Association between oxygen delivery and digital ulcers in systemic sclerosis.

OBJECTIVE: Tissue hypoxia due to microvasculopathy is the main cause of digital ulcers (DUs) in systemic sclerosis (SSc). Reduced oxygen delivery (DO2) to the tissues may also contribute to the development of DU. This study was conducted to investigate the association between DO2 and DUs in patients with SSc. METHODS: In all, 111 patients and 30 healthy controls were enrolled. DO2 was calculated by using the formula; DO2 = Cardiac output × arterial oxygen saturation (SpO2) × serum haemoglobin level × 1.39 × 10. Both right index finger SpO2 measurements (index-SpO2) and highest value of SpO2 (maximum SpO2) obtained among the fingers of the subjects were used for the calculations and DO2 results were adjusted both for weight and body surface area (BSA). RESULTS: Mean DO2 was lower in SSc patients as compared to controls in all 4 different calculations but the difference was only statistically significant when using index-SpO2 and adjusting for BSA (498 mL/min/m2 vs 549 mL/min/m2, p = 0.03). There was a strong positive correlation between cardiac output and DO2 calculated by using the index-SpO2 (r = 0.903; p < 0.001). Of the SSc patients, 46 (41.4 %) had DUs within the last 12 months. Patients with DUs had higher mean mRSS, lover mean FVC and more frequently diffuse disease, interstitial lung disease, anti-SCL70 antibody positivity (p < 0.05 for all). No difference was observed in DO2 among DU positive or DU negative groups by any calculation (p > 0.05 for all). CONCLUSIONS: DO2 in SSc patients seems to be lower than healthy controls. However, DO2 is similar between the patients with and without DUs. Our results suggest that the contribution of DO2 is negligible to the development of DU and support the major role of microvasculopathy in SSc patients with DUs.

Pulmonary hypertension in Behçet's disease: echocardiographic screening and multidisciplinary approach.

BACKGROUND: Little is known about the prevalence and causes of pulmonary hypertension (PH) in Behçet's disease (BD). This study was conducted to determine the prevalence and causes of PH in BD. METHODS: In this descriptive study, we screened 154 patients with BD for PH using transthoracic echocardiography between February 2017 and October 2017. An estimated systolic pulmonary arterial pressure (sPAP ≥ 40 mmHg) was used as the cutoff value to define PH. Patients with BD were categorized into 5 groups according to organ involvement including mucocutaneous/ articular, ocular, vascular, gastrointestinal, and neurologic involvement. Additional laboratory and imaging results were obtained from hospital file records to determine the causes of PH. RESULTS: PH was detected in 17 (11%) patients. Nine (52.9%) of these patients had group II PH (due to left heart disease), 4 (23.5%) had IV PH (due to pulmonary arterial involvement), and 1 had III PH (due to chronic obstructive lung disease). The frequency of PH was higher in BD patients with vascular involvement than those without (52.9% vs 28.5%; p = 0.04). Among 10 patients with pulmonary artery involvement (PAI) 4 (40%) had PH. Although the vascular BD group had the highest rate of PH, we observed no statistically significant difference in the frequency of PH between the predefined BD subgroups. DISCUSSION: : PH is not rare in patients with BD. The majority of BD patients with PH are in group II or IV PH. Patients with vascularinvolvement carry a higher risk for the development of PH. Monitoring BD patients with PAI should be considered for the development of group IV PH.

Impaired Balance and Gait Characteristics in Patients With Chronic Heart Failure.

