Simultaneous Ablation of Ventricular Tachycardia and Hemodynamic Improvement of Mid-ventricular Obstructive Hypertrophic Cardiomyopathy by Coronary Venous Ethanol Ablation.

Transvenous coronary ethanol ablation may be successfully applied to simultaneously treat ventricular arrhythmia superimposed within a segment of hypertrophic cardiomyopathy. This presentation nicely describes this emerging technique for ventricular tachycardia ablation and identifies potential additional benefits of venous ethanol administration in patients with left ventricular obstructive physiology.

Comparison of frequency of silent cerebral infarction as assessed by serum neuron specific enolase in patients with non-valvular atrial fibrillation: Warfarin versus direct oral anticoagulant.

BACKGROUND: Cerebral infarction in patients with atrial fibrillation (AF) may clinically vary from being silent to catastrophic. Silent cerebral infarction (SCI) is the neuronal injury in the absence of clinically appearent stroke or transient ischaemic attack. Serum neuron specific enolase (NSE) is suggested to be a valid surrogate biomarker that allows to detect recent neuronal injury. We aimed to evaluate the incidence of recent SCI by positive NSE levels in patients with non-valvular AF (NVAF) on oral anticoagulants. METHODS: Blood samples for NSE were collected from 197 consecutive NVAF patients. NSE levels of greater than 12 ng/ml was considered as positive and suggestive of SCI. RESULTS: Patients were mainly female with a mean age of 69 years. Ninety-eight of them (49.7%) were taking warfarin. Mean INR level was 2.3 ± 0.9. Mean CHA2DS2-VASc score of the study population was 3.5 ± 1.5. Seventy-two patients (36.5%) were found to have NSE elevation. They were more likely to have history of chronic heart failure and previous stroke/TIA. Increased left atrial diameter and higher CHA2DS2-VASc were other factors associated with SCI. Patients on DOACs and patients taking aspirin on top of oral anticoagulant treatment were less likely to have SCI. Multivariate analysis demonstrated that increased left atrial diameter (OR: 2.5; 95% CI: 1.52-4; p < 0.001) and use of warfarin (OR: 2.8; 95% CI: 1.37-5.61; p = 0.005) were detected as independent predictors of SCI. CONCLUSIONS: Our study revealed that DOACs were associated with significantly reduced SCIs compared with warfarin, probably due to more effective and consistent therapeutic level of anticoagulation.

Predictors of Pacemaker-Induced Cardiomyopathy and Importance of Nutritional Status and Prognostic Nutritional Index.

Background: Long-term right ventricular (RV) pacing may cause progressive left ventricular systolic dysfunction, and malnutrition is related to adverse cardiovascular outcomes in patients with heart failure. We aimed to evaluate the relationship between immunonutritional status and the development of pacing-induced cardiomyopathy (PICMP). Methods: This study included 434 patients who underwent permanent pacemaker (PPM) implantation and had preserved left ventricular ejection fraction (LVEF) of > 40%. At six months of follow-up, the patients with LVEF < 40% were defined as having PICMP. Baseline prognostic nutritional index (PNI) was calculated based on serum albumin and lymphocyte count. Results: Overall, 16.5% of the our study patients developed PICMP. The PICMP group had more males (p = 0.013), lower baseline LVEF values (p = 0.014) and lower baseline PNI levels (p < 0.001). RV pacing ratios and paced QRS intervals were higher in the PICMP group (p < 0.001 for both), but the types of implanted pacemakers were similar for all patients (p = 0.709). According to regression analyses, baseline LVEF (p = 0.020), PNI (p < 0.001), C-reactive protein level (p = 0.012), RV pacing ratio (p < 0.001) and paced QRS interval (p = 0.001) were independent predictors of PICMP development. A cut-off PNI value ≤ 43.2 at the time of PPM implantation could predict PICMP development with a sensitivity of 85.5% and specificity of 86.7% (p < 0.001). Conclusions: Identifying poor nutritional status using the PNI may be an important concept to predict PICMP development, and optimizing nutritional status might help to reduce adverse outcomes in these patients.

