Myocardial Blush Grade Predicts Postoperative Atrial Fibrillation following Mitral Valve Replacement: A Novel Perspective.

Background: Atrial fibrillation (AF) remains the most common arrhythmia following mitral valve surgery. Although numerous clinical and laboratory indicators and possible mechanisms of postoperative AF (PoAF) have been described, the role of microvascular dysfunction in pathogenesis has not been assessed. We aimed to evaluate the association between microvascular dysfunction and PoAF in patients undergoing isolated mitral valve replacement. Methods: 188 patients undergoing mitral valve replacement were included in this retrospective study. Demographic characteristics of the patients were recorded. Angiographic assessment of microvascular perfusion was performed using the myocardial blush grading technique for each patient. Univariate and multivariate logistic regression analyses were utilized to determine predictors of PoAF. Results: Of 188 patients (56.69 ± 8.9 years, 39.4% male) who underwent mitral valve replacement, 64 (34%) patients developed PoAF. In the PoAF group, a lower basal hemoglobin level (12.64 ± 0.89 vs. 14.46 ± 0.91 g/dL; p < 0.001), a higher left atrial diameter [5.9 (5.2-6.47) vs. 4.9 (4.5-5.8) cm; p < 0.001], and a lower total blush score (TBS) (8.33 ± 0.84 vs. 8.9 ± 0.31; p < 0.001) were detected. Multivariate logistic regression analysis revealed that preoperative LA diameter (OR:2.057; 95% CI: 1.166-3.63; p = 0.013), preoperative hemoglobin (OR:0.12; 95% CI: 0.058-0.245; p < 0.001), and abnormal TBS (OR:15.1; 95% CI: 1.602-142.339; p = 0.018) were independent predictors of PoAF. Conclusions: Our findings demonstrated that TBS at the preoperative period was an independent predictor of PoAF in patients undergoing isolated mitral valve replacement.

Effect of candesartan treatment on echocardiographic indices of cardiac remodeling in post-myocardial infarction patients.

OBJECTIVE: Myocardial infarction has unfavorable effect on structural and functional properties of the myocardium, referred to as cardiac remodeling. Left ventricular mass, left ventricular mass index, and relative wall thickness are important predictors of cardiac remodeling. In this study, we investigated the effect of candesartan treatment in comparison with zofenopril treatment on echocardiographic indices of cardiac remodeling in post myocardial infarction patients. MATERIAL AND METHODS: In this prospective study, patients who underwent successful percutaneous coronary intervention were randomly assigned to a candesartan or zofenopril treatment. After randomization, echocardiographic indices of cardiac remodeling including left ventricular mass, left ventricular mass index, and relative wall thickness were evaluated before the start of treatment along with 1- and 6-month follow-ups. RESULTS: According to our study, candesartan group showed significant reduction of estimated left ventricular mass and left ventricular mass index at 6-month follow-up visit compared to baseline values (199.53±38.51 g vs. 212.69±40.82 g; 99.05 g/m2 (90.00-116.5) vs. 106.0 g/m2 (96.0∼123.00), p<0.05, respectively). This trend was also observed in zofenopril group during the 6-month period (201.22±40.07 g vs. 207.52±41.61 g; 101.0 g/m2 (92.25-111.75.0) vs. 104.50 g/m2 (95.0∼116.75), p<0.05, respectively). Although both classes of drugs had favorable effects on post-myocardial infarction cardiac remodeling, the absolute benefit was more prominent in candesartan group as compared to zofenopril group (p<0.05). CONCLUSION: Our results suggest that candesartan treatment following myocardial infarction may potentially be useful in terms of improving post-myocardial infarction cardiac remodeling.

