NT-proBNP level in stage 3-4 chronic kidney disease and mortality in long-term follow-up: HAPPY study subgroup analysis.

OBJECTIVE: This was an investigation of the relationship between the N-terminal pro-brain natriuretic peptide (NT-proBNP) level and mortality in patients with stage 3-4 chronic kidney disease (CKD). METHODS: This study was designed as a subgroup analysis of the Heart Failure Prevalence and Predictors in Turkey (HAPPY) study. The HAPPY study included 4650 randomly selected individuals from the 7 geographical regions of Turkey. A total of 191 subjects from the original cohort with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.1.73 m² were enrolled in this study and the relationship between NT-proBNP and mortality was investigated. Prognostic variables for total and cardiovascular mortality were also examined using Cox regression analysis. RESULTS: The mean length of follow-up was 76.12±22.45 months. The mean NT-proBNP level was 423.54±955.88 pg/mL. During follow-up, 51 subjects (26.7%) died from any cause and 36 subjects (18.8%) died from a cardiovascular cause. The presence of hypertension (hazard ratio [HR]: 1.89; 95% confidence interval [CI]: 1.01-3.50; p=0.048), anemia (HR: 2.49; 95% CI: 1.20-5.15; p=0.014), male gender (HR: 2.64; 95% CI: 1.44-4.86; p=0.002) and log NT-proBNP (HR: 4.93; 95% CI: 2.83-8.58; p<0.001) were independent variables for total mortality. The presence of hypertension (HR: 2.47; 95% CI: 1.09-5.56; p=0.029), male gender (HR: 2.79; 95% CI: 1.38-5.62; p=0.004), eGFR (HR: 0.94; 95% CI: 0.91-0.98; p=0.005) and log NT-proBNP (HR: 6.31; 95% CI: 3.11-12.81; p<0.001) were independent predictors of cardiovascular mortality. CONCLUSION: NT-proBNP was found to be an independent prognostic marker in patients with stage 3-4 CKD.

[Turkish Cardiology Association Consensus Report: COVID-19 Pandemic and Cardiovascular Diseases (May 13, 2020)]. / Türk Kardiyoloji Dernegi Uzlasi Raporu: COVID-19 Pandemisi ve Kardiyovasküler Hastaliklar Konusunda Bilinmesi Gerekenler (13 Mayis 2020).

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

[Consensus Report from Turkish Society of Cardiology: COVID-19 and Cardiovascular Diseases. What cardiologists should know. (25th March 2020)]. / Türk Kardiyoloji Dernegi Uzlasi Raporu: COVID-19 Pandemisi ve Kardiyovasküler Hastaliklar Konusunda Bilinmesi Gerekenler (25 Mart 2020).

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

Electrocardiographic and clinical predictors of permanent pacemaker insertion following Perceval sutureless aortic valve implantation.

BACKGROUND: Sutureless aortic valve replacement surgery (AVR) is a reasonable alternative surgical approach in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. We sought to evaluate the incidence of pacemaker (PM) implantation following sutureless AVR and to analyse possible pre-operative electrocardiographic and clinical predictors of PM implantation. METHODS AND RESULTS: Between November 2013 and March 2015, 58 patients (male 43%, age 77.9 ±â€¯4.9 years) having undergone sutureless AVR with a Perceval prosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy) were taken into consideration for our analysis. During a mean follow up of 13.8 ±â€¯5.0 months (median 13 months), 14 patients (24.1%) underwent pacemaker (PM) implantation following sutureless AVR procedure. Among these patients, 12 (86%) presented III degree atrioventricular (AV) block, 1 (7%) presented II degree AV block, and remaining one (7%) severe symptomatic bradycardia. The comparison of pre-operative characteristics between PM group and no PM group highlighted that QRS duration, EuroSCORE II index and chronic renal dysfunction were significantly associated with the development of AV conduction abnormalities/symptomatic bradycardia requiring PM implantation (respectively, p = 0.01, p = 0.02 and p = 0.03). CONCLUSIONS: The incidence of PM implantation after sutureless AVR was 24.1% in the present study. The EuroSCORE II, QRS duration and renal dysfunction were significantly associated with higher risk of AV conduction abnormalities/symptomatic bradycardia requiring PM placement.