BACKGROUND AND AIMS: Heart failure affects most systems of the body and causes various problems in patients. Balance deficits and gait deviations can be a result of these effects. There is little information in the literature about balance and gait parameters in chronic heart failure (CHF). This study aimed to investigate balance abnormalities together with gait deficits for possible associations in patients with CHF and compare them to healthy controls. METHODS: Twenty-two (22) patients with CHF (59±2.5 years) and 22 age- and gender-matched healthy subjects (59.4±6.8 years) participated in the study. This study is a cross-sectional/comparison study. Balance was evaluated using the Activity-Specific Balance Confidence Scale (ABC) and the Mini-Balance Evaluation Systems Test (Mini-BESTest) balance battery, which includes the timed up-and-go test (TUG) and dual-task TUG. Gait analysis was performed using a Biodex Gait Trainer. Peripheral muscle strength (quadriceps muscle and handgrip strength) was assessed using a hand dynamometer and exercise capacity using the six-minute walk test (6MWT). RESULTS: The CHF patients had significantly lower Mini-BESTest total, reactive postural control, and gait stability scores, significantly longer TUG/dual-task TUG time, and lower ABC score compared to the healthy control group (p<0.05). Chronic heart failure patients also showed significantly lower gait speed, stride length, gait cycle and step length (p<0.05). Dominant-side quadriceps muscle and handgrip strength and 6MWT distance were significantly reduced in CHF (p<0.05). Anticipatory postural adjustments and sensory orientation did not differ between groups. CONCLUSIONS: Our study demonstrated impaired balance and gait performance and reduced muscle strength and exercise capacity in patients with CHF. Cardiac rehabilitation including balance and walking training should be planned for CHF patients to eliminate balance disorders, gait impairment and prevent falls in this patient group.

Evaluation of atrial fibrosis in atrial fibrillation patients with three different methods.

BACKGROUND: The presence of atrial fibrosis has already been known as a risk factor for atrial fibrillation (AF) development. We aimed to evaluate atrial fibrosis with previously defined three different methods, which were cardiac magnetic resonance imaging (C-MRI), echocardiographic strain imaging, and biomarkers and show the relationship between these methods in patients with AF scheduled for cryoballoon ablation. METHODS: A total of 30 patients were enrolled. Atrial T1 relaxation durations were measured using C-MRI before the procedure of atrial fibrillation catheter ablation. Fibroblast growth factor-21 (FGF-21) and fibroblast growth factor-23 (FGF-23) levels were measured at serum derived from the femoral artery (Peripheral FGF 21 and 23) and left atrium blood samples (Central FGF 21 and 23) before catheter ablation. Preprocedural transthoracic echocardiography was performed. The median follow-up duration for atrial tachyarrhythmia (ATa) recurrence was 13 (12-18 months) months. RESULTS: The mean ages of the study group were 55.23 ± 12.37 years, and there were 17 (56.7%) female patients in study population. There were negative correlations between post contrast T1 relaxation durations of both posterior and posterosuperior atrium, and central FGF-23 (r: - 0.561; p = 0.003; r:-0.624; p = 0.001; Posterior T1 vs. central FGF-23 levels and Posterosuperior T1 vs central FGF-23 levels, respectively). The positive correlations were observed between postcontrast posterior T1 relaxation durations and left ventricle ejection fraction (r:0.671; p = 0.001); left atrial emptying fraction (r:0.482; p = 0.013); peak atrial longitudinal strain (r:0.605; p = 0.001), and peak atrial contraction strain (r:0.604; p = 0.001). Also negative correlation was observed between postcontrast posterior T1 relaxation durations, and left atrial volume index (r: - 0.467; p = 0.016).

The relationship between retinal microcirculation and right heart catheterization and echocardiography findings in patients with idiopathic pulmonary arterial hypertension.

OBJECTIVE: To determine the possible alterations of retinal microcirculation associated with right-sided intracardiac pressures in patients with IPAH. METHODS: Twenty patients with IPAH and 20 age- and sex-matched healthy controls were included in the study. Hemodynamic data were obtained from the most recent right heart catheterization. Echocardiographic examination was performed within 24 h of ophthalmological examination. For the right eyes of all participants, high-resolution scans of chorioretinal microvascular networks at different depths of the retina were captured via OCT angiography. RESULTS: The perfusion of the superficial and deep capillary plexus (SCP and DCP), and choriocapillaris (CCP) flow area were significantly lower than those in healthy control subjects (p < .05 for all). In IPAH group, PVR and mPAP were correlated significantly with the perfusion measurements at SCP and DCP (r = .461, r = .626 and r = .625, r =0.730, respectively, p < .05). sPAP and TRV were positively correlated with the perfusion measurements at SCP and DCP (r = .600, r = .662 and r = .670, r = .655 p < .05). CONCLUSIONS: The positive correlation of retinal perfusion at SCP and DCP with right-sided echocardiographic and hemodynamic measurements unveiled that retinal microcirculation is affected by the pressure alterations in the pulmonary circulation of IPAH patients.

