Cerebral microembolism during atrial fibrillation ablation can result from the technical aspects and mostly does not cause permanent neurological deficit.

INTRODUCTION: Atrial fibrillation ablation can be associated with microembolism detected in the intracranial arteries and risk of neurological incidents. The aims of this study were to evaluate microembolic signals (MES) during pulmonary vein isolation (PVI) and establish the potential significance of MES for damage of the brain in radiological investigation and neurological state. MATERIAL AND METHODS: In the prospective study we included patients with atrial fibrillation undergoing percutaneous pulmonary vein isolation (radiofrequency ablation/balloon cryoablation) with ultrasound monitoring of microembolisms in the middle cerebral artery. Neurological examination and MRI of the head were performed in all participants. RESULTS: The study enrolled 80 patients at a mean age of 58 years. Microembolisms during the monitoring of the flow in the right middle cerebral artery were recorded in 61 (76.3%) patients in the amount of 51-489 (mean: 239). Most often the microembolic signals were registered during the trans-septal puncture and the stage of ablation. In 89%, microembolisms were gaseous. Mean score on the Fazekas scale for the whole group before ablation: 0.87 ±0.7 (0-3, med. 1); after: 0.93 ±0.71. In 3 (4.3%) patients the lesions worsened during the follow-up period. None of the patients revealed a cardiovascular event during the follow-up period and no changes were observed in the neurological status. CONCLUSIONS: The majority of cerebral microembolisms generated during PVI are gaseous in nature. The cerebral microembolisms associated with PVI probably result from the technical aspects of the procedure and do not cause either permanent brain damage in the radiological investigation or neurological deficit.

Left atrial function in obese and non-obese patients undergoing percutaneous pulmonary vein isolation.

Obesity constitutes a risk factor for atrial fibrillation (AF) and modifies the efficacy of invasive AF treatment. Left atrial (LA) global longitudinal strain (GLS), which is measured using speckle-tracking echocardiography (STE), is one of the new methods that are helpful in evaluating the function of LA. The aim of the study was to evaluate LA function in obese and non-obese patients that were undergoing percutaneous pulmonary vein isolation (PVI) before and 6 months after the procedure. 89 patients (F/M: 31/58; mean age: 55.8 ± 9.8 years) with paroxysmal or persistent symptomatic AF that had been qualified for percutaneous PVI were prospectively enrolled in the study. Body mass index (BMI) constituted as a discriminating factor for the study groups: obese group: BMI ≥ 30 kg/m2 (29 patients, F/M: 13/16, mean age: 55.13 ± 10.1 years) and non-obese group BMI < 30 kg/m2 (60 patients, F/M: 18/42, mean age: 57.17 ± 9.0 years). Transthoracic echocardiography (TTE) with LA GLS and segmental longitudinal strain were analysed 1 day before and 6 months after PVI. PVI efficacy was evaluated 6 months after PVI via a seven-day Holter monitoring. Baseline analysis revealed significantly lower two-chamber (2-Ch) LA GLS in the obese patients compared to the non-obese subjects (- 10.55 ± 3.7 vs - 13.11 ± 5.1, p = 0.004). Segmental strain analysis showed no significant differences between the groups. The data that was obtained 6 months after PVI showed a significantly lower 4-Ch LA GLS in the obese patients compared to the non-obese subjects (- 11.04 ± 5.0 vs - 13.91 ± 4.2, p = 0.02), which was accompanied by a significantly lower segmental 4-Ch LA function in the obese patients (med-sept: - 11.66 ± 11.2 vs - 15.97 ± 5.3, p = 0.04; api-sept: - 9.04 ± 6.3 vs - 13.62 ± 6.5, p < 0.001; api-lat: - 7.62 ± 4.0 vs - 13.62 ± 6.5, p < 0.001; med-lat: -9.31 + - 7.9 vs - 15.04 + - 6.3, p = 0.003, global: - 11.04 + - 5.0 vs - 13.91 + - 4.2, p = 0.02). PVI efficacy was confirmed in 52 (58.4%) patients and was similar in both groups. Comparison of the baseline and 6-month strain revealed no differences in LA GLS in either group. Differences in LA GLS before and after the procedure (delta LA GLS) were not obesity dependent. Apical-septal and apical-lateral strain in the obese group, which were measured in 4-Ch view, were significantly lower after the procedure compared to the baseline (p < 0.001). Obese patients with paroxysmal AF were characterised by impaired LA GLS, which is persistent and was accompanied by segmental dysfunction after PVI at the 6-month follow-up. PVI efficacy was comparable between the obese and non-obese patients.