The established electrocardiographic classification of anterior wall myocardial infarction misguides clinicians in terms of infarct location, extent and prognosis.

BACKGROUND: The currently used scheme for the classification of infarct location and extent in anterior myocardial infarction (MI) is intuitive rather than being evidence-based, and recent evidence suggests that it may be misleading both in anatomic and prognostic sense. MATERIAL AND METHODS: Consecutive patients with the diagnosis of anterior MI were enrolled. All electrocardiograms (ECG) were first classified according to established scheme and then reassessed using newer criteria for angiographic site of occlusion. The site of left anterior descending (LAD) occlusion was determined using multiple angiographic views. Clinic, echocardiographic and angiographic outcomes were compared. RESULTS: A total of 379 anterior MI cases were enrolled, final study population consisted of 267 patients. The established scheme did not predict infarct size or adverse outcomes. Location of the myocardium subtended by the occluded coronary network did not match with the anatomic location as ECG classification implies. Many high-risk patients with proximal LAD were classified as "anteroseptal", whereas the majority of the patients labeled as "extensive anterior MI" had in fact distal occlusions. On the other hand, expert interpretation was fairly accurate in predicting adverse outcomes and the site of angiographic involvement. CONCLUSION: Classifying patients according to the established scheme neither gives prognostic information nor accurately localizes infarction. It should be regarded as obsolete and its use should be abandoned. Instead, the extent of infarction can be inferred from newer criteria provided by the angiographic correlation studies.

Early repolarization pattern as a predictor of atrial fibrillation recurrence following radiofrequency pulmonary vein isolation.

BACKGROUND: Early repolarization patterns (ERP) have been found to be associated with poor cardiovascular end points. We aimed to evaluate the ERP prevalence among patients with structurally normal hearts undergoing radiofrequency (RF) pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) ablation and its association with the AF recurrence. METHODS: All consecutive patients who underwent RF-PVI as index procedure for paroxysmal AF in our center were evaluated. EXCLUSION CRITERIA: structural heart disease, ongoing use of Class I/III antiarrhythmics, complete-bundle-branch-block. Lateral (I, aVL, V5 -V6 ), inferior (II, III, aVF), or infero-lateral (both) ERP were defined in baseline ECG as horizontal/downsloping J-point elevation ≥1 mm in two consecutive leads with QRS slurring/notching. Documented episodes of AF lasting ≥30 s were considered recurrence. RESULTS: Of 701 cases, 434 patients (305 males, 58 ± 11 years) were included for analysis. ERP observed in 67 patients (15.4%) (Infero-lateral n = 26, inferior n = 23, lateral n = 18) which were significantly younger, demonstrating longer PR-interval and lower heart rates. At a mean follow-up of 22.1 ± 9.7 months, AF recurrences were found in 107 patients (24.6%). In middle-aged patients (≥40-<60 years; n = 206, 79% male), those with an infero-lateral ERP had higher recurrence compared with the ones without (56.3% vs. 19%; p = 0.002). Infero-lateral ERP was significantly predicting recurrence (HR 2.42, 95% CI 1.21-4.82; p = 0.01). CONCLUSION: Early repolarization patterns was more prevalent in our AF population than in the general population. Infero-lateral ERP in baseline ECG might predict AF recurrence in the follow-up after RF-PVI in middle-aged patients.

Long-term outcome of pulmonary vein isolation in patients with paroxysmal atrial fibrillation and Brugada syndrome.