Comprehensive assessment of Mahaim accessory pathways' anatomic distribution.

OBJECTIVE: To present the authors' experience of Mahaim-type accessory pathways (MAPs), focusing on anatomic localizations. METHODS: Data from consecutive patients who underwent electrophysiological study (EPS) for MAP ablation in two tertiary centres, between January 1998 and June 2020, were retrospectively analysed. RESULTS: Of the 55 included patients, 27 (49.1%) were male, and the overall mean age was 29.5 ± 11.6 years (range, 12-66 years). MAPs were ablated at the tricuspid annulus in 43 patients (78.2%), mitral annulus in four patients (7.3%), paraseptal region in three patients (5.5%), and right ventricle mid-apical region in five patients (9.1%). Among 49 patients who planned for ablation therapy, the success rate was 91.8% (45 patients). CONCLUSION: MAPs were most often ablated at the lateral aspect of the tricuspid annuli, sometimes at other sides of the tricuspid and mitral annuli, and infrequently in the right ventricle. The M potential mapping technique is likely to be a useful target for ablation of MAPs.

Radiofrequency catheter ablation of patients with permanent junctional reciprocating tachycardia and long-term follow-up results.

BACKGROUND: Permanent junctional reciprocating tachycardia (PJRT) is an infrequent form of atrioventricular re-entrant tachycardia. We report the clinical and electrophysiological properties of PJRT and outcomes of radiofrequency catheter ablation (RCA) in a large group of patients. METHODS: We included 62 patients with the diagnosis of PJRT. Radiofrequency catheter ablation was performed in all. RESULTS: Location of accessory pathway was right posteroseptal in 37 (59,7%) cases, right midseptal in 3 (4,8%), left posterior in 7 (11,3%), left lateral in 5 (8,1%), left posterolateral in 3 (4,8%), left anterolateral in 2 (3,2%), left posteroseptal in 2 (3,2%), middle cardiac vein in 2 (3,2%), and left coronary cusp in 1 (1,6%). Single procedure success rate was 90.3%. None of patients had recurrence during follow-up after repeat ablations. Overall long-term success rate was 98.4%. Left ventricular systolic function recovered in all patients with tachycardia-induced cardiomyopathy (TIC). CONCLUSION: Retrograde decremental accessory pathways are mainly located in posteroseptal region. Radiofrequency catheter ablation is a safe and effective approach in patients with PJRT.

Characteristics of a large-scale cohort with accessory pathway(s): A cross-sectional retrospective study highlighting over a twenty-year experience.

OBJECTIVE: Catheter ablation following electrophysiologic study (EPS) is the mainstay of diagnosis and treatment for patients with atrioventricular reentrant tachycardia (AVRT), demonstrating excellent long-term outcome and a low rate of complications. In this study, our aim was to assess our experience in patients with accessory pathway (AP) and to compare our data with the literature. METHODS: We included 1,437 patients who were diagnosed and treated for AP in our hospital between 1998 and 2020. The demographic data of all the patients, AP location, and periprocedural results were recorded. RESULTS: Of the 1,437 patients, 1,299 (90.4%) were men; and the mean age of the population was 26.67 years. The location of 1,418 APs were along the left free wall (647 [45.6%] patients), in the posteroseptal region (366 [25.3%] patients), in the anteroseptal region (290 [20.4%] patients), and along the right free wall (115 [8.1%] patients). The ratio of the second AP existence was 3.0% and AVNRT co-existence was 2.0%. A total of 55 (3.8%) patients had recurrent sessions for relapse. Our center's total success rate was 95.5%, and total complication rate was 0.26%. CONCLUSION: According to our retrospective analysis, EPS is a highly functional tool in the diagnosis and management of arrhythmias such as AVRT for high-risk patient groups like military personnel with the aim of risk stratification and medical management.

Invasive validation of the left ventricular global longitudinal strain for estimating left ventricular filling pressure.