Effect of candesartan treatment on echocardiographic indices of cardiac remodeling in post-myocardial infarction patients

SUMMARY Objective: Myocardial infarction has unfavorable effect on structural and functional properties of the myocardium, referred to as cardiac remodeling. Left ventricular mass, left ventricular mass index, and relative wall thickness are important predictors of cardiac remodeling. In this study, we investigated the effect of candesartan treatment in comparison with zofenopril treatment on echocardiographic indices of cardiac remodeling in post myocardial infarction patients. Material and Methods: In this prospective study, patients who underwent successful percutaneous coronary intervention were randomly assigned to a candesartan or zofenopril treatment. After randomization, echocardiographic indices of cardiac remodeling including left ventricular mass, left ventricular mass index, and relative wall thickness were evaluated before the start of treatment along with 1- and 6-month follow-ups. Results: According to our study, candesartan group showed significant reduction of estimated left ventricular mass and left ventricular mass index at 6-month follow-up visit compared to baseline values (199.53±38.51 g vs. 212.69±40.82 g; 99.05 g/m2 (90.00-116.5) vs. 106.0 g/m2 (96.0∼123.00), p<0.05, respectively). This trend was also observed in zofenopril group during the 6-month period (201.22±40.07 g vs. 207.52±41.61 g; 101.0 g/m2 (92.25-111.75.0) vs. 104.50 g/m2 (95.0∼116.75), p<0.05, respectively). Although both classes of drugs had favorable effects on post-myocardial infarction cardiac remodeling, the absolute benefit was more prominent in candesartan group as compared to zofenopril group (p<0.05). Conclusion: Our results suggest that candesartan treatment following myocardial infarction may potentially be useful in terms of improving post-myocardial infarction cardiac remodeling.

Assessment of arterial stiffness and epicardial adipose tissue thickness in predicting the subclinical atherosclerosis in patients with ankylosing spondylitis.

OBJECTIVE: Atherosclerosis is a chronic, progressive, inflammatory disease. Recognition of subclinical atherosclerotic vascular changes before clinical manifestation in an asymptomatic population is important for risk stratification and optimal management, which finally leads to the prevention of cardiovascular disease. We aimed to determine the risk of premature subclinical atherosclerosis by evaluating epicardial adipose tissue thickness (EATT) and arterial stiffness parameters in patients with ankylosing spondylitis (AS). METHODS: We performed a prospective study of 60 consecutive patients meeting modified New York criteria for AS compared to 60 controls matched for age and sex. Patients with traditional cardiovascular risk factors were excluded. Arterial stiffness parameters and EATT (examined via echocardiography) values of all patients and control groups were measured. RESULTS: There was no difference between basal characteristic and echocardiographic parameters in patients with AS and in the control group. EATT and pulse wave velocity (PWV) were higher in the AS patients compared to the control group. EATT was 5.74 ± 1.22 mm and 4.91 ± 1.21 mm (p < .001) and PWV was 9.90 ± 0.98 m/s and 6.46 ± 0.83 m/s (p = .009) in the AS and control groups, respectively. Also, PWV was significantly correlated with EATT, age, and central blood pressure in patients with AS. CONCLUSIONS: EATT and PWV, markers of atherosclerosis and cardiovascular disease, were significantly higher in patients with AS than the control group. In addition, in this study, it has been shown that there is a significant relationship between PWV and EATT in patients with AS.

Serum galectin-3 level predicts early recurrence following successful direct-current cardioversion in persistent atrial fibrillation patients.

