4D), a novel integral membrane glycoprotein, plays a role in atherosclerosis, angiogenesis and chronic inflammation. Elevated levels of sema4D were presented in myocardial infarction, heart failure and atrial fibrillation. Aim of the study was to investigate the relation between sema4D and recurrence after catheter ablation (CA) in paroxysmal AF. METHODS: The present study included 161 paroxysmal AF patients (PAF) (101 patients undergone CA) and 60 healthy subjects. Serum levels of sema4D were measured and study participants were followed-up for 3 months and 1 year since CA in terms of recurrence respectively. RESULTS: Sema4D levels were significantly elevated in the recurrent group compared to the non-recurrent PAF patients (p < 0.001). Sema4D was importantly positively correlated with both left atrial volume index (r = 0.51, p < 0.013) and high sensitive C-reactive protein (r = 0.38), p < 0.011). In multivariate analysis, sema4D [odds ratio (OR) = 1.23, 95% CI 1.11-1.42; p < 0.001] and left atrial diameter (OR = 1.13, 95% CI 1.02-1.23; p = 0.012) were found to be significant independent risk parameters for recurrence. CONCLUSIONS: Sema4D is a novel biomarker that may help to identify individuals with recurrence after CA procedure in long term period in PAF.

Coronary Sinus Diameter to Inferior Vena Cava Diameter Ratio in the Diagnosis of Cardiac Tamponade: A Novel Approach.

BACKGROUND: In cardiac tamponade, coronary sinus (CS) as an intrapericardial structure can be easily compressed, whereas inferior vena cava (IVC) dilates. This inverse relationship may augment their roles in the evaluation of tamponade imaging. AIM: We assessed the usefulness of computerized tomographic measures of CS diameter and also CS/IVC ratio to predict tamponade in clinically stable patients with large pericardial effusion. METHODS: Sixty-six clinically stable patients who had large pericardial effusions were included. Coronary sinus diameter was measured from the point at 1 cm proximal to the CS ostium. Inferior vena cava diameter was measured from the segment between its right atrial orifice and hepatic vein. RESULTS: Patients with tamponade had smaller CS diameter and CS/IVC ratio. After adjusting with other parameters, only either CS diameter or CS/IVC ratio predicted tamponade, respectively. (Nagelkerke r value for CS was 53.7% and 72.1% for CS/IVC ratio). In Receiver Operating Characteristic Curve analysis, a cutoff value of 6.85 mm for CS diameter had 82.6% sensitivity and 83.7% specificity and a cutoff value of 27% for CS/IVC ratio had 87.0% sensitivity and 86.0% specificity for predicting cardiac tamponade. CONCLUSIONS: The tomographic measures of both the CS diameter and the CS/IVC ratio predicted tamponade in clinically stable patients with large pericardial effusion. Compared with CS diameter, CS/IVC ratio seemed to be a more powerful predictor of tamponade.

A new risk model for the evaluation of the thromboembolic milieu in patients with atrial fibrillation: the PALSE score.

BACKGROUND: The evaluation of thromboembolic risk is the cornerstone of atrial fibrillation (AF) management. Thromboembolic risk is associated with the presence of left atrial (LA) thrombus and spontaneous echo contrast (SEC), namely the thromboembolic milieu. AIMS: We aimed to assess the predictors of the thromboembolic milieu in terms of LA thrombus and/ or SEC in patients with paroxysmal AF undergoing electrical cardioversion or catheter ablation, and to develop an effective risk model for detecting the thromboembolic milieu. METHODS: We included a total of 434 patients with nonvalvular paroxysmal AF who underwent transesophageal echocardiography prior to cardioversion or catheter ablation. RESULTS: In patients with the thromboembolic milieu, total protein and C­reactive protein levels, LA diameter, and systolic pulmonary artery pressure (SPAP) were higher, while left ventricular ejection fraction (LVEF) was lower than in patients without the thromboembolic milieu. In a multivariate logistic regression analysis, age, total protein levels, LVEF, LA diameter, and SPAP were independent predictors of LA thrombus and/or SEC. In a receiver operating characteristic curve analysis, the optimal cutoff values for the discrimination of patients with the thromboembolic milieu were as follows: 60 years for age; 7.3 mg/dl for total protein; 40% for LVEF; 40 mm for LA diameter; and 35 mm Hg for SPAP. Based on these cutoff values, we developed a novel risk model, namely, the PALSE score. The area under the curve for the PALSE score was 0.833. Patients with a PALSE score lower than 1 did not show thrombus or spontaneous echo contrast. CONCLUSIONS: The PALSE score, which includes total protein levels, age, LA diameter, SPAP, and LVEF, seemed to accurately predict the presence of the thromboembolic milieu in patients with paroxysmal AF.