PURPOSE: An elevated left ventricular (LV) filling pressure is the main finding in heart failure patients with preserved ejection fraction, which is estimated with an algorithm using echocardiographic parameters recommended by the recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines. In this study, we sought to determine the efficacy of the LV global longitudinal strain (GLS) in predicting an elevated LV filling pressure. METHODS AND RESULTS: A total of 73 prospectively selected patients undergoing LV catheterization (mean age 63.19 ± 9.64, 69% male) participated in this study. Using the algorithm, the LV filling pressure was estimated using the echocardiographic parameters obtained within 24 hours before catheterization. The LV GLS was measured using an automated functional imaging system (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to the mean left atrial pressure (LAP) was used as a reference, and a LAP of >12 mm Hg was defined as elevated. Invasive LV filling pressure was elevated in 43 patients (59%) and normal in 30 patients (41%). Nine of 73 (12%) patients were defined as indeterminate based on the 2016 algorithm. Using the ROC method, -18.1% of LV GLS determined the elevated LAP (AUC =0.79; specificity, 73%; sensitivity, 84%) with better sensitivity compared to that by the algorithm (AUC =0.76; specificity, 77%; sensitivity, 72%). CONCLUSIONS: We demonstrated that LV GLS was an independent predictor of elevated LAP as the E/e' ratio and TR jet velocity and may be used as a major criterion for the diagnosis of HFpEF.

Relation of Acute Decompensated Heart Failure to Silent Cerebral Infarcts in Patients With Reduced Left Ventricular Ejection Fraction.

Heart failure (HF) is a prothrombotic state with increased rate of thromboembolic events. Magnetic resonance imaging studies demonstrated increased rate of silent cerebral infarcts (SCI) in this patient group and SCIs were shown lead to dementia, cognitive decline, and depression. We aimed to show acute decompensated phase is associated with increased rate of recent SCI in reduced ejection fraction HF patients. HF patients with sinus rhythm hospitalized for acute decompensation were studied. Neuron specific enolase (NSE), a sensitive neuronal ischemia marker, was used to detect recent SCI. Decompensated and compensated phase blood samples for NSE were collected on the day of admission and on the third day of compensation, respectively. One hundred and forty seven patients with mean age of 72 were studied. There were significantly more patients with positive NSE levels at decompensated state (29% vs 4%, p <0.001). Multivariate predictors for recent SCI were smoking, new onset atrial fibrillation, spontaneous echo contrast of left ventricle, and aneurysmatic apex. Statin use was found to be protective against NSE elevation. In conclusion, our data reveal that decompensated HF is significantly associated with increased levels of NSE suggestive for silent neuronal injury.

Serum neuron-specific enolase, a marker of neuronal injury, increases after catheter ablation of atrial fibrillation.

OBJECTIVE: Catheter ablation of atrial fibrillation (AF) can lead to thromboembolic complications, especially stroke. We measured the periprocedural serum neuron-specific enolase (NSE) level, which is a biomarker of neuronal injury, after ablation of AF. METHODS: Forty-three patients with paroxysmal AF were prospectively enrolled before radiofrequency ablation. A neurological examination was performed before and after the procedure. The serum NSE level was determined before and at the end of the procedure and at 2, 24, and 48 h after the procedure. RESULTS: No patients developed new neurological deficits. However, the median (interquartile range) NSE level increased after ablation from 6.7 (3.87) ng/mL at baseline to 11.48 (5.3) ng/mL at 24 h postoperatively. The NSE level exceed the upper reference limit of normal (17 ng/mL) in 14 patients (33%), and these patients were found to have a larger left atrium. CONCLUSIONS: Serum NSE increased in most of the patients undergoing ablation for AF, and it exceeded the normal limit in one-third of the patients. Although NSE is a biomarker of neuronal injury, the clinical importance of this increase after AF ablation and its relationship with the left atrial diameter should be evaluated in a longitudinal study.

Comparison of Frequency of Silent Cerebral Infarction After Coronary Angiography and Stenting With Transradial Versus Transfemoral Approaches.