OBJECTIVE: Atrial structural remodeling has been suggested to contribute to atrial fibrillation (AF) recurrence following direct-current cardioversion (DCCV). The role of several inflammatory and extracellular matrix turnover markers in AF recurrence following DCCV has been investigated. However, data on the impact of galectin-3, which is known to play a role in various fibrotic conditions, including cardiac fibrosis are lacking. The aim of this study was to demonstrate the predictive role of serum galectin-3 levels in AF recurrence following successful DCCV. METHODS: A total of 90 persistent AF patients who were sche-duled for DCCV were prospectively enrolled. Serum samples were assayed to determine pre-DCCV galectin-3 levels using the enzyme-linked immunosorbent assay method. Patients were followed up for 3 months for AF recurrence. RESULTS: Of 90 persistent AF patients (mean age: 55.33±7.94 years; 53.33% male) who underwent successful DCCV, 28 (31.11%) experienced early AF recurrence within 3 months. Patients with AF recurrence had a greater left atrial volume index (LAVI) (33.35±2.45 mL/m2 vs. 29.21±3.08 mL/m2; p<0.001) and serum galectin-3 levels were higher (0.88 ng/mL [min-max: 0.52-1.32] vs. 0.60 ng/mL [min-max: 0.38-0.91]; p<0.001). In multivariate analysis, the number of DCCV attempts (hazard ratio [HR]: 1.879, 95% confidence interval [CI]: 1.052-3.355; p=0.033), LAVI (HR: 1.180, 95% CI: 1.028-1.354; p=0.018), and serum galectin-3 level (HR: 11.933, 95% CI: 1.220-116.701; p=0.033) were found to be independently associated with early AF recurrence following successful DCCV. CONCLUSION: Circulating levels of galectin-3 may have an association with early AF recurrence following DCCV.

The association between serum angiogenin and osteopontin levels and coronary collateral circulation in patients with chronic total occlusion.

OBJECTIVE: A well-developed coronary collateral circulation lowers both in-hospital and long-term morbidity and mortality limiting the infarct. Angiogenin (AGN) and osteopontin (OPN) are known to be potent inducers of angiogenesis. The aim of the present study was to investigate the relationship between serum ANG and OPN levels and collateral filling grade in subjects with stable coronary artery disease (SCAD). METHODS: A total of 122 age- and gender-matched consecutive patients who were found to have total occlusion (n=70) and no significant stenosis in epicardial coronary arteries (n=52) who underwent coronary angiography due to SCAD between January 2015 and July 2017 were included in the study. AGN and OPN levels were measured using enzyme linked immunosorbent assay. Coronary collateral circulation was graded using Rentrop's classification of collateral filling. RESULTS: A total of 52 patients (61.60±11.78 years, 61.5% male) without significant epicardial coronary artery stenosis and 70 patients (62.87±8.24 years, 65.7% male) with totally occluded coronary arteries were included in the study. Subjects with total occlusion had significantly higher levels of AGN [122.00 (79.00-623.00) pg/mL vs. 98.00 (18.00-160.00) pg/mL, p<0.001] and OPN [1863.50 (125.00-6500.00) pg/mL vs. 451.00 (112.00- 1850.00) pg/mL, p<0.001] than those without significant stenosis. In addition, AGN [127.00 (87.00-623.00) pg/mL vs. 110.00 (79.00-188.00) pg/mL, p=0.011] and OPN [2681.00 (126.00-6500.00) pg/mL vs. 649.00 (125.00-4255.00) pg/mL, p=0.001] levels were significantly higher in patients with better developed collaterals. Serum AGN and OPN levels were found to be significantly associated with coronary collateral development. CONCLUSION: AGN and OPN are associated with better developed coronary collateral circulation and may have therapeutic implications for the promotion of coronary collateral development.

Long-term outcomes of pulmonary vein isolation using second-generation cryoballoon during atrial fibrillation ablation.