Aims: The therapeutical management of atrial fibrillation (AF) in the setting of Brugada syndrome (BS) might be challenging as many antiarrhythmic drugs (AADs) with sodium channel blocking properties might lead to to the development of ventricular arrhythmias. This study sought to evaluate the clinical outcome in a consecutive series of patients with BS having undergone pulmonary vein (PV) isolation by means of radiofrequency (RF) or cryoballoon (CB) ablation and the efficacy of catheter ablation for preventing inappropriate interventions delivered by implantable cardioverter defibrillators (ICD) on a 3-year follow up. Methods and results: Twenty-three consecutive patients with BS (13 males; mean age was 47 ± 18 years) having undergone PV isolation for drug-resistant paroxysmal AF were enrolled. Eleven patients (48%) had an ICD implanted of whom four had inappropriate shocks secondary to rapid AF. Over a mean follow-up period of 35.0 ± 25.4 months (median 36 months) the freedom from AF recurrence after the index PV isolation procedure was 74% without AADs. Patients with inappropriate ICD interventions for AF did not present futher ICD shocks after AF ablation. No major complications occurred. Conclusion: Catheter ablation is a valid therapeutic choice for patients with BS and paroxysmal AF considering the high success rates, the limitations of the AADs and the safety of the procedure, and it should be taken into consideration especially in those patients presenting inappropriate ICD shocks due to rapid AF.

Role of Electrocardiographic Tpeak-Tend for the Prediction of Ventricular Arrhythmic Events in the Brugada Syndrome.

Some previous studies have proposed the electrocardiographic Tpeak-Tend (TpTe) as a possible predictor of ventricular arrhythmic events in patients with Brugada syndrome (BrS). We sought to analyze the association between the parameters of repolarization dispersion (TpTe, TpTe/QT, TpTe dispersion, QTc, and QTd) and ventricular fibrillation/sudden cardiac death in a large cohort of patients with type 1 BrS. A total of 448 consecutive patients with BrS (men 61%, age 45 ± 16 years) with spontaneous (n = 96, 21%) or drug-induced (n = 352, 79%) type 1 electrocardiogram were retrospectively included. At the time of the diagnosis or during a mean follow-up of 93 ± 47 months (median 88 months), 43 patients (9%) documented ventricular arrhythmias. No significant difference was observed in TpTe, TpTe/QT, maximum TpTe, and TpTe dispersion between asymptomatic patients and those with syncope and malignant arrhythmias. TpTe/QT ratio did not also significantly differ between patients with ventricular fibrillation/sudden cardiac death and those asymptomatic ones. In conclusion, TpTe was not significantly prolonged in those patients with type 1 BrS presenting with unexplained syncope or malignant arrhythmic events during follow-up.

Implantable cardioverter defibrillator therapy in young individuals: comparison of conventional and subcostal approaches-a single-centre experience.

AIM: The aim of our study is to compare two approaches of implantable cardiac defibrillator (ICD) implantation, conventional (supra/subpectoral) and subcostal in young adults in terms of procedural complications and adverse events encountered during follow-up. METHODS AND RESULTS: From January 2007 to December 2013, all patients under the age of 50 years who received an ICD in our centre were included in this study. Patient's hospital records were analysed for procedural complications and adverse events during follow-up until December 2014. Data from device on first interrogation after implantation and on follow-up were also noted. A total of 106 patients of which 40.6% had Brugada's syndrome (65.1% male, age 33.6 ± 10.97 years) were included in analysis; 71 (61%) had ICD placed in (sub/supra) pectoral and 35 (33%) in subcostal position. Only seven patients received an epicardial lead system. During the follow-up period of 2.1 ± 1.8 years, 84.90% of the patients had no adverse events. Most of the complications, procedural and during follow-up, occur in conventionally placed, pectoral ICD. Lead follow-up data in both groups, conventional and subcostal, showed no difference in right ventricular (RV) shock impedance and R wave sensing, P-value = 0.56 and 0.77, respectively. Lead survival was 95 and 97%, respectively, in conventional and subcostal groups over a mean follow-up of 2.1 ± 1.8 years. Log-rank test for lead survival was not significant in terms of site of implantation. CONCLUSION: To the best our knowledge, this is the first study demonstrating subcostal ICD placement in young adults and resulting in equivalent to better outcomes when compared with conventionally placed pectoral ICD. Subcostal ICD placement might be considered an alternative option in young adults as it results in better procedural outcomes and also comparable rate of adverse events during follow-up, but bigger studies with a larger number of patients are needed for a definitive conclusion.

