PECS II block for cardiac implantable electronic device insertion: A pilot study.

AIM: Some truncal blocks could provide adequate surgical anesthesia and postoperative analgesia in cardiac implantable electronic devices (CIED) insertion. The aim of this study was to evaluate the feasibility of the pectoral nerves (PECS) II block for CIED insertion. METHODS: PECS II blocks were performed on the left side using the ultrasound-guided single injection technique in all patients. The primary outcome for feasibility was the percentage of the cases completed without intraoperative additional local anesthesia. Secondary outcomes were the amount of intraoperative additional local anesthetic, intraoperative opioid requirement, postoperative pain scores, first requirement for postoperative analgesia, postoperative analgesic consumption, patient satisfaction, and block-related complications. RESULTS: Of the total 30 patients, 19 (63.3%) required intraoperative additional local anesthetic. The median (IQR [range]) volume of the additional local anesthetic used was 7 (4-10 [2.5-12]) mL. Two patients needed additional IV analgesics in the first 24 h postoperatively. No statistically significant differences were determined between the patients requiring and not requiring intraoperative additional local anesthetic in respect of age, gender, duration of surgery, block performance time, and hospital stay. A total of 26 (86.6%) patients reported a high level of satisfaction with the procedure. CONCLUSIONS: PECS II block for cardiac electronic implantable device insertion provides effective postoperative analgesia for at least 24 h. Although PECS II block alone could not provide complete surgical anesthesia in the majority of the patients, when combined with supplementary local anesthetic, contributes to a smooth intraoperative course for patients.

Effect of Bendopnea on Achievement Medical Treatment Target Doses in Heart Failure.

BACKGROUND: The newly described bendopnea in heart failure (HF) is associated with increased cardiac filling pressures. The aim of the study was to show the effect of bendopnea follow-up on reaching optimal medical treatment doses in HF. METHODS: A total of 413 patients were screened, and we included 203 patients with HF who were previously evaluated for bendopnea. Demographic data, presence or absence of bendopnea, medical history, laboratory findings, and medical treatments were evaluated. Optimal medical therapy target doses at baseline and 3rd month were compared in groups with and without bendopnea. RESULTS: On admission, 64 patients (31.5%) had bendopnea. The rate of patients with bendopnea decreased in the 3rd month (n=42, 20.7%). The proportion of patients who used at least 50% of the recommended medical treatment dose on admission and in the 3rd month was compared; angiotensin-converting enzyme inhibitor /angiotensin receptor blockers use increased from 40.6% to 71.9% in those with bendopnea (P=0.013), from 56.1% to 81.3% in those without bendopnea (P<0.001) and beta-blockers use increased from 28.2% to 60.9% in those with bendopnea (P=0.042), from 31.6% to 69.8% in those without bendopnea (P<0.001). However, aldosterone antagonists use decreased from 70.3% to 67.2% in those with bendopnea (P=0.961), from 68.4 % to 64.1% in those without bendopnea (P=0.334). Bendopnea was independently effective in achieving ACE-I/ARB target doses (OR: 0.359, CI 95%: 0.151-0.854, P=0.020). CONCLUSION: Bendopnea follow-up in HF patients can provide a significant improvement in reaching the recommended treatment target doses.

Frontal Plane QRS-T Angle as a Marker of Cardiac Iron Overload in Patients with Beta Thalassemia Major.

Introduction: Cardiomyopathy due to myocardial iron deposition is the leading cause of death in transfusion- dependent beta-thalassemia major (ß-TM) patients. Although cardiac T2* magnetic resonance imaging (MRI) can be used for the early detection of cardiac iron level before the onset of symptoms associated with iron overload, this expensive method is not widely available in many hospitals. Frontal QRS-T angle is a novel marker of myocardial repolarization and is associated with adverse cardiac outcomes. We aimed to investigate the relationship between cardiac iron load and f(QRS-T) angle in patients with ß-TM. Methods: The study included 95 ß-TM patients. Cardiac T2* values under 20 were considered to indicate cardiac iron overload. The patients were divided into two groups according to the presence or absence of cardiac involvement. Laboratory and electrocardiography parameters, including frontal plane QRS-T angle, were compared between the two groups. Results: Cardiac involvement was detected in 33 (34%) patients. Multivariate analysis showed that frontal QRS-T angle independently predicted cardiac involvement (p < 0.001). An f(QRS-T) angle of ≥ 24.5° had a sensitivity of 78.8% and a specificity of 79% in detecting the presence of cardiac involvement. In addition, a negative correlation was found between cardiac T2* MRI value and f(QRS-T) angle. Conclusions: A widening f(QRS-T) angle could be considered a surrogate marker of MRI T2* to detect cardiac iron overload. Therefore, calculating the f(QRS-T) angle in thalassemia patients is an inexpensive and simple method for detecting the presence of cardiac involvement, especially when cardiac T2* values cannot be determined or monitored.