Lower soluble Klotho and higher fibroblast growth factor 23 serum levels are associated with episodes of atrial fibrillation.

AIMS: The proarrhythmic effect of fibroblast growth factor 23 (FGF23) was observed in patients with end stage kidney disease (ESKD). However, there is no data on the role of FGF23 and soluble Klotho (sKlotho) in the pathogenesis of atrial fibrillation (AF) beyond ESKD. The aim of the study was to assess the peripheral vein and left atrial (LA) serum levels of FGF23 and sKlotho along with calcium-phosphates parameters in patients with AF undergoing percutaneous radiofrequency pulmonary vein isolation (PVI). METHODS AND RESULTS: Sixty-nine consecutive patients (mean age: 55.8 ±â€¯9.7 years, F/M: 26/43, CHA2DS2-Vasc: 1.7 ±â€¯1.1) with paroxysmal/persistent AF undergoing PVI were included into the study. Blood samples were taken during PVI - baseline from the peripheral vein, then from the LA immediately after a septal puncture. RESULTS: There were significant differences in the concentrations of peripheral and LA serum sKlotho, intact FGF23 (iFGF23), calcium and phosphates; peripheral FGF23, calcium and phosphates levels were significantly higher, and sKlotho levels were significantly lower than the LA concentrations. Serum sKlotho levels correlated with the CHADS2-VASc score (r = 0.254, p = 0.034) and glucose level (r = 0.300, p = 0.005). Serum sKlotho gradient (LA - peripheral vein) correlated with the baseline AF burden in the Holter monitoring (r = -0.389, p = 0.003). PVI efficacy was confirmed in 52 (75%) patients. There was a significant difference in the iFGF23 gradient between patients with AF and without AF (80.3 vs. -47.6 pg/ml, p = 0.009) in the six-month follow-up. A receiver operating characteristic (ROC) analysis revealed that an iFGF23 gradient >28.7 pg/ml (AUC = 0.742, p = 0.002) was a predictor for AF recurrence. CONCLUSIONS: There is a gradient between the LA and peripheral vein in the markers of calcium-phosphate metabolism in patients undergoing PVI. Lower sKlotho and higher iFGF23 serum levels are associated with episodes of AF. Serum iFGF23 gradient is a potent predictor for the recurrence of AF.

Renalase is associated with adverse left atrial remodelling and disease burden in patients with atrial fibrillation undergoing pulmonary vein isolation.

BACKGROUND: Renalase is a catecholamine-metabolising enzyme, but its possible association with atrial fibrillation (AF) remains unknown. AIM: We sought to evaluate plasma renalase concentration in patients with AF undergoing pulmonary vein isolation (PVI) with respect to AF clinical characteristics, left atrial (LA) remodelling, and PVI efficacy. METHODS: This case-control study included 69 patients (median age 58 years) with either paroxysmal (89%) or persistent (11%) AF, referred for PVI, and a control group consisting of 15 patients without AF, matched for age, sex, and comorbidi-ties. An evaluation of transthoracic echocardiography with LA speckle tracking and plasma renalase concentration using an enzyme-linked immunosorbent assay was performed. AF recurrence was defined as any AF episode on seven-day electro-cardiographic monitoring at six-month follow-up. RESULTS: Renalase level was higher in the study group than in the control group (mean 27.99 vs. 21.48 µg/mL, p = 0.004), but it was lower in patients with persistent AF (19.05 vs. 28.77 µg/mL; p = 0.023) and among patients with AF episodes di-rectly preceding PVI (24.50 vs. 29.66 µg/mL; p = 0.04). Renalase concentration within the first quartile was associated with higher mean heart rate (70 vs. 61 bpm, p = 0.029), greater AF burden (36.9% vs. 9.3%, p = 0.027), greater LA diameter (41.1 vs. 37.9 mm, p = 0.011), and a trend towards less negative global LA strain (-9.4 vs. -13.5, p = 0.082). Logistic regres-sion revealed that global four-chamber LA strain was the only independent predictor of renalase variability (p = 0.0045). Renalase concentration did not predict AF recurrence at six-month follow-up (area under curve [AUC] = 0.614, p = 0.216). CONCLUSIONS: Low renalase level may be associated with impaired rate control, higher AF burden, and advanced LA remodel-ling in AF patients undergoing PVI, but it does not predict sinus rhythm maintenance.