Silent cerebral infarction (SCI) can be seen after coronary procedures. We investigated whether vascular access sites have an impact on the risk of SCI. A total of 255 consecutive patients who underwent diagnostic or interventional coronary procedures through transfemoral (n = 126 patients) or transradial (n = 129 patients) approach were evaluated. Neuron-specific enolase (NSE) levels were studied before and 12 hours after the procedure. Elevation of greater than 12 ng/ml was considered as SCI. Patients were mainly men (60%) with a mean age of 62 years. SCI was observed in 74 of 255 patients (29%). It was significantly more prevalent among transradial group. Elevation of NSE was observed in 36% of transradial group (n = 47) and 21% of the transfemoral group (n = 27) (p = 0.008). Patients with SCI were more likely to have male sexuality, hyperlipidemia, history of smoking, and previous myocardial infarction. Multivariate analysis demonstrated that patients who underwent coronary procedures through transradial approach were 2.1 times more likely to have an SCI than patients with transfemoral approach (95% confidence interval [CI] 1.205 to 3.666; p = 0.008). Other independent predictors of NSE elevation were previous myocardial infarction (odds ratio 8.6; 95% CI 4.209 to 17.572; p <0.001) and smoking history (odds ratio 7.251; 95% CI 3.855 to 13.639; p <0.001). The present study suggests that transradial coronary procedures carry higher risk of SCI when compared with transfemoral route.

Evaluation of right ventricular pacing parameters in patients with proliferative scar.

BACKGROUND: Dermal and myocardial injury results in a healing process, characterized by inflammation and fibrosis. We aimed to investigate association between proliferative scarring at the operation site and right ventricular (RV) pacing and sensing parameters, two clinical outcomes associated with impaired dermal and myocardial healing, respectively. METHODS: We performed an observational retrospective study among regularly followed pacemaker (PM)/implantable cardioverter defibrillator (ICD)-implanted patients at our medical center. Patients, who had a first RV active fixation PM/ICD lead implantation procedure and a minimum follow-up of 1 year, were included in the study. Redo procedures, passive fixation RV leads, epicardial leads, generator replacement procedures, and patients using class I and III anti-arrhythmic drugs were excluded. Patients in the control group, matched by age, sex and implanted device and lead type, were randomly selected from the patient pool. Lead impedance, pacing threshold, and R wave measurements obtained at baseline and at 3rd, 6th, and 12th month were analyzed. RESULTS: Baseline characteristics of study and control groups were similar. While baseline and follow-up lead impedance and R wave measurements along with baseline and 3rd-month pacing thresholds showed no significant difference between two groups, 6th- and 12th-month pacing thresholds revealed statistically significant increase in proliferative scar group compared to control group (0.87 vs 0.72 p = 0.003 and 0.87 vs 0.71 p = 0.003, respectively). CONCLUSIONS: PM/ICD-implanted patients with proliferative scar on pocket wound may show increased RV pacing thresholds compared to patients with normal healing of pocket wound.

Extrathoracic subclavian-axillary vein location and morphological features over the first rib for pacemaker and defibrillator lead implantation.

BACKGROUND: We aimed to describe the variations of extrathoracic subclavian-axillary vein location and its morphology over the first rib by venography in order to facilitate venous puncture using fluoroscopic landmarks without contrast venography, and evaluate the success rate of punctures, which is made with our method. METHODS: Patients who had undergone de novo lead implantation with the help of prepuncture venography between 2011 and 2015 were enrolled. For detection of the segmental location of the axillary vein, the zones were defined (Zone 1: Posterior, Zone 2: Lateral, Zone 3: Medial) at the first rib by fluoroscopy. Additionally, patients, who underwent venous puncture with our method after January 2017, were evaluated in terms of puncture success. RESULTS: Four hundred thirty-three patients who had prepuncture contrast venography for defibrillator or pacemaker lead implantation in 2011-2015 were analyzed. The most common position of the axillary vein was found to be over zone 2 (91%) while the zone 1 location was 8.5% and the zone 3 was 0.5%. Venous valves were detected on the first rib in 98 patients. After January 2017, venous puncture using fluoroscopic landmarks was performed to 171 patients. The punctures were successfully performed over zone 2 with our method in 90.7% of the patients. CONCLUSIONS: The most common radioanatomic position of the extrathoracic subclavian-axillary vein was observed at zone 2 according to our method and the probability of presence of venous valve over the first rib is 22%. Additionally, the success rate of puncture using fluoroscopic landmarks over zone 2 was 90.7%.