Should we change our carotid stenting technique? Does balloon postdilatation increase periprocedural cranial embolism? A diffusion-weighted magnetic resonance imaging study.

Introduction: Silent cranial embolism has been demonstrated to cause dementia, cognitive decline and even ischemic stroke. Aim: To compare the periprocedural asymptomatic cranial embolism rates of classical carotid artery stenting (CAS) and non-classical CAS methods using cranial diffusion-weighted magnetic resonance imaging (DW-MRI). Material and methods: 367 clinically uncomplicated patients who underwent CAS at our center between December 2010 and June 2020 (mean age: 69.3 ±11.9) were analyzed retrospectively. The patients were divided into 2 groups, classical CAS (130 patients) and non-classical CAS (237 patients). Classical CAS patients were defined as those who received a stent after suboptimal balloon dilatation (with a 3.0-4.0 mm balloon at 8-10 atmosphere (atm)) and underwent balloon postdilatation after stent deployment (with a 5.0-5.5 mm balloon at 8-10 atm). Non-classical CAS patients were defined as those in whom a stent was deployed after optimal balloon dilatation (with a 4.0-5.0 mm balloon at 10-14 atm) and did not undergo balloon postdilatation. Results: Periprocedural asymptomatic ipsilateral microembolism on cranial DW-MRI was detected in 25 (10.5%) patients in the non-classical CAS group and 24 (18.5%) in the classical CAS group. This difference between the two groups was found to be statistically significant (p = 0.033). Conclusions: The rate of ipsilateral asymptomatic cranial embolism detected on cranial DW-MRI was lower in the CAS procedures in which optimal predilatation was performed but postdilatation after stent deployment was not performed compared to the CAS procedures in which suboptimal predilatation and postdilatation after stent deployment were performed.

Usefulness of the systemic immune-inflammation index in predicting atrial fibrillation recurrence after direct current cardioversion.

Background: We aimed to determine whether there is a relationship between the systemic immune-inflammation (SII) index and the recurrence of atrial fibrillation (AF) after successful direct current cardioversion (DCCV). Methods: The study included 99 patients with persistent AF who underwent successful cardioversion between 2015 and 2020. Results: In multiple regression analyses, the SII index was found to be a better independent predictor of AF recurrence after successful DCCV (p < 0.001). The cut-off value of SII (563) was associated with 96.9% sensitivity and 55.2% specificity to predict AF recurrence after DCCV. Conclusion: As a simple biomarker, SII index is an independent parameter for predicting AF recurrence after successful DCCV in patients with persistent AF. Also, SII levels can predict AF recurrence better than neutrophil-to-lymphocyte ratio.

A rare cause of syncope in patients with situs inversus totalis and corrected transposition of the great arteries: Very late lead perforation.

Situs inversus c-TGA refers to a complex anatomical malformation. The risk of developing AV block increases by 2% per year. Pacemaker lead perforation is a rare but serious complication after pacemaker implantation and that develops more than 1 month is defined as late lead perforation. Here, we presented a case of very late lead perforation that occurred 5 years later after pacemaker implantation in a patient with congenital heart disease who had pacemaker due to AV block. Even in the late period, this complication should be kept in mind in patients with a pacemaker who present with syncope.

Vitamin D Deficiency and Relation to the New York Heart Association Functional Class in Chronic Heart Failure.

OBJECTIVE: Heart failure is an important mortality and morbidity. In this study, we aimed to investigate the frequency of vitamin D deficiency in chronic heart failure patients who live in a sunny region and to evaluate its relationship with the New York Heart Association (NYHA) functional classes. METHODS: The study included 657 patients. Demographic clinical, and laboratory parameters were evaluated according to the NYHA classes. Ordinal regression analysis was used to determine the parameters defining the NYHA class. RESULTS: The median serum 25-hydroxy-vitamin D [25(OH)D] level of study population was 16.88 ng/mL. It was 30 ng/mL. 25(OH)D level was positively correlated with eGFR, calcium, albumin, hemoglobin, transferrin saturation, serum iron, while a negative correlation was found with heart rate, parathormon, NT-proBNP, and CRP. Together with dereased ß blocker use, increase in N-terminal pro-brain natriuretic peptide levels and left atrial diameter, a decrease in vitamin D level (OR: 0.970, 95% CI: 0.945-0996, P=.024) was independently associated with an increase in the New York Heart Association class. CONCLUSION: Vitamin D deficiency and insufficiency are common in patients with chronic heart failure, and vitamin D level is an important determinant of the NYHA functional class in patients with heart failure.

