Neutrophil-to-lymphocyte ratio predicts functionally significant coronary artery stenosis in patients with stable coronary artery disease.

OBJECTIVE: The aim of this study was to determine the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the functional severity of coronary stenosis assessed according to the fractional flow reserve (FFR) in stable coronary artery disease (CAD). METHODS: The clinical and laboratory data of 420 patients who underwent index coronary angiography for stable angina pectoris were analyzed retrospectively. The functional severity of an intermediate lesion was determined by FFR. An FFR value of >0.80 was considered non-significant (Group 1), whereas ≤0.80 was accepted as significant stenosis (Group 2). RESULTS: A total of 137 (32.6%) patients had functionally significant coronary artery stenosis. The median NLR value was significantly greater in Group 2 compared with Group 1 [3.13 (0.93-9.75) vs 2.22 (0.75-6.02); p<0.001]. In multivariable logistic regression analysis, the Gensini score [odds ratio (OR): 1.04; 95% confidence interval (CI): 1.02-1.06; p<0.001], diabetes mellitus (OR: 2.56; 95% CI: 1.38-4.75; p=0.003), smoking (OR: 2.09; 95% CI: 1.12-3.94; p=0.021), and NLR (OR: 1.62; 95% CI:1.26-2.09; p<0.001) were found to be independent predictors of the presence of functionally significant coronary stenosis using an FFR value of ≤0.80. The optimal cut-off value of NLR for predicting functionally significant coronary stenosis was 2.3. An NLR value greater than 2.3 had a sensitivity of 72% and a specificity of 61% to predict stenosis with an FFR value of ≤0.80. CONCLUSION: The pre-angiographic NLR is a simple, noninvasive, and inexpensive biomarker that was significantly higher in patients with functionally significant coronary stenosis; it can be used to predict the hemodynamic severity of intermediate coronary stenosis in patients with stable CAD.

Changes in neutrophil-to-lymphocyte ratios in postcardiac arrest patients treated with targeted temperature management.

OBJECTIVE: The prognostic value of changes in neutrophil-to-lymphocyte ratios (NLR) in cardiac arrest survivors receiving targeted temperature management (TTM) is unknown. The current study investigated NLR in postcardiac arrest (PCA) patients undergoing TTM. METHODS: This retrospective single-center study included 95 patients (59 males, age: 55.0±17.0 years) with in-hospital and out-of-hospital cardiac arrests who underwent TTM for PCA syndrome within 6 h of cardiac arrest. Hypothermia was maintained for 24 h at a target temperature of 33°C. NLR was calculated as the absolute neutrophil count divided by the absolute lymphocyte count. RESULTS: Of the 95 patients, 59 (62%) died during hospital stay. Fewer vasopressors were used in patients who survived. Out-of-hospital cardiac arrest was more frequent in decedents (p=0.005). Length of stay in the hospital and intensive care unit were significantly longer in patients who survived (p=0.0001 and p=0.001, respectively). NLR on admission and during rewarming did not differ between survivors and decedents. NLR during cooling was significantly higher in decedents (p=0.014). Delta NLR cut-off of 13.5 best separated survivors and decedents (AUC=0.68, 95% CI: 0.57-0.79, p=0.003 with a sensitivity and specificity of 64% and 67%, respectively). In multivariate logistic regression analysis, larger increase in NLR was significantly associated with decreased survival (OR: 0.96, 95% CI: 0.94-0.99, p=0.008). CONCLUSION: Changes in NLR are an independent determinant of survival in patients with return of spontaneous circulation PCA treated with TTM. An NLR change can be used to predict survival in these patients.

Right ventricular outflow tract function in chronic heart failure.