Usefulness of positive T wave in lead aVR in predicting arrhythmic events and mortality in patients with hypertrophic cardiomyopathy.

BACKGROUND: Positive T wave in lead aVR (TaVR) has been associated with increased risk of adverse events in patients with various cardiovascular diseases. OBJECTIVE: The purpose of this study was to investigate the prevalence and prognostic significance of positive TaVR in patients with hypertrophic cardiomyopathy (HCM). METHODS: This study investigated 421 consecutive patients with HCM (177 women; age 51.1 ± 14.9 years). Admission electrocardiogram was examined for the presence of a positive TaVR. The primary endpoint was defined as a composite of major arrhythmic events (MAEs), which included sudden cardiac death, sustained ventricular tachycardia or fibrillation, or appropriate implantable cardioverter-defibrillator therapy. Cardiovascular mortality and all-cause death were evaluated as secondary endpoints. RESULTS: During median follow-up period of 6.0 years (interquartile range 4.0-11.6 years), 53 patients (12.6%) experienced the primary endpoint. On multivariable competing analysis, after adjusting for other confounding factors, the presence of positive TaVR was found to be an independent and strong predictor of the primary composite endpoint. Time-dependent receiver operating characteristic analysis, net reclassification index, and integrated discrimination improvement showed that the addition of positive TaVR to conventional HCM risk factors improved prediction of arrhythmic events. However, in subgroup analysis, a positive TaVR lost statistical significance in patients with apical HCM but remained significant in patients with all other hypertrophy patterns. CONCLUSION: Positive TaVR is associated with MAE in HCM patients, independent of and incremental to traditional risk factors.

Prognostic nutritional index as a novel marker for prediction of prognosis in patients with peripartum cardiomyopathy.

The clinical significance of poor nutritional status in patients with peripartum cardiomyopathy (PPCM) is not clearly understood. Prognostic nutritional index (PNI) is a simple nutritional assessment tool, which was first demonstrated to be valuable in patients with colorectal surgeries. We aimed to investigate the predictive value of PNI in patients with PPCM.A total of 92 patients diagnosed with PPCM were enrolled in this study. PNI was calculated using the following formula: 10 × serum albumin value (g/dL) + 0.005 × total lymphocyte count. The primary endpoint was defined as composite adverse cardiac events that included cardiac death or hospitalization due to worsening heart failure (HF). Cardiac death, hospitalization due to worsening HF, and persistent left ventricular (LV) systolic dysfunction were evaluated, respectively, as secondary endpoints.Primary composite endpoint was higher in the lower PNI group. After adjusting for other risk factors, PNI was found to be as an independent predictor of primary composite endpoint (odds ratio 0.805; 95% confidence interval 0.729-0.888; P < .001). In addition, PNI was significantly associated with secondary endpoints; persistent LV systolic dysfunction as well as cardiac death.This study identified nutritional status assessed by the PNI seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.

Relationship between apical thrombus formation and blood viscosity in acute anterior myocardial infarction patients.

Aim: This study sought to investigate the predictive value of whole blood viscosity (WBV) to identify high-risk patients who will develop an apical thrombus during the acute phase of anterior transmural infarction. Materials & methods: Consecutive 1726 patients with first acute anterior myocardial infarction were evaluated. WBV was calculated according to the Simone's formula. Results: Patients with an apical thrombus had prolonged pain to balloon time, higher rate of post-PCI thrombolysis in myocardial infarction flow ≤1 and significantly higher mean WBV values at both shear rates than those without an apical thrombus. Conclusion: WBV values at both shear rates were found to be significant and independent predictors for early LV apical thrombus formation complicating a first-ever anterior wall myocardial infarction.

Fragmented QRS as a candidate marker for left ventricular nonrecovery in patients with peripartum cardiomyopathy.