BACKGROUND: Currently available second-generation cryoballoon (CB2) is accepted as an effective and safe tool for pulmonary vein isolation (PVI). Although much more data exist about 1-year outcomes of CB2 ablation, data on long-term outcomes are scarce. OBJECTIVE: We aimed to assess the long-term outcomes of PVI using CB2 in a large-scale symptomatic atrial fibrillation (AF) population at our tertiary referral center. METHODS: In this nonrandomized prospective observational study, a total of 486 patients with paroxysmal (71%) or persistent (29%) AF who underwent index PVI using CB2 at our hospital between January 2013 and June 2017 were enrolled. Atrial tachyarrhythmia (ATa)-free survival was defined as the absence of AF, atrial flutter, or atrial tachycardia recurrence ≥30 s following a 3 months blanking period. Predictors of recurrence were evaluated by univariate and multivariate Cox proportional hazards regression models. RESULTS: Acute procedural success rate was 99.8% (1898/1902 PVs). Mean procedural and fluoroscopy time were 64.9 ± 9.2 and 12.1 ± 2.6, respectively. At median 39 (interquartile range: 26-56) months follow-up, ATa-free survival was 78.6% after a single procedure (280/345 [81.2%] for paroxysmal AF vs. 102/141 [72.3%] for persistent AF, P = .019) and 84.4% after a mean 1.48 ± 0.42 ablations. Cox regression analysis showed that left atrium diameter, duration of AF history, and early ATa recurrence were found as the independent predictors of late recurrence. Phrenic nerve palsy was observed in 17 (3.5%) patients. CONCLUSIONS: CB2-based PVI is effective to maintain sinus rhythm in a significant proportion of paroxysmal and persistent AF patients with an acceptable complication rate at long-term follow-up.

Impact of anatomical features of the left atrial appendage on outcomes after cryoablation for atrial fibrillation.

AIMS: Pulmonary vein isolation (PVI) using cryoballoon has been accepted as a safe and effective method for treatment of atrial fibrillation (AF). Despite advances in catheter-based technologies, some patients still experience AF recurrence. In this study, we aimed to compare left atrial appendage (LAA) morphology in AF patients and subjects with sinus rhythm and also investigate the association between LAA morphology and success of PVI using cryoballoon in subjects with AF. METHODS: In this prospective study, 359 AF patients who underwent pre-ablation computed tomographic angiography (CTA) scan between January 2013-March 2016 were included as the patient group. 100 age and gender-matched subjects in sinus rhythm who had no AF episodes in 24-h Holter monitoring that underwent CTA were included as the control group. RESULTS: Non-chicken wing LAA morphology was more common in AF patients (p < 0.001). LAA was significantly deeper (p < 0.001) and short-axis diameter of LAA orifice and LAA orifice area were significantly larger (p < 0.001) in AF patients. Low take-off type morphology of LAA was more common in controls compared to AF patients (p = 0.006). At a median follow-up of 37 months, only longitudinal-axis left atrial diameter on CT (p = 0.003) and cauliflower-type LAA morphology (p = 0.004) were independent predictors of AF recurrence. CONCLUSION: This is the first study in the literature that investigates the relationship between anatomical variations of LAA and AF recurrence following cryoablation. Our findings demonstrate that cauliflower-type LAA morphology is associated with two-fold increased risk of AF recurrence.

Pulmonary vein orientation is independently associated with outcomes following cryoballoon-based atrial fibrillation ablation.

AIMS: Several studies have investigated the influence of pulmonary vein (PV) anatomy on outcomes of atrial fibrillation (AF) ablation. We aimed to evaluate the relationship between PV orientation and AF-free survival following cryoablation. METHODS: 160 patients scheduled for cryoablation between September 2012-March 2014 were included. Patients underwent a pre-procedural cardiac CT scan with retrospective ECG gating. PV orientation was assessed according to the position of the PV orifice relative to the sagittal plane with reference to coronal and horizontal planes. RESULTS: 160 patients (57 ±â€¯9 years, 54% male, 33% persistent AF) were included and followed for a median of 17 (12-36) months. Excluding a blanking period of 3 months, freedom from AF after a single ablation procedure was 76%. Ventral-caudal left upper PV (p = 0.044) and ventral-caudal left lower PV orientation (p = 0.001) were more common in patients with AF recurrence. In multivariate Cox regression analysis, only left lower PV orientation [particularly dorsal-caudal (HR: 3.447, 95% CI: 1.180-10.070, p = 0.024) and ventral-caudal (HR: 3.391, 95% CI: 1.088-10.571, p = 0.035) orientations compared to dorsal-cranial orientation] as well as LA diameter (HR: 3.420, 95% CI: 1.809-6.465, p < 0.001) were significantly associated with AF recurrence. CONCLUSION: This is the first study to demonstrate the impact of PV orientation on prediction of AF recurrence following cryoablation. Preprocedural assessment of PV orientation may modify operator preferences on treatment strategies in AF.