Ablation of parahisian premature ventricular extrasystoles by subtricuspid retrograde approach using inverted catheter technique: back to the anatomy.

This report illustrates a feasible and anatomical solution aiming to improve the success and decrease the possible hazards such as atrioventricular block during ablation of parahisian PVCs. We tried to illustrate the specific anatomy pertaining parahisian region and to explain a retrograde subvalvular catheter technique to overcome these procedural obstacles.

Transvenous extraction of a 26-year-old Accufix atrial lead using TightRail rotating dilator sheath.

With the increasing number of implanted pacemakers and implantable cardioverter defibrillators, removal is required more frequently. Presently described is the transvenous extraction of a 26-year-old Accufix atrial lead using a mechanical dilator sheath. A 50-year-old male patient was admitted to the clinic with a pacemaker pocket infection. The atrial lead was an Accufix Bipolar J-Atrial active fixation lead, a model that was recalled in 1994, after reports of 2 deaths and 2 nonfatal injuries related to protrusion of the J retention wire. Both the atrial and ventricular leads were extracted using a mechanical dilator sheath. The Pacemaker Lead Extraction with the Excimer Sheath (PLEXES) Trial reported that of the 57 Accufix leads randomized to a non-laser approach, only 47% were removed successfully, compared with 96% of laser-randomized cases. Since laser sheaths are not available in Turkey, use of a mechanical dilator sheath was required. To our knowledge, this is the oldest Accufix lead extracted with a non-laser sheath. During the extraction of the ventricular lead, the tip of the lead broke off inside the right ventricle and the residual part was left inside the heart. During 3 months of follow-up, no signs of infection or any other undesirable events were encountered.

Percutaneous transapical approach and transcatheter closure for ventricular tachycardia ablation.

In patients with mechanical aortic and mitral valve prosthesis, left ventricular endocardial ablation via retrograde transaortic or antegrade transmitral approach carry high risk of catheter entrapment and death. In such cases, ablation can be performed via ventricular transseptal or transapical approach. Transapical approach, with the ease of catheter maneuverability and better endocardial contact, may be performed surgically or percutaneously. In this case report, we describe a patient with both aortic and mitral mechanical prosthesis who underwent ventricular tachycardia ablation via percutaneous transapical endocardial approach with the use of closure device.

Stent and implantable cardioverter defibrillator implantation in medically resistant vasospastic angina patient.

Vasospastic angina, also known as Prinzmetal's angina, is thought to occur due to vascular hyper-reactivity to various stimuli. Response to medical therapy is usually good; however, 1 out of 5 patients has resistant symptoms. Rarely, potentially lethal arrhythmias can occur due to vasospasm, and those patients are reported to have a poorer prognosis. Presently described is a case of resistant vasospastic angina with persistent symptoms under calcium channel blocker and nitrate treatment. The patient presented with hemodynamically unstable rapid-rate ventricular tachycardia, which was quite resistant to recurrent cardioversion. She was treated with stent implantation for definite vasospastic segments of the coronaries, in combination with medical therapy. An implantable cardioverter defibrillator was also implanted for secondary prevention of ventricular arrhythmia, as vasospasm was considered to be a diffuse disease without a certain definitive treatment.

Ablation of epicardial premature ventricular contractions in a patient with ischemic cardiomyopathy and implementation of cardiac resynchronization therapy in the same procedure.

Premature ventricular contractions (PVCs) can cause clinical deterioration in patients with heart failure and increase the frequency of shocks delivered by an implantable cardioverter defibrillator (ICD). Epicardial PVC/ventricular tachycardia (VT) is seen less often in ischemic cardiomyopathy. Radiofrequency catheter ablation is the most effective treatment option for the management of PVC/VT and can improve cardiac function. Presently described is a patient with ischemic cardiomyopathy and frequent PVCs and VT runs with multiple ICD therapies who was treated with simultaneous radiofrequency catheter ablation in the anterior interventricular vein and cardiac resynchronization therapy defibrillator upgrade in the same procedure.