BACKGROUND: Fragmented QRS (fQRS) complex, with various morphology, has been recently described as a diagnostic criterion of several cardiac diseases. However, there are little data regarding the prognostic role of fQRS in peripartum cardiomyopathy (PPCM) patients. We aimed to investigate the effect of fQRS on predicting left ventricular (LV) nonrecovery in patients with peripartum cardiomyopathy (PPCM). METHODS: Ninety patients (mean age: 34.7 ± 6.5 years) with the diagnosis of PPCM were analyzed retrospectively. The median follow-up period of was 67.0 (12.0-192.0) months. Fragmented QRS was defined as the presence of various RSR' patterns (QRS duration < 120 ms) with or without Q wave, which include an additional R wave (R' prime) or notching of the R wave or S wave, or the presence of more than one R' (fragmentation) without typical bundle branch block. Recovery of LV function was defined as the presence of LV ejection fraction (EF) >45%. RESULTS: Of the patients, 54 (60%) did not recover LV function at the last follow-up visit (nonrecovery group), while 36 of the patients (40%) exhibited LV recovery (recovery group). LV ejection fraction (EF) and fQRS were identified as independent predictors of LV nonrecovery in patients with PPCM (odds ratio OR: 5.546, 95% confidence interval CI: 0.792-0.979, p = .019 and OR: 5.986, 95% CI: 1.313-11.787, p = .014, respectively). CONCLUSION: Our data firstly indicated that presence of fQRS was a significant predictor of LV nonrecovery in patients with PPCM. The fQRS might assist in identifying high-risk patients.

Importance of lead aVR on predicting adverse cardiac events in patients with noncompaction cardiomyopathy.

BACKGROUND: Noncompaction cardiomyopathy (NCCM) is a relatively rare cardiac abnormality with high rates of mortality and morbidity. T-wave amplitudes during ventricular repolarization in lead aVR (TaVR) have been reported to be associated with the prognosis of various cardiovascular diseases. This study sought to investigate the prevalence and prognostic role of positive TaVR in patients with NCCM. METHODS: We evaluated consecutive 161 patients with NCCM (65.8% men, mean age 42.5 ± 15.2 years old). Presentation electrocardiogram was assessed regarding classical parameters as well as T-wave amplitudes in lead aVR. The primary endpoint was defined as composite lethal arrhythmic events, including sudden cardiac death, ventricular fibrillation, or sustained ventricular tachycardia or appropriate implantable cardioverter-defibrillator shock. Heart failure requiring hospitalization, cardiovascular death, and all-cause mortality were also investigated as secondary endpoints. RESULTS: Patients with positive TaVR showed higher rates for arrhythmic events, hospitalization for heart failure, and death compared with patients without it. In multivariate Cox model, after adjusting for other known clinical and electrocardiographic risk factors, the positive TaVR was found to be a strong independent predictor of primary endpoint (HR: 4.8, 95% CI: 1.2-19.3; p = .025) and all-cause death (HR: 3.5, 95% CI: 1.0-12.1; p = .045). CONCLUSION: Our findings revealed that positive TaVR is significantly and independently associated with adverse outcomes in NCCM patients. This unique ECG criterion in the often ignored lead provides incremental information beyond what is available with other traditional risk factors.

Monocyte to high-density lipoprotein cholesterol ratio predicts adverse cardiac events in patients with hypertrophic cardiomyopathy.

Aim: The aim of the study was to investigate the monocyte count to HDL cholesterol ratio (MHR) on the prognosis of patients with hypertrophic cardiomyopathy (HCM). Materials & methods: A total of 411 patients with HCM were assessed. The primary end point was cardiovascular death or malignant arrhythmic events. Results: During the follow-up, primary end point was developed in 54 (13.1%) patients. Receiver operating characteristic (ROC) analysis showed that using a cut-off level of 14.57, MHR predicted the occurrence of primary end point with a sensitivity of 72% and specificity of 72%. In the multivariate model, high MHR was the only significant predictor of the primary end point. Conclusion: This study showed that higher MHR level is an independent predictor of malignant arrhythmia and death in patients with HCM.

Usefulness of the whole blood viscosity to predict stent thrombosis in ST-elevation myocardial infarction.