BACKGROUND: Heart failure (HF) is a common, progressive, complex clinical syndrome and a subset of HF patients has symptoms out of proportion to the resting hemodynamics and left ventricular ejection fraction (LVEF). Right ventricular (RV) function is a powerful prognostic factor in HF, but assessing it is a challenge because of the right ventricle's complex geometry. OBJECTIVE: The aim of this study was to investigate the clinical application value of RV outflow tract (RVOT) function measured by transthoracic echocardiography in HF patients. METHOD: We prospectively investigated 36 chronic HF patients with dilated heart and LV systolic dysfunction and 21 healthy control subjects (normal ventricular function and ECG, and no cardiac risk factors). In addition to clinical and conventional echocardiographic parameters, RVOT size and fractional shortening (RVOT-FS) parameters were analyzed. RESULTS: The RVOT-FS was less in HF patients than healthy controls (18.8±15.7 vs 55.8±6.7, p<0.001) and correlated positively with TAPSE (r=0.814, p<0.001) and inversely with SPAP (r=-0.728, p<0.001) and functional capacity (r=-0.842, p<0.001). There was a statistically significant difference in RVOT-FS among the HF subgroups with regard to NYHA functional capacity (p<0.001), although there was no statistically significant difference with regard to LVEF. CONCLUSION: Although the apparent discordance between LVEF and the degree of functional impairment in HF is not well understood, it may be explained in part by alterations in RV function. We found that the RVOT-FS was a noninvasive and easily applicable measure of RV function and might be used for a comprehensive evaluation and follow-up of HF patients with a combined assessment of RV by other RV parameters.

Effect of circadian variability in frequency of premature ventricular complexes on left ventricular function.

BACKGROUND: Frequent idiopathic premature ventricular complexes (PVCs) can result in a reversible form of cardiomyopathy. OBJECTIVE: The purpose of this study was to assess the impact of variability in PVC frequency throughout the day on PVC-induced cardiomyopathy. METHODS: The subjects of this study were 107 consecutive patients (58 men [54%]; mean age 49.7 ± 15.0 years; left ventricular ejection fraction 50.4% ± 11.4%) referred for ablation of frequent PVCs. All patients underwent 24-hour Holter monitoring before the ablation procedure. The circadian variation in PVC burden was determined and correlated with the presence or absence of cardiomyopathy. RESULTS: A total of 43 patients (40%) had cardiomyopathy. Patients with cardiomyopathy had an ejection fraction of 38.4% ± 6.9%, a higher PVC burden (28.5% ± 11.5% vs 19.5% ± 10.5%; P = .0001), less variability in circadian PVC distribution (coefficient of variation hourly: 31.5% ± 21% vs 59.8% ± 32.4%; P = .0001), and more frequent interpolated PVCs (20 patients [47%] vs 15 patients [23%]; P = 0.022), and were more frequently asymptomatic than patients without cardiomyopathy (56% vs 19%; P = .0001). In multivariate analysis, consistency in PVC burden throughout the day was an independent predictor of PVC-induced cardiomyopathy (odds ratio 16.3; 95% confidence interval 1.7-155.3; p = 0.015). CONCLUSION: In patients with frequent PVCs, consistency in hourly PVC frequency throughout the day is an independent predictor of PVC-induced cardiomyopathy.

Single- and dual-site pace mapping of idiopathic septal intramural ventricular arrhythmias.

BACKGROUND: Pace mapping (PM) is used to identify the origin of ventricular arrhythmias (VAs). For intramural VAs, the site of origin often cannot be reached and therefore PM is less accurate. OBJECTIVE: The purpose of this study was to assess the value of single- and dual-site pace maps to differentiate intramural from nonintramural VAs. METHODS: In 18 consecutive patients with idiopathic intramural VAs, pace mapping was performed at 2 breakthrough sites in adjacent anatomic structures. Twelve-lead electrocardiograms of the 2 pace maps were averaged in MATLAB and compared (correlation coefficient [CC]) with the targeted VA. Dual-site pace mapping was performed in a control group of 18 patients with nonintramural VAs at the sites of earliest electrical activation and a breakthrough site in an adjacent anatomic location. RESULTS: Dual-site pace maps had a higher CC than did best single-site pace maps (0.87 ± 0.1 vs 0.81 ± 0.16; P = .02) in patients with intramural VAs. At the site of origin, single-site pace maps had a higher CC than did dual-site pace maps obtained from adjacent anatomic locations (0.93 ± 0.04 vs 0.89 ± 0.05; P = .0004) in patients with nonintramural VAs. Sensitivity, specificity, positive predictive value, and negative predictive value of dual-site pace maps for identifying an intramural VA were 89%, 82%, 84%, 88%, and 86%, respectively. Furthermore, the receiver operating characteristic curve analysis revealed that a CC cutoff value of ≤0.86 for a single-site pace map best differentiated intramural from nonintramural VAs. CONCLUSION: A higher CC value for a dual-site pace map obtained from the earliest breakthrough site as well as a CC cutoff value of ≤0.86 for a single-site pace map obtained from the site of earliest electrical activation can best differentiate intramural from nonintramural VAs.