Is Takayasu's arteritis more severe in children?

OBJECTIVES: Takayasu's arteritis (TAK) is a chronic vasculitis, affecting predominantly the aorta and/or its major branches. The aim of this study was to compare the differences between childhood and adult onset TAK. METHODS: We retrospectively evaluated 179 TAK patients followed between August 2005 and July 2019. Demographic characteristics, laboratory features, disease activity, echocardiographic data at diagnosis and treatment regimens in the disease course were compared between the paediatric and adult onset patients. RESULTS: Twenty-five paediatric-onset (<18 years of age at diagnosis) and 154 adult-onset patients (≥18 years of age at diagnosis) were enrolled. The mean age at diagnosis for children and adults were 13.6±4 and 35.6±13, respectively. Paediatric onset TAK patients had more intense inflammation at the time of diagnosis reflected in their clinical findings. Acute phase reactants were high in all paediatric patients and significantly higher in patients with paediatric-onset TAK (p=0.006 and p=0.005, respectively). Abdominal predominant disease was more common in the paediatric group, in contrast, focal disease and aortic arch predominant disease were more common in the adult group. Ascending aortic dilatation, left ventricular hypertrophy and moderate-severe aortic insufficiency were more frequent in echocardiography findings of paediatric onset TAK patients. In comorbidities, hypertension was more common in paediatric TAK patients during follow-up, whereas cerebrovascular disease was more common in adult patients. CONCLUSIONS: Our paediatric onset TAK patients presented with a more severe inflammation and more widespread vascular involvement. Multicentre studies from different geographic areas are needed to verify our observation and understand the underlying causes.

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

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

Assessment of Diastolic Function and Thiol-Disulphide Homeostasis in Arsenic-Exposed Workers.

OBJECTIVES: Exposure to arsenic is associated with various cardiovascular diseases. The imbalance between antioxidant and oxidant homeostasis plays a crucial role in the cardiovascular effects of arsenic. The aim of this study was to investigate the effect of arsenic exposure on diastolic function by measuring thiol and disulphide in arsenic-exposed workers. METHODS AND RESULTS: A total of 107 male arsenic-exposed workers and 36 healthy subjects were enrolled. Mitral inflow velocity and parameters of diastolic function were measured. As oxidative stress indicators, total thiol, native thiol, disulphide, and their percent ratios were determined. The mean age was 39.1 ± 9.5 years in the arsenic-exposed group and 37.4 ± 9.6 years in the controls. The median blood arsenic level was 42 µg/dL in the arsenic-exposed group and 3.75 µg/dL in the controls. E-wave, E/A ratio, and e' wave were lower and left atrial diameter, A-wave, average E/e' ratio, and tricuspid regurgitation velocity were higher in the arsenic-exposed group. Native and total thiol concentrations were lower, and disulphide/native and disulphide/total thiol ratios were higher in the arsenic-exposed group. Fourteen (13.1%) workers had diastolic dysfunction, 26 (24.3%) had indeterminate, and 67 (62.6%) had normal diastolic function, compared to 1 (2.8%), 2 (5.6%), and 33 (97.7%) in the control group, respectively. In regression analysis, disulphide/native thiol ratio (p < 0.001) and blood arsenic level (p < 0.001) predicted increased average E/e' ratio in the arsenic-exposed group. CONCLUSIONS: This study showed strong associations among arsenic exposure, oxidative stress, and diastolic function, and revealed the influence of arsenic exposure on diastolic dysfunction through oxidative stress.

Initial experience with the TightRail™ Rotating Mechanical Dilator Sheath for transvenous lead extraction.