CHA2DS2-Vasc score, age and body mass index as the main risk factors of hyperintense brain lesions in asymptomatic patients with paroxysmal non-valvular atrial fibrillation.

BACKGROUND: The aim was to assess the occurrence, severity and risk factors for silent white matter hyperintensities (WMH) in brain magnetic resonance imaging (MRI) in patients with atrial fibrillation (AF) and to determine the potential relationship between WHM and cognitive decline. METHODS: Seventy-four patients with paroxysmal non-valvular AF were enrolled (age 59 (IQR 50-63)years, males 45/61%). All patients were on adequate warfarin treatment before inclusion and had no history of stroke or TIA. The presence and severity of brain WMH were classified according to the Fazekas scale, while general neurocognitive function was assessed using the Mini-Mental State Examination (MMSE). RESULTS: WMH were found in 51 patients (67.6%; age: 59±7.9years; males: 29/58%). CHADS2-VASc score (OR for 1 point 2.18; 95% CI=1.3-3.65; p=0.003), age (OR for 1year 1.11; 95% CI=1.04-1.18; p=0.001) and BMI (OR for 1kg/m(2) 1.23; 95% CI=1.04-1.45; p=0.017) were independent factors of any brain lesions. A positive correlation between Fazekas scale score and CHA2DS2-VASc score was shown in the entire group (Gamma 0.48; p<0.001). In the group with brain lesions, AF time (p=0.02) and LVEDD (p=0.03) significantly determined the Fazekas scale score (lesions severity). There were no differences in the MMSE score between patients with and without WMH (median: 28 (IQR 27-29) vs 29 (IQR 27.5-30); p=0.2). CONCLUSIONS: Both the presence and severity of brain WMH are related to the CHADS2-VASc score and are not connected with cognitive impairment in this population. Age, BMI, AF time and the indices of heart remodeling constitute important factors influencing brain lesions.

Quality of life in patients with paroxysmal atrial fibrillation after circumferential pulmonary vein ablation.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia and is associated with a deterioration of quality of life (QoL). Catheter ablation is a therapeutic strategy for some patients with AF. The effectiveness of pulmonary vein isolation is still under assessment. AIM: To assess the long-term influence of circumferential pulmonary vein ablation (CPVA) on QoL in patients with AF. METHODS: The study population consisted of 33 patients (26 males, age 54.2 ± 9 years) with highly symptomatic (EHRA II-III) drug refractory paroxysmal AF, who underwent CPVA. A clinical examination, electrocardiogram (ECG), and Holter ECG were performed before and during a one-year follow-up. The SF-36 Medical Outcomes Survey Short-Form QoL questionnaire, scored on a 0-100 scale for each of eight domains: bodily pain (BP), general health (GH), mental health (MH), physical functioning (PF), role-emotional (RE), role-physical (RP), social functioning (SF), and vitality (V), was collected before and one year after CPVA. RESULTS: In the one-year follow-up 27 (82%) patients were free of AF. EHRA symptoms were improved one-year after CPVA regardless of CPVA efficacy. After the follow-up the SF-36 questionnaire results improved significantly in all of the subscales in patients without a recurrence of AF after CPVA. In subjects with a recurrence of AF, all of the subscales did not indicate any statistically significant differences. There was an association between the CPVA and the following QoL domains: GH (p = 0.018), PF (p = 0.042), and V (p = 0.041). The highest values of the GH and V domains were found in the non-recurrence patients one year after CPVA. CONCLUSIONS: CPVA results in the clinical improvement of patients with symptomatic AF regardless of the final arrhythmia termination. Patients after successful CPVA experienced a significant improvement in all of the subscales of the QoL.

Differentiation of arrhythmia originating from the right or left ventricular outflow tract based on the QRS morphology of premature ventricular beats and duration of repolarisation.