Platelet Toll-like receptor and its ligand HMGB-1 expression is increased in the left atrium of atrial fibrillation patients.

BACKGROUND: Atrial fibrillation(AF) is the most common sustained arrhythmia. Its most feared sequelae are stroke and peripheral thromboembolism due to atrial thrombi formation. Mechanisms underlying the relationship between platelet activation and left atrial thrombi have not been clearly elucidated yet. We aimed to investigate whether immune-mediated platelet activation occurred in AF patients in this cross-sectional study. METHODS: Persistent and paroxysmal AF patients who underwent cryoballoon-based AF ablation between March 2015 and July 2016 were included as the patient group. Patients without AF in whom transseptal puncture was performed at the same period for purposes other than AF ablation were included as the control group. Peripheral and left atrial blood samples were obtained for determination of platelet Toll-like receptor(TLR)-2, TLR-4 and high mobility group box-1(HMGB-1) expression levels. RESULTS: A total of 75 subjects (53 patients with AF and 22 control subjects) [mean: 60.33 (SD: 6.14) years, 57.33% male] were included. Left atrial and peripheral TLR-2, 4 and HMGB-1 expression levels were significantly higher in the patient group when compared to the controls. Left atrial platelet TLR-2 and TLR-4 expression and serum HMGB-1 levels were higher in persistent AF patients compared to paroxysmal AF patients. In the patient group, left atrial expression of TLR-2, 4 and HMGB-1 were significantly higher than the peripheral expression levels. CONCLUSION: Findings of our study suggest evidence for immune-mediated platelet activation in the left atria of AF patients.

Does Septoplasty Improve Heart Functions of Patients With Septum Deviation in Terms of Echocardiography Findings?

OBJECTIVE: The authors aimed to determine pulmonary artery pressure and right heart functions in patients with nasal septum deviation (NSD) with echocardiography (EchoCG) and compare the postoperative changes of EchoCG parameters with preoperative findings. METHODS: Seventy-six patients who underwent septoplasty composed the study group. Average age of patients was 23.50 ranging between 18 and 48 years of age. There were 53 males (69.7%) and 23 females (30.3%). Mean pulmonary artery pressure, tricuspid annular-plane systolic excursion, right ventricular diameter, and e/a ratio were measured by EchoCG preoperatively and same parameters were reobtained 3 months after surgery. RESULTS: Mean pulmonary artery pressure reduced from 23.88 ± 6.36 to 19.80 ±3.95 mm Hg and tricuspid annular-plane systolic excursion increased from 22.36 ±3.85 to 23.57±3.00 3 months after surgery. It represented statistically significant improvement at right heart functions postoperatively (P < 0.001). Although they were not statistically significant, there was also some improvement in right ventricular diameter and e/a ratio values postoperatively. CONCLUSION: Nasal septum deviation was associated with higher PAP values, which were improved after surgery. Although at a lower extent, a negative effect of NSD on right heart functions was also suspected. Thus, treatment of NSD without delay was proposed, not only to treat the nasal symptoms but possible future cardiovascular complications as well.

Management of Blood Pressure and Heart Rate in Acute Decompensated Heart Failure with Volume Overload.