Arrhythmogenic Noncompaction Cardiomyopathy: Is There an Echocardiographic Phenotypic Overlap of Two Distinct Cardiomyopathies?

The clinical diagnosis of right ventricular (RV) cardiomyopathies is often challenging. It is difficult to differentiate the isolated left ventricular (LV) noncompaction cardiomyopathy (NC) from biventricular NC or from coexisting arrhythmogenic ventricular cardiomyopathy (AC). There are currently few established morphologic criteria for the diagnosis other than RV dilation and presence of excessive regional trabeculation. The gross and microscopic changes suggest pathological similarities between, or coexistence of, RV-NC and AC. Therefore, the term arrhythmogenic right ventricular cardiomyopathy is somewhat misleading as isolated LV or biventricular involvement may be present and thus a broader term such as AC should be preferred. We describe an unusual case of AC associated with a NC in a 27-year-old man who had a history of permanent pacemaker 7 years ago due to second-degree atrioventricular block.

The classical "R-on-T" phenomenon.

The polymorphic ventricular tachycardia (PVT) is uncommon arrhythmia with multiple causes and has been classified according to whether they are associated with long QT interval or normal QT. Whereas "Torsade de pointes (TdP)" is an uncommon and distinctive form of PVT occurring in a setting of prolonged QT interval, which may be congenital or acquired (congenital or acquired), "PVT with normal QT" is associated with myocardial ischemia, electrolyte abnormalities (hypokalemia), mutations of the cardiac sodium channel (Brugada syndrome), and the ryanodine receptor (catecholaminergic PVT). This distinction is crucial because of the differing etiologies and management of these arrhythmias. Moreover, the PVT in the setting of acute MI generally occurs during the hyperacute phase, is related to ischemia ("ischemic PVT") and is not associated with QT prolongation. It is triggered by ventricular extrasystoles with very short coupling interval (the "R-on-T" phenomenon) and is not pause-dependent. However, recently there has been described a new PVT during the "healing phase" of MI in patients with no evidence of ongoing ischemia and following excessive QT prolongation, the electrophysiologic abnormality being a "pause-dependent infarct-related TdP" due to a LQTS in healing MI patients. Therefore, "ischemic PVT" differs from "infarct-related TdP" in terms of pathophysiology and ECG manifestations.

Occult obstructive sleep apnea and clinical outcomes of radiofrequency catheter ablation in patients with atrial fibrillation.

BACKGROUND: Recurrent atrial fibrillation (AF) after successful cardioversion can be predicted by obstructive sleep apnea (OSA) diagnosed by polysomnography. However, it is not known whether the validated STOP-BANG questionnaire can predict AF recurrence after radiofrequency ablation (RFA). Our objective is to determine the prevalence of unrecognized OSA in patients with AF and its relation to freedom from AF after RFA. METHODS: Validated surveys were administered to 247 consecutive AF patients following radiofrequency ablation from January to October 2011. OSA status was assessed at baseline RFA. Clinical follow up occurred at 3-6 month intervals. RESULTS: OSA had been previously diagnosed in 94/247 (38%). Among 153 patients without prior diagnosis of OSA, 121 (79%) had high risk STOP-BANG scores for OSA. Probability of maintaining sinus rhythm after RFA was similar among patients with known OSA (66/94, 70%) and high risk OSA scores (95/124, 77%) and higher than among patients with low risk OSA scores (29/32, 91%, P=0.03). Among patients without prior OSA, a high risk STOP-BANG score did predict recurrent AF (OR = 3.7, 95 % CI 1.4-11.4, P = 0.0005). Multivariate analysis showed a higher risk of atrial arrhythmia recurrence for non-paroxysmal AF patients (OR = 3.1, ± 95 % CI 1.4-7.1, P = 0.005). CONCLUSIONS: The majority of AF patients undergoing RFA have high risk OSA scores, suggesting that OSA is vastly underdiagnosed in this population. STOP-BANG independently predicted recurrent AF in patients without a prior diagnosis of OSA.

Predictive value of programmed ventricular stimulation after catheter ablation of post-infarction ventricular tachycardia.

