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

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

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

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

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

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

Higher degree of left atrial structural remodeling in patients with atrial fibrillation and left ventricular systolic dysfunction.

BACKGROUND: Catheter ablation significantly improves the left ventricular (LV) function in patients with atrial fibrillation (AF) and LV systolic dysfunction. In this study, we compared the degree of left atrial structural remodeling (LA-SRM) in patients with normal versus reduced LV ejection fraction (LVEF). We also studied the impact of LA-SRM on LVEF improvement in patients undergoing ablation of AF. METHOD AND RESULTS: We categorized 384 patients into 2 groups based on their cardiac function: reduced LVEF group (LVEF ≤50%; n = 105) and normal LVEF group (LVEF > 50%; n = 279). LVEF was determined prior and mean 8 ± 3 months after catheter ablation for AF. Percentage of LA-SRM was quantified using LGE-MRI and patients were classified into 4 groups based on the amount of structural remodeling in their LA wall: minimal ≤ 5%, mild = 5-20%, moderate = 20-35%, and extensive ≥ 35%. The average preablation LA-SRM (21.5 ± 13.2% vs 15.4 ± 10.0%; P < 0.001) was significantly higher in reduced LVEF group than normal LVEF group. Among the 105 patients with reduced LVEF, while there was a modest 11.7 ± 8.4% average increase in LVEF following ablation, the greatest increase was seen in patients with less extensive LA-SRM (minimal = 19.3 ± 5.1%, n = 3, P = 0.02 and mild = 16.6 ± 9.9%, n = 48, P < 0.001). Patients with moderate and extensive fibrosis had an average EF improvement of 8.7 ± 11.1% and 2.8 ± 6.4%, respectively (n = 39, P < 0.001 and n = 15, P = 0.11, respectively). CONCLUSION: Patients with LV systolic dysfunction displayed a comparatively greater LA-SRM than patients with normal LVEF. Patients with lesser LA-SRM experienced a greater improvement in LVEF after catheter ablation for AF.

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

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

Relationship between left atrial tissue structural remodelling detected using late gadolinium enhancement MRI and left ventricular hypertrophy in patients with atrial fibrillation.

AIMS: Therapeutic effectiveness of ablation of atrial fibrillation (AF) is related to cardiovascular comorbidities. We studied the relationship between left ventricular hypertrophy (LVH) and left atrial tissue structural remodelling (LA-SRM), in patients presenting for AF ablation. METHODS AND RESULTS: We identified 404 AF patients who received a late gadolinium enhancement magnetic resonance imaging (LGE-MRI) prior to catheter ablation. Left ventricular hypertrophy was defined as LV mass index >116 g/m(2) in men and >104 g/m(2) in women. One hundred and twenty-two patients were classified as the LVH group and 282 as the non-LVH group. We stratified patients into four stages based on their degree of LA-SRM (minimal, <5% fibrosis; mild, >5-20%; moderate, >20-35%; and extensive, >35%). All patients underwent catheter ablation with pulmonary vein isolation and posterior wall and septal debulking. The procedural outcome was monitored over a 1-year follow-up period. The mean LA-SRM was significantly higher in patients with LVH (19.4 ± 13.2%) than in non-LVH patients (15.3 ± 9.8%; P< 0.01). Patients with LVH generally had extensive LA-SRM (moderate and extensive stages; 38.5% of LVH group) as compared with non-LVH patients (23.1% of non-LVH group; P < 0.01). A Cox regression analysis showed that patients with LVH also had significantly higher AF recurrence rates than non-LVH patients (43.2 vs. 28%; P = 0.008) during the 1-year follow-up period post-ablation. CONCLUSION: Patients with LVH tend to have a significantly greater degree of LA-SRM, when compared with patients without LVH. Moreover, LA-SRM is a predictor for procedural success in patients undergoing AF ablation procedure.

The effect of fat pad modification during ablation of atrial fibrillation: late gadolinium enhancement MRI analysis.