BACKGROUND: Heart failure (HF) is a global health problem. Like most chronic diseases, HF also courses with acute exacerbations, which have been found to be associated with significant morbidity and mortality. A substantial proportion of acute decompensated heart failure (ADHF) patients clinically present with volume overload. METHODS: The goal of this work was to review the current literature and recent guidelines of European Society of Cardiology and American Heart Association/ American College of Cardiology regarding the management strategies in patients with ADHF and volume overload. RESULTS: In the setting of ADHF and volume overload, prompt diagnosis of the disease should be made. Underlying pathologies should be identified and corrected if possible. Specific approaches may be necessary depending on the etiology. DISCUSSION: Current guidelines direct clinicians on the appropriate principles of management in this group of patients; however, approach should be individualized.

Anti-Hyperglycemic Agents for the Treatment of Type 2 Diabetes Mellitus: Role in Cardioprotection During the Last Decade.

Type 2 diabetic patients are known to have a tendency to develop cardiovascular (CV) disease (CVD), and related unfavourable outcomes such as heart failure, myocardial infarction (MI), cerebrovascular events (e.g. stroke), and related mortality. Long- term clinical trials have revealed contradictory findings regarding the relationship between glycemic control and CV benefits due to variations in the key characteristics of the study population. During the last decade, number of pharmacological agents used for glucose- lowering in the treatment of type 2 diabetes mellitus (T2DM) has increased owing to the introduction of dipeptidyl peptidase- IV (DPP- IV) inhibitors, glucagon- like peptide- 1 (GLP- 1) receptor agonists, and sodium-glucose co-transporter 2 (SGLT- 2) inhibitors. This review aims to focus on the mechanisms of action of these drugs in the cardiovascular system and the trials evaluating their impact on CVD. Furthermore, trials in the last decade evaluating the impact of traditional glucose- lowering drugs on CVD are included. For this purpose, we searched PubMed for articles in English using the search terms "type 2 diabetes mellitus, glucose- lowering drugs, antidiabetic medications, cardiovascular, cardiovascular disease, cardiovascular system" between inception to September 2016. We also searched separately for each medication in addition to the keyword "cardiovascular disease" on PubMed. To identify further articles, we hand searched related citations in review articles and commentaries.

Serum galectin-3 level as a marker of thrombogenicity in atrial fibrillation.

BACKGROUND: Left atrial appendage flow velocity (LAAFV) and presence of spontaneous echo contrast (SEC) have been reported to be predictors of thromboembolism in atrial fibrillation (AF) patients. Galectin-3 is a biomarker reflecting pro-inflammatory status, whose role in AF has recently drawn attention, particularly in persistent AF population. AIM: In this study we aimed to investigate the association between serum galectin-3 levels and echocardiographic predictors of thromboembolism in persistent AF patients. METHODS: We included 65 persistent AF patients (55.50±10.67 years, 46.15% male). Transesophageal echocardiography (TEE) was performed to assess LAAFV and presence of left atrial (LA)/LA appendage (LAA)-located SEC and thrombus prior to direct current cardioversion or catheter ablation for AF. RESULTS: Median galectin-3 level was 0.63 ng/mL. Serum galectin-3 levels were significantly correlated with LAAFV (r=-.440, P<.001). Serum galectin-3 levels were associated with presence of SEC (P<.001), and LA thrombus (P=.008). Receiver operating characteristic analysis revealed that a serum galectin-3 greater or equal to the cut-off value of 0.69 predicted presence of SEC with a sensitivity and specificity of 91.00% and 79.00%, respectively (P<.001). CONCLUSION: In conclusion, in the setting of persistent AF, serum galectin-3 levels are associated with presence of SEC and LAAFV on TEE. Our findings suggest that serum galectin-3 level may have a place in thromboembolism risk stratification in persistent AF patients.

Pulmonary vein anatomy and its variations in a Turkish atrial fibrillation cohort undergoing cryoballoon-based catheter ablation.