AIMS: In parallel with increasing implantation rates and patients' longer life expectancy, the need for transvenous lead extraction (TLE) as a specialized procedure has shown a significant growth over years. Herein, we aimed to present our initial experience in TLE by using a novel TightRail™ Rotating Mechanical Dilator Sheath. METHODS AND RESULTS: Between October 2014 and March 2015, a total of 42 leads in 23 patients were removed at our tertiary referral centre. All of the extracted leads were >12 months old and indications for extraction were based on the recommendations of the Heart Rhythm Society. The leads were removed by using the TightRail™ Mechanical Dilator Sheath (Spectranetics Corporation) with the rotational cutting force only. Indications for lead removal included cardiac device infection in 12 (52.2%) cases, lead malfunction in the 10 (43.5%) cases, and upgrade to cardiac resynchronization therapy-defibrillator (CRT-D) in the remaining 1 case (4.3%). The extracted devices were pacemaker in 10 (43.4%) cases, implantable cardioverter-defibrillator (ICD) in 7 (30.4%) cases, and CRT in the remaining 6 (26.0%) subjects. Among 42 leads, 10 (23.8%) were right ventricular, 14 (33.3%) were atrial, 13 (31.0%) were defibrilator, and 5 (11.9%) were coronary sinus electrodes. The median time from implantation was 72 (18-216) months. Complete procedural success with TightRail™ system alone was achieved in 22 (95.7%) patients (41/42 leads) and overall clinical success was 100%. One right ventricular lead was completely removed with the help of femoral snare. All the patients were discharged uneventfully without any complication. CONCLUSION: Our preliminary data with small sample size show that TightRail™ Mechanical Dilator Sheath is a new useful tool for chronically implanted pacemaker (PM)/ICD leads. Continued investigation including large patient cohort is required to evaluate success and complication rates in comparison to other tools and techniques.

Usefulness of 'figure-of-eight' suture to achieve haemostasis after removal of 15-French calibre femoral venous sheath in patients undergoing cryoablation.

AIMS: Among patients undergoing cryoballoon-based atrial fibrillation (AF) ablation, in order to reduce access site complications, improve staff efficiency, and decrease length of stay, various techniques have been implemented to achieve immediate haemostasis. We aimed to assess the efficacy and safety of 'figure-of-eight (FoE)' suture when compared with conventional manual compression for immediate closure of 15-French (Fr) calibre right femoral venous access after cryoablation. METHODS AND RESULTS: A total of 200 patients (48% female, mean age 55 ± 12.4 years, and 77% paroxysmal AF) with symptomatic AF underwent initial cryoablation procedure. All the patients were anticoagulated with heparin during the procedure. In a sequential allocation, FoE suture (Group 1 = 100) and conventional manual compression (Group 2 = 100) were used in achieving haemostasis at right femoral venous access site following 15 Fr sheath removal. In the FoE suture group, haemostasis was achieved immediately after tying the knot (n = 95) or within ≤1 min of light pressure (n = 4). One patient had failure of the stitch as the silk suture snapped during knotting, and haemostasis was achieved by manual compression as per the usual protocol. The median time to haemostasis was shorter in the suture group (0 vs. 14 min, P < 0.001). On immediate and short-term (3 months) follow-up, there was no evidence of minor or major vascular access site complications like haematoma, re-bleeding, fistula formation, or thrombosis at right femoral site in the suture group. CONCLUSION: The 'FoE' suture, as a simple, efficacious and likely safe technique, might be an alternative approach to achieve an immediate haemostasis after removal of 15 Fr right femoral venous sheaths in patients undergoing cryoablation.

Predictors of left atrial volume index reduction following cryoballoon-based pulmonary vein isolation.

AIMS: Ablation for atrial fibrillation (AF) has been suggested to be associated with 'reverse left atrial remodelling'. Reduction in left atrial volume index (LAVIR) is regarded as a determinant of reverse remodelling following pulmonary vein isolation (PVI). However, there is paucity on data about the predictors for LAVIR after PVI. In this study, we aimed to investigate predictors of LAVIR at 12 months in AF patients undergoing cryoballoon-based PVI. METHODS AND RESULTS: Patients with symptomatic paroxysmal or persistent AF despite ≥1 antiarrhythmic drug(s), who were scheduled for cryoballoon-based AF ablation procedure per the recent consensus recommendations, were enrolled and followed-up for 12 months in this prospective observational study. Left atrial volume was derived using the biplane area-length method. A total of 160 patients (54.25 ± 7.66 years, 44.40% female) were involved in the study. Reduction in left atrial volume index occurred in 120 patients. Age [hazard ratio (HR): 0.901, 95% confidence interval (CI): 0.828-0.981, P = 0.017], hypertension (HR: 0.151, 95% CI: 0.048-0.471, P = 0.001), mild mitral regurgitation (MR) (HR: 5.327, 95% CI: 1.489-19.058, P = 0.010), and AF recurrence (HR: 0.017, 95% CI: 0.005-0.065, P< 0.001) were found to be independent predictors for LAVIR. CONCLUSION: To the best of our knowledge, this is the largest study in the literature investigating the predictors of LAVIR following AF ablation. According to this data, younger patients without hypertension or moderate MR are most likely to experience LAVIR following ablation.

