A gray zone: Role of transesophageal echocardiography before atrial tachycardia catheter ablation.

INTRODUCTION: There is a lack of studies in the literature directly investigating the relationship between atrial tachycardia (AT) and left atrial (LA)/left atrial appendage (LAA) thrombus, and current guidelines do not provide strong recommendations regarding the use of transesophageal echocardiography (TEE) before AT catheter ablation. This study aims to elucidate the relationship between AT and the presence of LA/LAA thrombus and contribute to the literature on the use of TEE before AT catheter ablation. METHODS: This single-center retrospective observational study screened patients who underwent TEE between February 10, 2019, and February 10, 2023. Patients were assigned to the AT patient and control groups. TEE was conducted to exclude thrombus in the AT ablation group. The control group included patients who underwent TEE for interatrial septum evaluation and had LA imaging during TEE but did not have atrial arrhythmia. To mitigate bias between the AT patient group and the control group, they were randomized 1:1 using propensity-score matching (PSM). Following randomization, each group consisted of 49 patients. RESULTS: All analyses were conducted after PSM. There were no statistically significant differences between the AT patient and control groups in terms of baseline clinical characteristics and echocardiographic features. Additionally, no significant differences were found between the blood viscosities calculated at low and high shear rates in both groups. The study revealed a significant difference between the two groups in the presence of LA spontaneous echo contrast (SEC) (24.5% in AT group vs 0% in Control group, p = .001), but not in the presence of thrombi (8.2% in AT group vs 0% in Control group, p = .117). CONCLUSION: Compared to the control group, the presence of SEC was significantly higher in the AT patient group. The increased frequency of SEC in AT patients suggests the hypothesis that AT may contribute to LA stasis. The routine use of TEE before AT catheter ablation remains controversial, despite the presence of LA thrombus and SEC in the AT patient group. The clinical assessment of thrombus presence before the procedure must be conducted on a patient-specific basis.

Ventricular preexcitation of every other beat or ventricular bigeminy or both?

Bigeminy is a cardiac arrhythmia in which there is a single ectopic beat, or irregular heartbeat, following each regular heartbeat. This case demonstrates the diagnostic challenges that can be encountered while interpreting ECGs of patients with "apparent ventricular bigeminy'.

Transitioning from Radiofrequency Ablation to Cryoablation for Treatment of Pediatric Atrioventricular Nodal Reentrant Tachycardia: A Single Tertiary Center Experience.

Catheter ablation of the slow pathway is the recommended treatment for atrioventricular nodal reentrant tachycardia (AVNRT) in children. Both radiofrequency ablation (RF) and cryoablation (CA) have been used for this purpose. In this report, we describe our experience during the transition period from RF to CA for the treatment of pediatric AVNRT. Between January 2012 and August 2021, a retrospective evaluation was conducted of the clinical features, procedural outcomes, and follow-ups of pediatric AVNRT patients who underwent catheter ablation at a pediatric electrophysiology center. The catheter ablation outcomes of 89 pediatric AVNRT patients were evaluated: 29 patients were ablated using RF (RF group) and 60 patients were ablated using CA (CA group). No significant difference was found between the groups in terms of gender, age, weight, and success and recurrence rates. The procedure duration and total lesion numbers were statistically significantly lower in the RF group compared with the CA group (86.67 ± 45.8 and 156.1 ± 37.7 min; p = 0.01, 4 [3-6] and p < 0.01, 8 [7-9] lesions, respectively). Catheter ablation was successful in all patients. There were no permanent complete atrioventricular blocks in both groups. A total of six patients (6.8%) developed recurrences. The cryoablation of pediatric AVNRT is a safe and effective procedure with comparable acute and mid-term follow-up success rates compared with RF, even during a period of transition from RF to CA.

Development and validation of clinical prediction model to estimate the probability of death in hospitalized patients with COVID-19: Insights from a nationwide database.