OBJECTIVE: Pulmonary vein (PV) anatomy has drawn attention since assumption that atrial fibrillation (AF) may originate from PVs and that electrical isolation of PVs may be beneficial in eliminating these triggers. The present study aims to investigate PV anatomy and its variations in a sample of Turkish patients undergoing PV isolation (PVI) for AF. METHODS: 250 patients underwent multidetector computed tomography before cryoballoon-based PVI for AF. PV and left atrial (LA) anatomy were evaluated in 3-dimensional epicardial reconstructions. RESULTS: 980 PVs were observed. All PVs drained into the LA. Mean superoinferior (SI) dimension for each vein was significantly larger than mean anteroposterior (AP) dimension. Accessory PVs were only seen on right side. Accessory veins were significantly smaller in both AP and SI diameter than other veins. Right-sided PV ostia were more round. Expected anatomy of 2 atrial ostia for right upper and lower lobe veins on each side was seen in 94.8% of patients. Remainder had other variant anatomy in right PVs. Conjoined ostium in the LA was seen in 35.6% of patients. CONCLUSION: PV variations were common in Turkish AF cohort undergoing PVI, which may be important to know about prior to ablation therapy for procedural success.

Traditional and Alternative Therapies for Refractory Angina.

Refractory angina (RFA) is an unfavourable condition that is characterized with persistent angina due to reversible myocardial ischemia in patients with coronary artery disease that remains uncontrollable despite an optimal combination of pharmacological agents and revascularization. Despite significant advances in revascularization techniques and agents used in pharmacological therapy, there is still a significant population suffering from RFA and the global prevalence is even increasing. Anti- anginal treatment and secondary risk-factor modification are the traditional approaches for this group of patients. Furthermore, now there is still a large number of alternative treatment options. In order to review traditional and alternative treatment strategies in patients with RFA, we searched Pubmed for articles in English using the search terms "pharmacological therapy, refractory angina", "alternative therapy, refractory angina" between inception to June 2016. We also went through separately for each alternative treatment modality on Pubmed. To identify further articles, we handsearched related citations in review articles and commentaries. We also included data from the European Society of Cardiology (2013), and the Canadian Society of Cardiology/ Canadian Pain Society (2012) guidelines. Data show that besides traditional pharmacological agents, such as nitrates, beta- blockers or calcium channel blockers, novel antiischemic drugs and if symptoms persist, several non- invasive and/ or invasive alternative strategies may be considered. Impact of some pharmacological agents, such as rho- kinase inhibitors, and novel alternative treatment modalities, such as coronary sinus reducers, stem cell therapy, gene and protein therapy, on outcomes are still under investigation.

Association of Neutrophil-to-Lymphocyte Ratio with the Severity and Morphology of Coronary Atherosclerotic Plaques Detected by Multidetector Computerized Tomography.

BACKGROUND: Studies have demonstrated a consistent relationship between white blood cell (WBC) counts and coronary artery disease (CAD). The neutrophil/lymphocyte ratio (NLR) has been considered as a potential marker for identifying individuals under risk of CAD and associated events. In this study, we aimed to evaluate whether NLR was associated with the severity and morphology of coronary atherosclerotic plaques shown by multidetector computed tomography (MDCT). METHODS: Our study population consisted of 684 patients who underwent dual-source 64 slice MDCT for the assessment of CAD. Coronary arteries were evaluated on a 16-segment basis and critical coronary plaque was described as luminal narrowing > 50%, whereas plaque morphology was assessed on a per segment basis. Total WBC, neutrophil and lymphocyte counts were determined using commercially available assay kits. RESULTS: WBC count [7700 (6400-8800) vs. 6800 (5700-7900), p < 0.05] and NLR [2.40 (1.98-3.07) vs. 1.86 (1.50-2.38), p < 0.001] were found to be higher in patients with critical stenosis than in those without. In the binary logistic regression analysis, NLR was a predictor of critical stenosis (odds ratio, 1.68; 95% confidence interval, 1.39-2.03, p < 0.001). NLR levels differed among plaque morphology subtypes (p < 0.05) and was significantly higher in non-calcified plaque (NCP) compared to mixed plaque (MP) and calcified plaque (CP) (p < 0.05). In the multinomial logistic regression analysis, NLR was found to be an independent predictor of NCP, MP and CP (p < 0.001). CONCLUSIONS: These data show that NLR is associated with both the severity and morphology of coronary atherosclerotic disease.