BACKGROUND: A recent meta-analysis demonstrated a survival benefit in post-infarction patients whose ventricular tachycardia (VT) was rendered noninducible by catheter ablation. Furthermore, patients with noninducible VT had a lower VT recurrence rate than did patients whose VT remained inducible after ablation. OBJECTIVES: The purpose of this multicenter cohort study was to assess whether noninducibility after VT ablation is independently associated with improved survival. METHODS: Data from 1,064 patients who underwent VT ablation for post-infarction VT at seven international centers were analyzed. The ablation procedure was considered successful if no VT was inducible at the end of the procedure and unsuccessful if VT remained inducible or if programmed stimulation was not performed at the end of the ablation. RESULTS: Median follow-up time was 633 days. Noninducibility was independently associated with lower mortality (adjusted hazard ratio: 0.65; 95% confidence interval: 0.53 to 0.79; p<0.001). Atrial fibrillation, diabetes, and age were other independent predictors of higher mortality. Ablation of only the clinical VT in patients who also had inducible, nonclinical VTs was not associated with improved survival. CONCLUSIONS: Noninducibility after VT ablation in patients with post-infarction VT is independently associated with lower mortality during long-term follow-up.

Recurrence of PVCs in patients with PVC-induced cardiomyopathy.

BACKGROUND: The natural history of premature ventricular complex (PVC)-induced cardiomyopathy is incompletely understood. OBJECTIVE: The purpose of this study was to assess long term follow-up data in patients who underwent successful PVC ablation for PVC-induced cardiomyopathy. METHODS: The subjects of this study were 60 patients (17 women; mean age 52.5 ± 16.8 years; ejection fraction [EF] 37.3 ± 8.5%, median 40%, interquartile range [IQR] 15) with PVC-induced cardiomyopathy who underwent successful ablation of their predominant PVCs between 2005 and 2012. Patients were followed up for a mean of 23.6 ± 17.2 months. EF improved to 57.2 ± 4.7% (median 55%, IQR 5; P = .0001) within 9.6 ± 8.4 months of the ablation procedure. During follow-up, 10 of 60 patients (16.7%) had recurrent frequent PVCs and 50 patients (83.3%) did not. Patients underwent repeat assessment of EF and PVC burden. RESULTS: During follow-up of 23.6 ± 17.2 months, 10 patients had recurrent frequent PVCs, with an increase of their PVC burden from 1.4 ± 0.9% (median 1.05%, IQR 1.59) after the initial ablation to 27.2 ± 8.8% (median 26.0%, IQR 18.2; P = .018). Their EF decreased from 55.7 ± 3.4% (median 55%, IQR 5.8) after the initial ablation to 40.2 ± 5.1% (median 40%, IQR 15; P = .005). In the remaining patients with PVC-induced cardiomyopathy, EF and PVC burden remained unchanged during follow-up. Patients with PVC recurrence had a higher number of pleomorphic PVC morphologies during initial presentation (4.7 ± 2.2 vs 2.5 ± 2.8, P = .002). CONCLUSION: Recurrence of frequent PVCs in patients with a history of PVC cardiomyopathy can result in recurrence of cardiomyopathy. Follow-up in patients with PVC-induced cardiomyopathy is important, especially if patients were asymptomatic from the PVCs and have pleomorphic PVCs.

Noninducibility in postinfarction ventricular tachycardia as an end point for ventricular tachycardia ablation and its effects on outcomes: a meta-analysis.

BACKGROUND: Although ventricular tachycardia (VT) ablation is a widely used therapy for patients with VT, the ideal end points for this procedure are not well defined. We performed a meta-analysis of the published literature to assess the predictive value of noninducibility of postinfarction VT for long-term outcomes after VT ablation. METHODS AND RESULTS: We performed a systematic review of MEDLINE (1950-2013), EMBASE (1988-2013), the Cochrane Controlled Trials Register (Fourth Quarter, 2012), and reports presented at scientific meetings (1994-2013). Randomized controlled trials, case-control, and cohort studies of VT ablation were included. Outcomes reported in eligible studies were freedom from VT/ventricular fibrillation and all-cause mortality. Of the 3895 studies evaluated, we identified 8 cohort studies enrolling 928 patients for the meta-analysis. Noninducibility after VT ablation was associated with a significant increase in arrhythmia-free survival compared with partial success (odds ratio, 0.49; 95% confidence interval, 0.29-0.84; P=0.009) or failed ablation procedure (odds ratio, 0.10; 95% confidence interval, 0.06-0.18; P<0.001). There was also a significant reduction in all-cause mortality if patients were noninducible after VT ablation compared with patients with partial success (odds ratio, 0.59; 95% confidence interval, 0.36-0.98; P=0.04) or failed ablation (odds ratio, 0.32; 95% confidence interval, 0.10-0.99; P=0.049). CONCLUSIONS: Noninducibility of VT after VT ablation is associated with improved arrhythmia-free survival and all-cause mortality.