Femoral venous pressure waveform as indicator of phrenic nerve injury in the setting of second-generation cryoballoon ablation.

AIMS: Femoral venous pressure waveform (VPW) analysis has been recently described as a novel method to assess phrenic nerve function during atrial fibrillation ablation procedures by means of the cryoballoon technique. In this study, we sought to evaluate the feasibility and effectiveness of this technique, with respect to the incidence of phrenic nerve injury (PNI), in comparison with the traditional abdominal palpation technique alone. METHODS: Consecutive patients undergoing second-generation cryoballoon ablation (CB-A) from June 2014 to June 2015 were retrospectively analyzed. Diagnosis of PNI was made if any reduced motility or paralysis of the hemidiaphragm was detected on fluoroscopy. RESULTS: During the study period, a total of 350 consecutive patients (man 67%, age 57.2 ±â€Š12.9 years) were enrolled (200 using traditional phrenic nerve assessment and 150 using VPW monitoring). The incidence of PNI in the overall population was 8.0% (28/350); of these, eight were impending PNI (2.3%), 14 transient (4.0%), and six persistent (1.7%). Patients having undergone CB-A with traditional assessment experienced 18 phrenic nerve palsies (9.0%) vs two in 'VPW monitoring' group (1.3%; P = 0.002). Specifically, the former presented 12 transient (6.0%) and six persistent (3.0%) phrenic nerve palsies, and the latter exhibited two transient (1.3%; P = 0.03) and no persistent (0%; P = 0.04) phrenic nerve palsies. CONCLUSION: In conclusion, this novel method assessing the VPW for predicting PNI is inexpensive, easily available, with reproducible measurements, and appears to be more effective than traditional assessment methods.

Learning curve using the second-generation cryoballoon ablation.

AIMS: To study the learning curve with the second-generation cryoballoon technology focusing on safety, efficacy and procedural characteristics. METHODS: We included 300 patients (men 64.6%, mean age 58.3 ±â€Š12.4 years), 240 of whom were treated by four operators without prior experience in atrial fibrillation ablation and compared them with 60 consecutive patients treated by senior operator. To study the learning curves, we divided the study period into two trimesters and analyzed procedure duration, fluoroscopy times, complications, characteristics of the freeze-thaw cycles and midterm outcomes. RESULTS: Hands-on help from senior operators to achieve pulmonary vein isolation was needed only in the first study trimester (24.1%), most commonly to achieve right inferior pulmonary vein isolation (55.2%). The mean procedure duration shortened from 76.7 ±â€Š17.4 to 65.1 ±â€Š11.4 min (P < 0.0001), and fluoroscopy time decreased from 18.5 ±â€Š7.3 to 12.1 ±â€Š4.3 min (P < 0.0001) for first and second trimester, respectively, and approached senior operator's results (58.2 ±â€Š12.8 and 8.7 ±â€Š4.5 min). Most of the major complications (one stroke, four pseudoaneurysms and one retroperitoneal hematoma) occurred during the first study trimester. Most characteristics of the freeze cycles remained unchanged in both study periods. Compared with junior operators, the senior operator achieved lower nadir temperatures in both inferior veins. However, there was no significant difference in midterm outcomes between junior and senior operators (79.5 vs 83.3%, P = 0.589). CONCLUSION: The learning curve with the second-generation cryoballoon is steep. Inexperienced operators, trained in high-volume centers, can achieve pulmonary vein isolation safely and efficiently with short procedure and fluoroscopy times after having performed 20-30 cases.