A prospective DE-MRI study evaluating the role of TGF-ß1 in left atrial fibrosis and implications for outcomes of cryoballoon-based catheter ablation: new insights into primary fibrotic atriocardiomyopathy.

BACKGROUND: Transforming growth factor (TGF)-ß1 mediated atrial fibrosis plays a major role in the development of vulnerable atrial substrate for atrial fibrillation (AF). Although cryoablation effectively eliminates the triggers for AF, the impact of atrial substrate on the success of cryoablation remains unclear. OBJECTIVE: We aimed to investigate the association of plasma TGF-ß1 level with extent of left atrium (LA) fibrosis using delayed-enhanced magnetic resonance imaging (DE-MRI) and also effects of LA fibrosis on the success of cryoablation. METHODS: A total of 41 symptomatic lone paroxysmal AF patients (58.5% male; age: 49.2 ± 7.6 years) underwent initial cryoablation. Cardiac DE-MRI at 1.5-Tesla scanner to quantify atrial fibrosis, plasma TGF-ß1, clinical and echocardiographic data were collected before cryoablation. Postablation blanking period was observed for 3 months. RESULTS: DE-MRI revealed LA fibrosis in 27 (65.9%) patients with a median enhancement of 5% of the LA surface area. A total of 179 pulmonary veins (PV) were successfully isolated without any major complication. At median 18 months follow-up, 32 patients (78.1%) remained free of AF recurrence. Only plasma TGF-ß1 level (P = 0.001) was found to be the predictor of the extent of LA fibrosis. Multivariate Cox regression analysis pointed out that the extent of LA fibrosis (HR: 1.127, P = 0.007) and early AF recurrence (HR: 1.442, P = 0.011) were the independent predictors of AF recurrence in late follow-up. CONCLUSION: Higher levels of TGF-ß1 are associated with more extensive LA fibrosis and extent of LA fibrosis predict recurrences in patients undergoing cryoablation for lone AF.

Cardiac Autoantibody Levels Predict Recurrence Following Cryoballoon-Based Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation Patients.

INTRODUCTION: Recent evidence has suggested that autoantibodies may play an important role in the development of atrial fibrillation (AF). The predictive value of preprocedural autoantibodies against beta-1 adrenergic receptor (anti-ß1-R) and M2-muscarinic acetylcholine receptor (anti-M2-R) for AF recurrence following cryoballoon-based pulmonary vein isolation (PVI) is still unclear. We aimed to determine the predictive value of preprocedural anti-ß1-R and anti-M2-R levels for AF recurrence. METHODS: Eighty patients (mean age 54.25 ± 7.70 years; 40% female) with paroxysmal AF and preserved left ventricular function who underwent cryoballoon-based PVI were included in the study. Preprocedural anti-M2-R and anti-ß1-R levels were measured with ELISA. RESULTS: At 1-year follow-up after ablation, late AF recurrence was observed in 17 (21.25%) patients. In the Cox regression model, including number of antiarrhythmic drugs, early AF recurrence, anti-ß1-R levels >159.88 ng/mL, anti-M2-R levels >277.65 ng/mL, AF duration, and left atrial volume index, only anti-ß1-R levels >159.88 ng/mL (HR: 4.281, P = 0.039) and anti-M2-R levels >277.65 ng/mL (HR: 4.313, P = 0.030) were found to be independent predictors of late AF recurrence. Anti-ß1-R level >159.88 ng/mL was shown to predict late AF recurrence with a sensitivity of 70.59% and specificity of 90.48%. A cut-off value of 277.65 ng/mL for anti-M2-R level predicted AF recurrence with a sensitivity of 70.59% and specificity of 95.24%. CONCLUSION: Preprocedural serum anti-ß1-R and anti-M2-R levels are independent predictors of late AF recurrence following cryoballoon-based PVI in paroxysmal AF patients. Detection of preprocedural anti-ß1-R and anti-M2-R levels may serve as a novel method for determination of paroxysmal AF patients who may not benefit from cryoballoon-based PVI.