BACKGROUND: Magnetic resonance imaging (MRI) can visualize locations of both the ablation scar on the left atrium (LA) after atrial fibrillation (AF) ablation and epicardial fat pads (FPs) containing ganglionated plexi (GP). METHODS: We investigated 60 patients who underwent pulmonary vein antrum (PVA) isolation along with LA posterior wall and septal debulking for AF. FPs around the LA surface in well-known GP areas (which were considered as the substitution of GP areas around the LA) were segmented from the dark-blood MRI. Then the FP and the ablation scar image visualized by late gadolinium enhancement (LGE)-MRI on the LA were merged together. Overlapping areas of FP and the ablation scar image were considered as the ablated FP areas containing GP. Patients underwent 24-hour Holter monitoring after ablation for the analysis of heart rate variability. RESULTS: Ablated FP area was significantly wider in patients without AF recurrence than those in patients with recurrence (5.6 ± 3.1 cm(2) vs 4.2 ± 2.7 cm(2) , P = 0.03). The mean values of both percentage of differences greater than 50 ms in the RR intervals (pRR > 50) and standard deviation of RR intervals over the entire analyzed period (SDNN), which were obtained from 24-hour Holter monitoring 1-day post-AF ablation, were significantly lower in patients without recurrence than those in patients with recurrence (5.8 ± 6.0% vs 14.0 ± 10.1%; P = 0.0005, 78.7 ± 32.4 ms vs 109.2 ± 43.5 ms; P = 0.005). There was a significant negative correlation between SDNN and the percentage of ablated FP area (Y = -1.3168X + 118.96, R(2) = 0.1576, P = 0.003). CONCLUSION: Extensively ablating LA covering GP areas along with PVA isolation enhanced the denervation of autonomic nerve system and seemed to improve procedural outcome in patients with AF.

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

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

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

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

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

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

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

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

Association of thrombotic and fibrinolytic factors with severity of culprit lesion in patients with acute coronary syndromes without ST elevation.

BACKGROUND: Increased procoagulant activity and/or impaired fibrinolysis contribute to the development and organization of thrombus, subsequently resulting in complete or incomplete obstruction in acute coronary syndromes (ACS). We investigated the relationship between culprit lesion severity and thrombotic and fibrinolytic parameters in patients who had non-ST elevation ACS (NSTE-ACS). METHODS: This study included 95 consecutive patients with NSTE-ACS. All patients underwent coronary angiography within the first 72 hours depending on the clinical situation. Stenosis >or=50% in the coronary artery was considered significant. NSTE-ACS patients were then divided into two groups: patients with critical stenosis (n = 53) and patients with noncritical stenosis (n = 35). Plasma levels of D-dimer, fibrinogen, thrombin-antithrombin III complex (TAT), and prothrombin fragment 1 + 2 (PF 1 + 2) were measured. RESULTS: D-dimer (338 +/- 192 vs. 190 +/- 170 microg/dL, P < 0.001), TAT (4.4 +/- 2.0 vs. 1.2 +/- 0.7 ng/mL, P < 0.001), and PF 1 + 2 (1.6 +/- 0.6 vs. 0.7 +/- 0.3 nmol/L) levels were significantly higher in the critical stenosis group as compared to the noncritical stenosis group. However, fibrinogen levels were similar in both groups. The levels of TAT (r = 0.76, P < 0.001) and PF 1 + 2 (r = 0.73, P < 0.001) were correlated with the culprit lesion severity, but D-dimer and fibrinogen levels were not. Thrombolysis in myocardial infarction flow grades were also correlated with TAT (r = -0.42, P < 0.001) and PF 1 + 2 (r = -0.40, P < 0.001). CONCLUSION: The severity of culprit lesion may be associated with plasma D-dimer, TAT, and PF 1 + 2 levels in NSTE-ACS patients. These prothrombotic factors may have a role in the development of significant stenosis in the NSTE-ACS setting.

The predictive value of plasma brain natriuretic peptide for the recurrence of atrial fibrillation six months after external cardioversion.