Mortality and cerebrovascular events after radiofrequency catheter ablation of atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is associated with a significant increase in the risk of stroke and mortality. It is unclear whether maintaining sinus rhythm (SR) after radiofrequency ablation (RFA) is associated with an improvement in stroke risk and survival. OBJECTIVE: The purpose of this study was to determine whether SR after RFA of AF is associated with an improvement in the risk of cerebrovascular events (CVEs) and mortality during an extended 10-year follow-up. METHODS: RFA was performed in 3058 patients (age 58 ± 10 years) with paroxysmal (n = 1888) or persistent AF (n = 1170). The effects of time-dependent rhythm status on CVEs and cardiac and all-cause mortality were assessed using multivariable Cox models adjusted for baseline and time-dependent variables during 11,347 patient-years of follow-up. RESULTS: Independent predictors of a higher arrhythmia burden after RFA were age (estimated beta coefficient [ß] = 0.017 per 10 years, 95% confidence interval [CI] 0.006-0.029, P = .003), left atrial (LA) diameter (ß = 0.044 per 5-mm increase in LA diameter, 95% CI 0.034-0.055, P <.0001), and persistent AF (ß = 0.174, 95% CI 0.147-0.201, P <.0001). CVEs and cardiac and all-cause mortality occurred in 71 (2.3%), 33 (1.1%), and 111 (3.6%), respectively. SR after RFA was associated with a significantly lower risk of cardiac mortality (hazard ratio [HR] 0.41, 95% CI 0.20-0.84, P = .015). There was not a significant reduction in all-cause mortality (HR 0.86, 95% CI 0.58-1.29, P = .48) or CVEs (HR 0.79, 95% CI 0.48-1.29, P = .34) in patients who remained in SR after RFA. CONCLUSION: Maintenance of SR after RFA is associated with a reduction in cardiovascular mortality in patients with AF.

Infrequent intraprocedural premature ventricular complexes: implications for ablation outcome.

BACKGROUND: Frequent premature ventricular complexes (PVCs) can be eliminated with an ablation procedure. Ablation success rates have been reported to be in the 80% range. Reasons for failure of ablation have not been described in detail. The purpose of this study was to determine whether the paucity of PVCs at the beginning of the ablation procedure affects the outcome. METHODS: Catheter ablation was attempted in a consecutive series of 194 patients (age: 50 ± 14 years, 91 male, ejection fraction: 56.4 ± 8.4%) with frequent idiopathic PVCs. Based on receiver operator characteristics (ROC) analysis, patients were divided into 2 groups: Patients with frequent PVCs (≥32 PVCs within the first 30 minutes of the procedure: n = 135 [70%]); and patients with infrequent PVCs (<32 PVCs within the first 30 minutes of the procedure: n = 59 [30%]). Procedural outcomes were compared at 3 months postablation. A successful ablation was defined as a ≥80% reduction in the PVC burden compared to baseline. RESULTS: A successful procedure was performed in 148 patients (76%) resulting in a decrease in the PVC burden from 19.1 ± 13.6% to 0.38 ± 0.98%(P < 0.0001). Patients with frequent intraprocedural PVCs had a higher success rate than patients with infrequent intraprocedural PVCs (85% vs. 56%, P = 0.0001). Administration of sedation was no different in the 2 groups. The paucity of PVCs was independent of the site of origin in predicting procedural failure (OR: 6.9, 95% CI: 3.0-16.2 P = 0.0001). CONCLUSION: Paucity of PVCs at the beginning of an ablation procedure is associated with a lower ablation success rate independent of the site of origin.