The role of preprocedural monocyte-to-high-density lipoprotein ratio in prediction of atrial fibrillation recurrence after cryoballoon-based catheter ablation.

AIMS: Previous studies evidenced that increased monocyte count or activity and lower high-density lipoprotein (HDL) cholesterol levels were associated with more prevalent atrial fibrillation (AF) which attributed to pro-inflammatory and pro-oxidant effects. Monocyte-to-HDL ratio (M/H ratio) is a recently emerged indicator of inflammation and oxidative stress which have been only studied in patients with chronic kidney disease. We aimed to investigate the prognostic impact of M/H ratio on AF recurrence after cryoballoon-based catheter ablation. METHODS AND RESULTS: A total of 402 patients (43.5% female, age 53.5 ± 10.9 years, and 80.8% paroxysmal AF) with symptomatic AF underwent initial cryoablation procedure. Patients were categorized into quartiles on the basis of their pre-procedural M/H ratio. Post-ablation blanking period was observed for 3 months. At a mean follow-up of 20.6 ± 6.0 months, 95 patients (23.6%) had developed AF recurrence. Atrial fibrillation recurrence rates from the lowest to the highest M/H ratio quartiles were 7.4, 7.4, 16.8, and 68.4%, respectively (P < 0.001). On multivariate Cox regression analysis, the preablation M/H ratio (HR: 1.20, 95% CI: 1.15-1.25, P < 0.001), left atrial diameter, duration of AF history, and early AF recurrence were independent predictors of AF recurrence. Using a cut-off level of 11.48, the pre-ablation M/H ratio predicted AF recurrence during follow-up with a sensitivity of 85% and a specificity of 74%. CONCLUSION: Elevated pre-ablation M/H ratio was associated with an increased recurrence of AF after cryoballoon-based catheter ablation. Our results support the role of pre-ablation pro-inflammatory and pro-oxidant environment in AF recurrence after ablation therapy but suggest that other factors are also important.

M2-muscarinic acetylcholine receptor autoantibody levels predict left atrial fibrosis severity in paroxysmal lone atrial fibrillation patients undergoing cryoablation.

AIMS: Atrial fibrosis has been found to be associated with recurrent atrial fibrillation (AF) following catheter ablation. Autoantibodies against M2-muscarinic receptors (anti-M2-R) may play a role in the development of AF by inducing left atrial (LA) fibrosis. In this study, we aim to compare anti-M2-R levels between paroxysmal lone AF patients and healthy control subjects and to investigate the relationship between pre-ablation anti-M2-R level, LA fibrosis quantified by delayed enhancement magnetic resonance imaging (DE-MRI), and AF recurrence following cryoablation. METHODS AND RESULTS: Thirty-one patients with paroxysmal lone AF (53.4 ± 8.0 years, 61% male), who underwent cryoballoon-based ablation, along with 31 healthy control subjects were included. Enzyme-linked immunosorbent assay tests to measure serum anti-M2-R levels were performed in both groups and DE-MRI was done to quantify LA fibrosis prior to the ablation in the patients. Anti-M2-R levels were higher in the study population when compared with control subjects [212.4 (103.2-655.5) vs. 73.0 (39.5-299.1) ng/mL, P < 0.001]. Anti-M2-R level predicted moderate-extensive LA fibrosis independent of other measures [odds ratio: 1.26 (95% confidence interval (CI): 1.04-1.53), P = 0.017]. At a mean follow-up of 35.2 ± 3.5 months, nine patients (29.0%) had AF recurrence. In the Cox regression model including pre-ablation anti-M2-R level, LA diameter, LA volume index, and moderate-extensive LA fibrosis, only moderate-extensive LA fibrosis predicted late AF recurrence independent of other measures [hazard ratio: 29.41 (95% CI: 3.52-250.00), P = 0.002]. CONCLUSION: Serum anti-M2-R levels may be associated with the severity of LA fibrosis and may be implicated in the pathophysiology of AF recurrence following cryoablation. Detection of anti-M2-R levels may help select appropriate patients for the procedure.