BACKGROUND: Premature ventricular beats (PVBs) and monomorphic ventricular tachycardia originating from the right ventricular outflow tract (RVOT) are the most frequent forms of idiopathic ventricular arrhythmias, but arrhythmia originating from the left ventricular outflow tract (LVOT) may be found in about 10% of these patients. AIM: To compare electrocardiographic (ECG) patterns and duration of repolarisation after PVBs originating from the left and right superior part of the interventricular septum which were successfully treated with radiofrequency catheter ablation. METHODS: We studied 62 patients who did not receive antiarrhythmic drug treatment before ablation, including 50 patients with RVOT arrhythmia (21 males, mean age 42 ± 14 years, left ventricular ejection fraction [LVEF] 61 ± 6%) and 12 patients with LVOT arrhythmia (3 males, mean age 41 ± 17 years, LVEF 59 ± 9%). Pre-ablation 24-h Holter ECG recordings were analysed for the total number of PVBs. In addition, we evaluated ectopic beat QRS duration, prematurity index and duration of repolarisation (QT interval, JT interval and TpeakTend values uncorrected for the heart rate) based on ten random daytime PVBs during a period of stable sinus rhythm at a rate of 60-70 bpm. RESULTS: The study groups did not differ by age, LVEF, heart rate and the number of PVBs. RVOT arrhythmia was characterised by a lower prematurity index (0.59 ± 0.11 vs. 0.72 ± 0.09, p = 0.001) and a lower R/S ratio in leads V1-V3 (p < 0.01 for each lead). QRS duration of right-sided PVBs was shorter compared to that of left-sided PVBs (147 ± 13 vs. 166 ± 13 ms, p = 0.002), QT and JT intervals were similar (QT: 422 ± 32 vs. 429 ± 27 ms, p = 0.35; JT: 272 ± 27 vs. 266 ± 27 ms, p = 0.31), and TpeakTend was shorter in RVOT arrhythmia (100 ± 10 vs. 110 ± 6 ms, p = 0.01). Combination of R > S in lead V3 and TpeakTend-PVB > 110 ms identified LVOT arrhythmia with a sensitivity of 75% and specificity of 96%. CONCLUSIONS: Ventricular arrhythmias originating from the left or right superior part of the interventricular septum are not only characterised by different ECG patterns of ventricular ectopic beats but also show significant differences in the repolarisation phase.

[Troponin in forensic medicine]. / Troponina w medycynie sadowej.

In this review we try to answer the question whether and to what degree contemporary forensic pathology takes advantage of quantitative and qualitative troponin determinations. The report is simultaneously an introduction to discussing our results in this area. To perform this review we used the database "PubMed". Polish literature, concurrent with the objective of the study and not included in "PubMed" or included in "OLDMEDLINE" was also analyzed. The identified publications, which were concurrent with the aim of the study, were read and citations were checked. If among the cited papers we found one that was concurrent with the subject of the review, it was also included. While several studies support the use of post-mortem blood and body fluid levels of cardiac troponin T and I as a marker of sudden cardiac death, in our opinion, further research is required to determine the effects of post-mortem autolysis, microbial activity, metabolic derangement and the use of different sample matrices in autopsy cases.

Circumferential pulmonary vein RF ablation in the treatment of atrial fibrillation: 3-year experience of one centre.

INTRODUCTION: In patients with atrial fibrillation (AF), significantly symptomatic in particular, restoring and maintaining sinus rhythm is one of treatment strategies. Considering the limited efficacy and side effects of anti-arrhythmic agents, growing hopes are attributed to the developing techniques of percutaneous ablation. AIM: To determine the efficacy and safety of circumferential pulmonary vein ablation performed using the CARTO system in patients with paroxysmal or permanent AF. METHODS: The study involved 94 patients (mean age 54 years, males 65%, structural heart disease 29.4%) with symptomatic, recurrent and AF resistant to antiarrhythmic agents (paroxysmal AF 63.8%), selected for circumferential pulmonary vein ablation with the Pappone method. Follow-up examinations were performed after 1, 3, 6, 9, and 12 months. The symptoms, ECG, 24-hour ECG monitoring and complications were recorded. RESULTS: Mean procedure and fluoroscopy durations were 4.5 hours and 22.4 minutes respectively. The long-term follow-up ranged from 3 to 24 months, with median time of 12 months. At six months, 47.8% of patients remained free from AF, and improvement in terms of infrequent arrhythmia occurrence and low incidence of symptoms in an additional 36.7% was observed. Efficacy was lower in patients with permanent AF (12 months 90% vs 70%). Complications were seen in six (6.4%) patients: cardiac tamponade in two patients; and pericardial effusion, retroperitoneal bleeding, stroke, and pulmonary vein thrombosis each in one patient. CONCLUSIONS: Circumferential pulmonary vein ablation leads to resolution of arrhythmia or marked clinical improvement in about 75% of patients with symptomatic, resistant AF. The success rate is lower in patients with permanent rather than paroxysmal AF. As severe complications are not unlikely, the indications for such therapy must be carefully balanced.