In the current study, we aimed to develop and validate a model, based on our nationwide centralized coronavirus disease 2019 (COVID-19) database for predicting death. We conducted an observational study (CORONATION-TR registry). All patients hospitalized with COVID-19 in Turkey between March 11 and June 22, 2020 were included. We developed the model and validated both temporal and geographical models. Model performances were assessed by area under the curve-receiver operating characteristic (AUC-ROC or c-index), R2 , and calibration plots. The study population comprised a total of 60,980 hospitalized COVID-19 patients. Of these patients, 7688 (13%) were transferred to intensive care unit, 4867 patients (8.0%) required mechanical ventilation, and 2682 patients (4.0%) died. Advanced age, increased levels of lactate dehydrogenase, C-reactive protein, neutrophil-lymphocyte ratio, creatinine, albumine, and D-dimer levels, and pneumonia on computed tomography, diabetes mellitus, and heart failure status at admission were found to be the strongest predictors of death at 30 days in the multivariable logistic regression model (area under the curve-receiver operating characteristic = 0.942; 95% confidence interval: 0.939-0.945; R2 = .457). There were also favorable temporal and geographic validations. We developed and validated the prediction model to identify in-hospital deaths in all hospitalized COVID-19 patients. Our model achieved reasonable performances in both temporal and geographic validations.

Telltale termination of an A-on-V tachycardia with two blocked atrial activations: What is the mechanism?

The termination of tachycardia may provide important clues toward the mechanism of the tachycardia and that close vigilance may clinch the diagnosis before proceeding to other pacing maneuvers.

Unusual response to His-refractory atrial premature complex: What is the mechanism?

A 32-year-old woman underwent radiofrequency catheter ablation of narrow QRS tachycardia that was terminated with intravenous adenosine.

The other side of the medallion in heart failure: Reverse metabolic syndrome.

BACKGROUND AND AIMS: Lower levels of cardiovascular risk factors are associated with an increase in mortality in H.F. To explain this paradox, the term reverse metabolic syndrome (RMetS) has recently been proposed. We suggest defining these patients with lower levels of three risk factors can be combined under the heading "RMetS." We aimed to investigate the effect of MetS and RMetS on hemodynamic parameters and prognosis in patients with H.F. and reduced ejection fraction (HFrEF). METHODS AND RESULTS: We included 304 patients who were performed right heart catheterization and followed up for a median of 16 (0-48) months. We first grouped patients according to the presence of MetS or not, then we added the RMetS category and stratified patients into three groups as MetS, RMetS, and metabolic healthy. Compared with not MetS group, Pulmonary arterial pressures and VO2 were higher in MetS group. In the second step, LVEF, CI, VO2I, O2 delivery, and LVSWI were lowest in RMetS, pulmonary artery pressures were higher in MetS group. In multivariate Cox regression analysis, being in RMetS group was associated with 2.4 times and 1.8 times increased risk for composite end point (CEP) and all-cause mortality, respectively. In Kaplan Meier analysis, RMetS had the highest all-cause mortality and CEP. CONCLUSIONS: We determined that RMetS patients had the worst prognosis with unfavorable hemodynamic profile. Hence, a better understanding of the pathophysiology of RMetS may help refine the treatment targets of CV risk factors, may yield new interventions targeting catabolic syndrome.

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

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

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

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

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

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

A Doppler ghost in the pulmonary artery.

Long-standing left-to-right shunting across a patent ductus arteriosus (PDA) can result in Eisenmenger syndrome. In this report, we present echocardiographic findings of a 27-year-old female patient with pulmonary hypertension. In diagnostic work-up especially Doppler findings of the pulmonary artery suggested the presence of a reversed PDA as a cause of pulmonary hypertension. The diagnosis was confirmed by contrast study and computed tomography.

His bundle pacing using a simple stylet and a standard active fixation electrode.

Conventionally, His bundle pacing (HBP) is achieved using specially designed pacing leads and delivery sheaths. This paper describes the feasibility of permanent HBP with a pre-shaped simple stylet and a standard active-fixation electrode, through axillary vein access, without using dedicated delivery tools. This method may be a feasible and safe alternative to the only commercially available system.

Comparison of two types of rotational mechanical dilatator sheath: Evolution® and TightRail™.

INTRODUCTION: Powered extraction tools are usually needed in chronically implanted leads. Comparative data are essential among different rotating dilator sheaths. The aim of the study was to compare procedural/clinical outcomes and adverse events in patients underwent lead extraction utilizing two different rotating dilator sheaths. METHODS AND RESULTS: The current study was a retrospective review of consecutive patients at a single center. From December 2009 to August 2017, 163 lead extractions from 98 consecutive patients (median, 65 years; 71% male) utilizing a rotating mechanical sheath were analyzed for both efficacy (procedural and clinical success rates) and safety (adverse events). According to the type of the sheath used, the Evolution group (58 patients with 94 leads) and the TightRail group (40 patients with 69 leads) were determined. Extracted device was an implantable cardioverter-defibrillator (ICD) in two-thirds of patients. The majority of leads (87.7%) had passive-fixation mechanism. All ICD leads had dual-coil design. The median lead implant duration was 4 years, and no difference was found between the two groups. Infectious etiology was the main indication for extraction in 56.1% of patients. There were no statistically significant differences regarding the procedural success rate (96.6% vs 95.0%), clinical success rate (98.3% vs 97.5%), and total adverse event rate (5.2% vs 10.0%) between the Evolution and TightRail groups, respectively. Procedural success decreased with older leads and higher lead number. CONCLUSIONS: Procedural and clinical success rates utilizing both the Evolution and TightRail rotational extraction sheaths were high with low complication rate in chronically implanted leads.