Safety and efficacy outcomes in patients undergoing pulmonary vein isolation with second-generation cryoballoon†.

AIMS: The second-generation cryoballoon (Arctic Front Advance™) (Arc-Adv-CB) has a redesigned injection system which distributes the refrigerant homogenously to the frontal balloon surface. The aim of this study was to compare the efficacy and safety of the Arc-Adv-CB and its predecessor (Arctic Front™) (Arc-CB) in patients who underwent pulmonary vein isolation (PVI) for atrial fibrillation (AF). METHODS AND RESULTS: Three hundred and six patients (55.35 ± 10.60 years, 47.05% male) were included in the study. A total of 1205 pulmonary veins were attempted for PVI with either Arc-CB or Arc-Adv-CB. The follow-up durations were 30 (23-38) and 10 (8-13) months in Arc-CB and Arc-Adv-CB groups, respectively (P < 0.001). When the blanking period was considered, freedom from AF after a single ablation procedure was 68.53 and 90.83% in patients undergoing PVI with Arc-CB and Arc-Adv-CB, respectively. The most frequent complication was transient phrenic nerve palsy (PNP) which occurred in five(2.54%) and nine(8.26%) of patients undergoing PVI with Arc-CB and Arc-Adv-CB, respectively (P = 0.040). Left atrial (LA) diameter (hazard ratio, HR: 3.552, 95% CI: 2.034-6.201, P < 0.001), smoking history (HR:1.643, 95% CI: 1.011-2.671, P = 0.045), persistent AF (HR:1.725, 95% CI: 1.021-2.915, P = 0.041), duration of AF (HR:1.039, 95% CI: 1.000-1.080, P = 0.047), and early AF recurrence (HR:2.399, 95% CI: 1.443-3.989, P < 0.001) were associated with increased late AF recurrence. On the other hand, intraprocedural vagal reactions (HR: 0.550, 95% CI: 0.331-0.915, P = 0.021) and Arc-Adv-CB use (HR: 0.441, 95% CI: 0.225-0.866, P = 0.017) were associated with lower late AF recurrence. Left atrial diameter (HR: 3.072, 95% CI: 1.646-5.732, P < 0.001), early AF recurrence (HR: 1.906, 95% CI: 1.103-3.291, P = 0.021), and Arc-Adv-CB use (HR: 0.472, 95% CI: 0.239-0.931, P = 0.030) were independent predictors for late AF recurrence. CONCLUSION: Our study has shown that Arc-Adv-CB use is associated with lower late AF recurrences at the cost of an increased risk for PNP.

Assessment of cardiac autonomic nervous system involvement in systemic sclerosis via exercise heart rate recovery.

OBJECTIVE: To assess exercise heart rate recovery (HRR) indices in patients with systemic sclerosis (SSc) for an assessment of their cardiac autonomic function. SUBJECTS AND METHODS: Thirty-five patients with diffuse or limited SSc and 35 healthy controls were enrolled. All subjects underwent exercise testing and transthoracic echocardiography. The HRR indices were calculated by subtracting the first- (HRR1), second- (HRR2) and third-minute (HRR3) heart rates from the maximal heart rate. RESULTS: The SSc and control groups were similar in age (45.2 ± 11.6 vs. 43.9 ± 10.0 years), had identical gender ratios (31 female/4 male in both groups) and similar left ventricular ejection fraction (66.5 ± 5.1 vs. 67.7 ± 5.9%). The mean HRR1 (21.8 ± 4.4 vs. 27.7 ± 4.3 bpm, p = 0.001), HRR2 (43.8 ± 6.3 vs. 47.6 ± 4.4 bpm, p = 0.004) and HRR3 (58.8 ± 10.3 vs. 63.6 ± 7.3 bpm, p = 0.031) values were significantly lower in the SSc group than in the healthy controls. HRR indices were similar in the limited and diffuse SSc subgroups. CONCLUSIONS: The patients with SSc had lower HRR indices than normal subjects. Cardiac autonomic functions might be involved in SSc, even in patients without cardiac symptoms.