Single 3-Minute versus Double 4-Minute Freeze Strategy for Second-Generation Cryoballoon Ablation: A Single-Center Experience.

INTRODUCTION: Second-generation cryoballoon (CB-Adv) ablation is highly effective in achieving pulmonary vein isolation (PVI) with promising mid-term clinical outcome. However, the ideal freezing strategy is still under debate. The aim of this study was to assess the efficacy of a single 3-minute approach compared to the conventional 4-minute plus bonus application using CB-Adv. METHODS AND RESULTS: One hundred and sixty patients (67% male; mean age 58.0 ± 13.3 years) underwent PVI using CB-Adv for paroxysmal atrial fibrillation (PAF). Among 160 patients, 80 received a single 3-minute approach (3-mns group), while the remaining 80 conventional 4-minute plus bonus-freeze (4-mns group). Mean procedure and fluoroscopy times were 90.6 ± 15.8 and 18.3 ± 6.9 in the 4-mns group, 75.2 ± 17.1 and 13.5 ± 8.7 in the 3-mns group (P < 0.001, respectively). First-freeze isolation rate was 91.6% in the 4- versus 90.6% in the 3-mns group (P = 0.78). Persistent phrenic nerve palsy (PNP) occurred in 6/80 (3.5%) in the 4-mns group and 4/80 in the 3-mns group (P = 0.75). The overall freedom from ATas 2 years after the procedure was 78.1% (125/160): 77.5% (62/80 patients) in the 3-mns and 78.8% (63/80 patients) in the 4-mns group (P = 0.82). In multivariate analysis, time to PVI and nadir temperature independently predicted ATa recurrences (P < 0.001). CONCLUSIONS: CB-Adv ablation for PAF is highly effective, resulting in 78% 2-year freedom from arrhythmic recurrences. A "single 3-minute strategy" showed equal efficacy as compared to the conventional 4-minute plus bonus freeze approach at 2-year follow-up, providing shorter procedure and fluoroscopy time. Nadir temperature and time to PVI were predictors of arrhythmic recurrences. "Bonus-freeze" strategy might be unnecessary.

Second-Generation Cryoballoon Ablation in the Setting of Lone Paroxysmal Atrial Fibrillation: Single Procedural Outcome at 12 Months.

BACKGROUND: Lone atrial fibrillation (LAF) develops in younger individuals without cardiovascular or pulmonary disease. As pulmonary vein isolation has been recognized as an optimal treatment for drug-resistant atrial fibrillation, cryoballoon ablation with second-generation balloon (CB-A) may be an ideal solution for LAF patients. OBJECTIVE: The aim of this study was to investigate acute success, periprocedural complications and outcome over a 12-month follow-up period in a cohort of patients having undergone PV isolation (PVI) for LAF using CB-A technology. METHODS: A total of 75 consecutive patients (50 male, mean age 47 ± 12 years) with a diagnosis of lone paroxysmal atrial fibrillation who underwent pulmonary vein isolation (PVI) by CB-A from June 2012 were included. All patients underwent this procedure with the 28 mm CB-A. A total of 299 PVs (100%) could be isolated with CB-A alone. RESULTS: The freedom from AF recurrence after a single procedure was 92% of patients during the entire 13-month follow-up. When considering a blanking period (BP) of 3 months, success rate was 93.3%. Transient phrenic nerve palsy (PNP) was the most frequent complication, occurring in 5.3% of individuals (4 patients); complete recovery was documented for all of these patients prior to hospital discharge. CONCLUSIONS: CB-A is extremely effective in achieving PVI and affords freedom from AF at 13-month follow-up in 93% of young patients affected by drug-resistant LPAF following a 3-month BP. The most frequent complication observed was PNP, which reverted prior to discharge in all patients.