OBJECTIVES: The aim of this study was to assess the predictive value of plasma brain natriuretic peptide (BNP) level for the recurrence of atrial fibrillation (AF) after successful cardioversion in patients with persistent AF. STUDY DESIGN: The study included 58 patients (36 females, 22 males; mean age 59 years) with preserved left ventricular function, who underwent successful electrical cardioversion for persistent AF. Plasma BNP levels were measured before, 30 minutes and six months after cardioversion and electrocardiography was performed to assess AF recurrence. Echocardiography was performed in all the patients before cardioversion. RESULTS: At six months, 38 patients (65.5%) were in sinus rhythm (SR), whereas 20 patients (34.5%) reverted to AF. The mean baseline BNP level was significantly higher than that measured 30 minutes after cardioversion (255.6+/-159.6 pg/ml vs 70.5+/-57.0 pg/ml; p=0.00006). Patients who reverted to AF had significantly higher baseline (p=0.035) and six-month (p=0.001) BNP levels. In addition, they had a significantly greater decrease in BNP levels 30 minutes after cardioversion than patients who remained in SR (-271.9+/-42.4 pg/ml vs -139.4+/-25.3 pg/ml; p=0.008). ROC analysis of this drop with the cutoff value of 200 pg/ml predicted AF recurrence at six months with 80% sensitivity and 86% specificity. There were no correlations between baseline BNP level and duration of AF. However, left atrium diameter showed a significant negative correlation with the baseline BNP level (for = or <40 mm, 41-45 mm, and = or >45 mm: 394.6 pg/ml, 206.5 pg/ml, and 198.5 pg/ml, respectively; p=0.02). CONCLUSION: In patients with persistent AF, baseline plasma BNP level and the magnitude of its decrease after successful cardioversion may predict AF recurrence.

Risk Stratification of Patients Presenting with Transient Loss of Consciousness.

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

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

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

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

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

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

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

Application of the Multicenter Automatic Defibrillator Implantation Trial II risk score in a nontrial setting.

A post hoc analysis of the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II showed that patients with high mortality risk score did not benefit from implantable cardioverter-defibrillator (ICD) therapy. We sought to determine whether MADIT II risk score can identify patients with greater mortality in a nontrial "real-world" setting. We included 382 consecutive patients who received ICD for primary prevention of sudden cardiac death at the Minneapolis Veterans Affairs Medical Center from 2006 to 2010. MADIT II score was calculated by assigning 1 point each for age >70 years, New York Heart Association class >II, atrial fibrillation, QRS >0.12 seconds, and blood urea nitrogen level >26 mg/dl. Scores 0, 1 to 2, and ≥3 were classified as low, intermediate, and high risk, respectively. Of the 382 patients, 14% were low risk, 54% intermediate risk, and 32% high risk. After 3.0 ± 1.6 years of follow-up, incidence of appropriate ICD shocks was similar (p = 0.21) across MADIT II risk score categories. However, mortality rate was 21, 54, and 134 per 1,000 patient-year follow-up in low, intermediate, and high-risk patients, respectively, p <0.0001. Compared with low-risk patients, mortality was 6.4× greater in high-risk patients (hazard ratio 6.36, 95% confidence interval 1.9 to 20.5; p = 0.002). The c-index for the MADIT II score for predicting death was 0.69 (95% confidence interval 0.63 to 0.75). In conclusion, MADIT II risk score successfully identified patients with greater mortality in a nontrial-based, primary-prevention ICD cohort.

First diagonal coronary artery: left ventricular fistula presenting as unstable angina.

Coronary artery fistulae are characterized by communications between a coronary artery and a cardiac chamber or another vascular structure. They are usually congenital, but acquired forms may occur. Most patients are usually asymptomatic. However, some studies have emphasized that the incidence of symptoms and complications increases with age, particularly after the age of 20 (Liberthson et al. 1979, Hong et al. 2004). We aimed to present a very rare form of fistula originating from the first diagonal artery and connecting into the left ventricle.