[Association of plasma fibronectin level with left atrial electrical and structural remodelling in lone paroxysmal atrial fibrillation: a cross-sectional study]. / "Tek basina" paroksismal atriyum fibrilasyonunda plazma fibronektin düzeyi ile sol atriyumun elektriksel ve yapisal yeniden sekillenmesi arasindaki iliski: Kesitsel bir çalisma.

OBJECTIVE: Atrial fibrosis is one of the main components of atrial fibrillation (AF) pathophysiology and culminates in structural, electrical and contractile remodelling. Fibronectin is one of the well-known mediators of fibrogenesis. However, the association of plasma fibronectin with atrial remodelling has not been studied previously. Therefore, the aim of this study was to assess the relationship between plasma fibronectin level and atrial electrical and structural remodelling in patients with lone paroxysmal AF. METHODS: A total of 51 lone paroxysmal AF patients and 40 age-, gender- and body mass index-matched healthy control subjects were enrolled. Plasma levels of fibronectin and high sensitive C-reactive protein (hs-CRP) were measured and transthoracic echocardiography for assessment of total atrial conduction time (TACT) and left atrial (LA) volume index was performed on all study participants. RESULTS: Plasma fibronectin, hs-CRP, TACT, LA diameter and LA volume index were significantly higher in lone paroxysmal AF group compared to healthy controls (p<0.05). Also, there was a positive correlation between plasma fibronectin level and TACT (r=0.362, p<0.001) and LA volume index (r=0.371, p<0.001). In multivariate logistic regression analysis, age, plasma fibronectin level (Odds ratio - OR: 1.003, 95% CI: 1.001-1.005, p=0.026) and hs-CRP (OR: 2.312, 95% CI: 1.503-6.459, p=0.017) were found to be the predictors of LA structural remodelling; however, only plasma fibronectin level (OR: 1.003, 95% CI: 1.001-1.005, p=0.032) and hs-CRP (OR: 3.212, 95% CI: 1.214-5.752, p=0.033) were found as the predictors of LA electrical remodelling. CONCLUSION: Our study results showed that profibrotic and proinflammatory biomarkers were associated with left atrial structural and electrical remodelling in lone paroxysmal AF patients.

Prevention of recurrent cryptogenic stroke with percutaneous closure of patent foramen ovale; one year follow-up study with magnetic resonance imaging and Holter monitoring.

OBJECTIVES: In this study, we aimed to evaluate the effect of percutaneous closure of patent foramen ovale (PFO) on the recurrence of stroke and new cardiac arrhythmia using magnetic resonance imaging (MRI) and Holter monitoring. STUDY DESIGN: Patients with PFO had >1 previous stroke or transient ischemic attack documented with MRI in the first event. PFO with right to left shunt was detected by transesophageal echocardiography (TEE) and transcranial Doppler ultrasound. MRI examinations were performed on patients before and one year after PFO closure was applied. A twenty-four hour Holter monitoring was performed in all patients within 1 month before and 6 months after the procedure. RESULTS: Percutaneous PFO closure was performed on 47 patients (25 female, mean age: 38.7 years) who had cerebral ischemic events detected by MRI. A year after the procedure, TEE showed that there was no residual interatrial right-to-left shunting. After a 14 month follow-up, no new cerebrovascular event and no new lesion on MRI were recorded. The incidence of arrhythmia did not increase significantly after the procedure on Holter monitoring (p=0.917). CONCLUSION: One-year clinical and MRI follow-up study of patients with cerebral ischemic events and percutaneous closure of PFO showed no recurrent event and no significant complication associated with the procedure. In addition, Holter monitorization demonstrated that the procedure did not increase the incidence of arrhythmias compared with pre-procedural monitoring.