Transvenous retrograde reposition of an atrial lead.

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

A novel use of cardiac resynchronization therapy-defibrillator device in hypertrophic cardiomyopathy.

Dual-chamber implantable cardioverter-defibrillator is generally used in patients with atrioventricular block and hypertrophic cardiomyopathy with preserved left ventricular ejection fraction. In the current case, a cardiac resynchronization therapy-defibrillator device was implanted in a patient with non-obstructive hypertrophic cardiomyopathy with preserved ejection fraction and atrioventricular block to achieve both more physiological pacing and life-threatening ventricular arrhythmia management.

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

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

Heart rate variability parameters in children with ventricular preexcitation.

INTRODUCTION: The autonomic nervous system has a regulatory effect on cardiac electrophysiology and arrhythmogenesis. We aimed to assess cardiac autonomic status using heart rate variability (HRV) parameters in children with ventricular preexcitation. METHODS: The electrocardiography, Holter monitoring, transesophageal electrophysiological study (TEEPS), and invasive electrophysiological study (EPS) results of ventricular preexcitation patients obtained over a 7-year period in our clinic were evaluated. According to the TEEPS results, patients' accessory pathway conduction was classified as adverse (n = 40) or nonadverse (n = 25). The HRV parameters of patients were compared according to tachycardia inducibility that assessed by TEEPS and EPS. Also, HRV parameters were compared in patients with adverse and nonadverse pathway conduction. Further, the HRV parameters of preexcitation patients were compared with those of healthy controls. RESULTS: LF/HF, the best measure of sympathovagal balance, was statistically higher in patients with adverse conduction than in patients without adverse conduction and controls (P  =  0.001). The LF/HF ratio was higher in ventricular preexcitation patients with inducible tachycardia than those without in EPS (P  =  0.001). In addition, the LF/HF ratio was higher in symptomatic ventricular preexcitation patients than asymptomatic ones (P  =  0.001). No difference in HRV parameters was found between preexcitation patients and controls. CONCLUSION: Autonomic tonus in patients with ventricular preexcitation may affect accessory pathway conduction properties, tachycardia inducibility, and symptomology. The indicator of sympathovagal balance, LF/HF ratio, increased in ventricular preexcitation patients with inducible tachycardia and those that were symptomatic.

Serial echocardiographic changes with different body positions and sleeping side preference in heart failure patients.

BACKGROUND: The sleeping position plays an important role in overall health in both healthy individuals and heart failure (HF) patients, which complain of increasing dyspnea when adopting left lateral decubitus position (LLDP) that improves when turning over to the right lateral decubitus position (RLDP). Several theories have been proposed to explain this preference of HF patients; however, the underlying mechanisms remain unclear. METHOD: We evaluated consecutive dilated cardiomyopathy (DCMP) patients with regard to whether they had a sleeping position preference and analyzed early and late left ventricular filling velocities, tissue Doppler recordings, tricuspid annular plane systolic excursion (TAPSE), and left ventricular outflow tract time-velocity integral (LVOT-TVI). Baseline echocardiographic parameters were obtained first by LLDP, followed by the supine position (SP) and finally RLDP in each position for 10 minutes to ensure a stabilized hemodynamic milieu. RESULTS: A total of 26 DCMP patients were included in this study and a 78 echocardiographic examination performed. We detected that many HF patients preferred the right lateral decubitus sleeping position (RLDSP, 54%) and avoided from the left lateral decubitus sleeping position (LLDSP, 40%); the echocardiographic LVOT TVI and TAPSE parameters were statistically higher in RLDP compared to SP and LLDP. CONCLUSION: The echocardiographic LVOT TVI and TAPSE values as functional parameters of left and right ventricular function change with body position, and these hemodynamic changes may explain why HF patients willingly adopt RLDSP.