Aim: This study sought to investigate the predictive value of estimated whole blood viscosity (WBV) for stent thrombosis (ST) in ST-elevation myocardial infarction (STEMI) patients who underwent percutaneous coronary intervention. Materials & methods: A total of 1720 STEMI patients treated with primary percutaneous coronary intervention were followed up for median 36.0 months. WBV was calculated according to the Simone's formula. Results: During follow-up period, 119 patients were diagnosed as 'definite' ST. The rate of ST was significantly higher in the high WBV group. In multivariate analysis, adjusted for other factors, higher WBV significantly increased risk of ST at both shear rates. Conclusion: Being an easily accessible and costless parameter, WBV seems to be an emerging predictor of ST in patients with STEMI.

Transvenous retrograde reposition of an atrial lead.

Pacemaker lead dislodgement is one of the most undesired complications of pacemaker implantation. Repeated procedures are associated with an increased risk of complications, such as pocket infection, pneumothorax, and hematoma. We present a case who experienced dislodgement of the atrial pacemaker lead of a cardiac resynchronization therapy with defibrillator implantation device, which was corrected using a steerable ablation catheter by the transfemoral route.

A novel marker of persistent left ventricular systolic dysfunction in patients with peripartum cardiomyopathy: monocyte count- to- HDL cholesterol ratio.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening complication of pregnancy. There is limited data regarding the predictors of persistent left ventricular (LV) systolic dysfunction. Recently, monocyte-to-high density lipoprotein (HDL) cholesterol ratio (MHR) has emerged as a novel indicator of inflammation and oxidative stress. We aimed to assess the predictive value of MHR on LV recovery in patients with PPCM. METHODS: A total of 64 patients with PPCM who admitted to our tertiary reference hospital between 2009 and 2017 were retrospectively analyzed in this study. Demographic and clinical data, laboratory parameters and echocardiographic findings were recorded. The duration of follow-up was at least 12 months after diagnosis for all participants. Recovery of LV systolic function was defined as the presence of LV ejection fraction (LV EF) > 45%. Univariate analysis was used to determine the significant predictors of persistent LV systolic dysfunction (non-recovery). A receiver operating characteristic (ROC) curve was used to establish the cut-off values for predictors. RESULTS: The mean follow-up duration was 72.1 ± 5.5 months. Of the 64 patients, 35 (55%) had persistent LVSD at their last follow-up while 29 (45%) showed LV EF improvement. The baseline MHR levels were significantly higher in the non-recovery group (P < 0.001). In univariate analysis, increased MHR levels (odds ratio:1.17; 95% confidence interval, 1.01-1.35; P < 0.001) significantly predicted LV non-recovery. Using a cut-off level of 9.73, MHR predicted persistent LV systolic dysfunction with a sensitivity of 89% and specificity of 79%. Besides, lower baseline LVEF increased WBC and CRP levels were identified as predictors of LV non-recovery. CONCLUSIONS: Our data firstly indicated that elevated MHR was a significant predictor of persistent LV systolic dysfunction in PPCM. The MHR might contribute to determining high-risk patients with PPCM.

The prognostic value of positive T wave in lead aVR: A novel marker of adverse cardiac outcomes in peripartum cardiomyopathy.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is an uncommon complication of pregnancy. Clinical courses of PPCM are markedly heterogeneous. Positive T waves in lead aVR (TaVR) are shown to be associated with adverse cardiac events in several cardiovascular diseases. We aimed to investigate the prevalence and prognostic role of positive TaVR in patients with PPCM. METHODS: A total of 82 patients (mean age 29.1 ± 6.3 years) with the diagnosis of PPCM were enrolled. Presentation electrocardiogram (ECG) was investigated for presence of a positive TaVR. The median follow-up duration was 67.0 months. The primary endpoint was defined as composite cardiac events, including cardiac death, arrhythmic events, or persistent left ventricular systolic dysfunction. RESULTS: Patients with positive T wave in lead aVR showed higher rates for persistent left ventricular systolic dysfunction, arrhythmic events, and cardiac death compared to patients without it. In multivariate logistic regression analysis, after adjusting for other confounding factors, the presence of positive TaVR was found to be as an independent and strong predictor of primary composite endpoint (odds ratio 6.21, 95% CI 1.45-26.51; p = 0.014). In Kaplan-Meier survival analysis, both primary and secondary endpoints occurred more frequently in the positive TaVR group. Using the cut-off level of 0.25 mV, T-wave amplitude in lead aVR predicted primary endpoint with a sensitivity of 100% and specificity of 100%. CONCLUSION: Positive T wave in lead aVR, as a simple and feasible electrocardiographic marker, seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.