Improved visualisation of real-time recordings during third generation cryoballoon ablation: a comparison between the novel short-tip and the second generation device.

BACKGROUND: The third-generation Cryoballoon Advance Short-tip (CB-ST) has been designed with a 40 % shortened tip length compared with the former second generation CB advance device (CB-A). Ideally, a shorter tip should permit an improved visualisation of real-time recordings in the pulmonary vein (PV) due to a more proximal positioning of the inner lumen mapping catheter. We sought to compare the incidence of visualisation of real-time recordings in patients having undergone ablation with the CB-ST with patients having received CB-A ablation. METHODS: All patients having undergone CB ablation using CB-ST technology and the last 500 consecutive patients having undergone CB-A ablation were analysed. Exclusion criteria were the presence of an intracavitary thrombus, uncontrolled heart failure, moderate or severe valvular disease, and contraindications to general anaesthesia. RESULTS: A total of 600 consecutive patients (58.1 ± 12.9 years, 64 % males) were evaluated (100 CB-ST and 500 CB-A ablations). Real-time recordings were significantly more prevalent in the CB-ST population compared with CB-A group (85.7 vs 67.2 %, p < 0.0001). Real-time recordings could be more frequently visualised in the CB-ST group in all types of veins (LSPV 89 vs 73.4 %, p = 0.0005; LIPV 84 vs 65.6 %, p = 0.0002; RSPV 87 vs 67.4 %, p < 0.0001; RIPV 83 vs 62.4 %, p < 0.0001). CONCLUSION: The rate of visualisation of real-time recordings is significantly higher during third-generation CB-ST ablation if compared to the second-generation CB-A device. Real-time recordings can be visualised in approximately 85.7 % of veins with this novel cryoballoon.

Brugada Phenocopy Induced by Electrolyte Disorder: A Transient Electrocardiographic Sign.

Brugada syndrome (BrS) is an important cause of sudden cardiac death (SCD) with well-defined ST-segment elevation patterns on V1 -V3 . Observation of BrS-Type-electrocardiogram (ECG) patterns in medical conditions without true BrS is called "Brugada Phenocopy" (BrP). We present a case of 61-year-old male patient with hyperkalemia, hyponatremia, and BrS-Type-1 ECG pattern in the setting of acute postrenal failure. He was denying any syncope or family history of SCD. With normalization of electrolyte levels, BrS-Type-1-ECG resolved. Electrolyte disturbances are one of the most common reasons of BrP. Being aware of BrPs and differentiating from an unmasked BrS-ECG pattern could prevent patients from lethal consequences and unnecessary treatments.

Incidence of real-time recordings of pulmonary vein potentials using the third-generation short-tip cryoballoon.

AIMS: The third-generation Cryoballoon Advance Short-tip (CB-ST) has been designed with a 40% shortened tip length compared with the former second-generation CB Advance device. Ideally, a shorter tip should permit an improved visualization of real-time (RT) recordings in the pulmonary vein (PV) due to a more proximal positioning of the inner lumen mapping catheter. In the present study, we sought to analyse the rate of visualization of RT recordings in our first series of patients with the CB-ST device. METHODS AND RESULTS: All consecutive patients having undergone CB ablation using CB-ST technology were analysed. Exclusion criteria were the presence of an intracavitary thrombus, uncontrolled heart failure, moderate or severe valvular disease, and contraindications to general anaesthesia. A total of 60 consecutive patients (60.5 ± 11.2 years, 62% males) were evaluated. Real-time recordings were detected in 209 of 240 PVs (87.1%). Specifically, RT recordings could be visualized in 55 left superior PVs (91.7%), 51 left inferior PVs (85.0%), 53 right superior PVs (88.3%), and 50 right inferior PVs (83.3). CONCLUSION: The rate of visualization of RT recordings is significantly high during third-generation CB-ST ablation. Real-time recordings can be visualized in ∼87.1% of veins with this novel cryoballoon.