Monocyte Toll-Like Receptor Expression in Patients With Atrial Fibrillation.

Atrial fibrillation (AF) is the most common sustained arrhythmia. Inflammation has been suggested to play a vital role in the pathogenesis. Previous studies have investigated expression of inflammatory markers in AF. Several studies have focused on the effects of toll-like receptors (TLRs) on heart in terms of capability of modulating inflammation. In this study, we aimed to investigate whether peripheral monocyte TLR expression was associated with the AF presence, and recurrence of AF after cryoablation, as a reflection of inflammatory status. Patients with AF who were scheduled for cryoballoon-based ablation for AF and age- and gender-matched subjects in sinus rhythm were included. Peripheral monocyte TLR-2 and TLR-4 expressions were evaluated by flow cytometric analysis in peripheral venous blood samples obtained during evaluation in outpatient clinics: 172 patients (56.5 ± 6.6 years, 52.3% men) were included in the study. Peripheral monocyte TLR-2 and TLR-4 expression levels were significantly higher in patients with AF (p <0.05). Among patients with AF, 12 patients (14.0%) developed AF recurrence at a follow- up of 17 months. Multivariate Cox regression analysis showed that left atrial volume index (hazard ratio 2.040, 95% CI 1.197 to 3.477, p = 0.009) and monocyte TLR-4 expression (hazard ratio 1.226, 95% CI 1.042 to 1.443, p = 0.014) were independent predictors of AF recurrence after blanking period following second-generation cryoballoon-based pulmonary vein isolation for paroxysmal AF. In conclusion, our study highlights the role of TLR-mediated inflammation in the pathogenesis of AF. This link may also constitute a therapeutic target in patients with AF.

Increased left atrial pressure predicts recurrence following successful cryoablation for atrial fibrillation with second-generation cryoballoon.

PURPOSE: Several studies have demonstrated that left ventricular diastolic dysfunction (LVDD) and left atrial pressure (LAP), as a surrogate marker of LVDD, were associated with atrial fibrillation (AF) recurrence following radiofrequency catheter ablation (RFCA) for AF. In this study, we aimed to investigate the individual impact of several left ventricular diastolic function parameters on outcomes of cryoablation for paroxysmal AF using second-generation cryoballoon. METHODS: One hundred seventy patients who were scheduled for cryoablation with second-generation cryoballoon were included in this prospective study. All patients underwent comprehensive transthoracic and transesophageal echocardiographic examinations during sinus rhythm a day before catheter ablation. LAP was measured via transseptal sheath at the beginning of the ablation procedure. RESULTS: One hundred seventy patients (57.09 ± 11.80 years, 47.06 % male) were involved in the study. At a median follow-up of 19 months, when blanking period of 3 months was considered, freedom from AF after a single ablation procedure was 84.71 %. Patients with AF recurrence had significantly greater left atrial volume index (LAVI) (p = 0.005) and LAP (p < 0.001). Patients with AF recurrence had lower septal e' wave (p = 0.013), and higher E/e' ratio (p = 0.014). LAVI (p = 0.007) and LAP (p = 0.006) were independent predictors of AF recurrence. A cut-off value of 13.50 mmHg for LAP measured during the procedure was associated with a sensitivity and specificity of 80.8 and 84.7 % (p = 0.005) for predicting AF recurrence. CONCLUSIONS: Pre-procedural LAVI and procedural LAP measurement have clinical importance in predicting AF recurrence in patients undergoing cryoablation with second-generation cryoballoon. Effectiveness of cryoablation is reduced in patients with greater LAVI and LAP.