Asymptomatic Cerebral Emboli Following Carotid Artery Stenting: A Diffusion-Weighted MRI Study

BACKGROUND: Silent cranial embolism due to carotid artery stenting has been demonstrated to cause dementia, cognitive decline, and even ischemic stroke. The purpose of this study was to compare the periprocedural asymptomatic cranial embolism rates of different stent designs used for extracranial carotid stenosis with diffusion-weighted magnetic resonance imaging. METHODS: A total of 507 consecutive patients who underwent carotid artery stenting at our center from December 2010 to June 2020 (mean age, 66.4 ± 9.5) were analyzed retrospectively. The patients were divided into 3 groups as open-cell stent (334 patients), closed-cell stent (102 patients), and hybrid-cell stent (71 patients) groups. Diffusionweighted magnetic resonance imaging was performed for the patients before and after carotid artery stenting and compared. The diffusion limitations of 3 stent groups on cranial diffusion-weighted magnetic resonance imaging were compared with one another. RESULTS: Periprocedural asymptomatic same-side microembolism, which was the primary endpoint of our study, was detected in 58 (17.4%) patients in the open-cell stent group, 6 (5.9%) patients in the closed-cell group, and 8 (11.3%) patients in the hybrid cell group, and overall in 72 (14.2%) patients. On diffusion-weighted magnetic resonance imaging, periprocedural asymptomatic same-side cranial embolism was found to be statistically significantly higher in the open-cell group compared to the other two groups (P=.011). CONCLUSIONS: The result of this study showed us that the rate of same-side cranial embolism detected on cranial diffusion-weighted magnetic resonance imaging after carotid artery stenting performed with open-cell stent was higher than those of the carotid artery stenting procedure performed with closed-cell and hybrid-cell stents.

Prognostic value of the combination of uric acid and NT-proBNP in patients with chronic heart failure.

OBJECTIVE: Hyperuricemia is associated with poor outcomes in chronic heart failure (HF). We aimed to evaluate whether uric acid (UA) alone or in combination with N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a good predictor of all-cause mortality, HF hospitalization, and the composite endpoint of HF hospitalization or all-cause mortality in chronic HF. METHODS: UA and NT-proBNP levels were evaluated retrospectively in 861 chronic HF patients with a left ventricular ejection fraction of ≤50%. The patients were compared by dividing them into 4 groups according to the cut-off values of UA and NT-proBNP. RESULTS: Serum UA concentrations were ≥ 7.0 mg/dL in 46.5% of the subjects. With a median follow-up of 30 months, 201 (23.3%) patients died and 308 (35.8%) patients were hospitalized during the study. The all-cause mortality rate was higher in the hyperuricemic group than that of the normouricemic group (p < 0.001). A multivariate Cox regression model revealed that UA and NT-proBNP were independent predictors of all-cause mortality (HR: 1.105, 95% CI: 1.019-1.198, p = 0.016 and HR: 3.743, CI: 2.647-5.292, p < 0.001, respectively). Patients were divided into 4 groups based on UA (≥ 7 and < 7 mg/dL) and NT-proBNP (≥ 2279 and < 2279 ng/L) levels. All-cause mortality, HF hospitalization, and the composite endpoint of HF hospitalization or all-cause mortality rates were higher in the group with high UA and NT-proBNP levels (p < 0.001, p < 0.001, p < 0.001, respectively). CONCLUSION: Hyperuricemia alone is an independent predictor of all-cause mortality in chronic HF. However, the combination of UA and NT-proBNP appears to be a stronger predictor of poor outcomes.

Supraventricular arrhythmia in mitral valve prolapse : Predictive value of P-wave dispersion and atrial conduction time.

BACKGROUND: The incidence of supraventricular arrhythmia (SVA) is high in patients with mitral valve prolapse (MVP). The purpose of our study was to determine the role of parameters showing atrial conduction heterogeneity such as P­wave dispersion (PWD) and atrial electromechanical delay (AEMD) in predicting the development of SVA in MVP patients. METHODS: A total of 76 patients with MVP (56 female, 20 male) were included in the study. The patients were divided into two groups according to the presence or absence of SVA: 36 patients were allocated to the non-SVA group and 40 patients to the SVA group. Heart rate variability (HRV), PWD, and AEMD values were determined and compared. RESULTS: The PWD was found to be higher in the SVA group. Interatrial EMD was 32.00 ms (25.00-35.00) in patients with SVA while it was 18.00 ms in patients without SVA (11.00-23.75); the intra-atrial EMD was 17.0 ms (10.00-20.00) in patients with SVA whereas it was 10.00 ms (4.00-14.00) in patients without SVA. Lower HRV was found in the SVA group. CONCLUSION: In the SVA group, PWD and AEMD were increased while HRV values were decreased. Noninvasive parameters may help predict the presence and incidence of SVA during the follow-up of this group of patients.

Six-year outcomes of carotid artery stenting performed with multidisciplinary management in a single center.

OBJECTIVE: This study aimed to evaluate the first 30-day results of clinical, periprocedural asymptomatic cranial embolism, and long-term restenosis of the multidisciplinary conducted and evaluated carotid artery stenting (CAS) procedure in our patient group with real-life data. METHODS: A total of 610 patients who were subjected to consecutive CAS procedures in our center between December 2010 and February 2019 were clinically and radiologically followed up for a mean duration of 6 years. Of the 610 patients, 274 (45%) were symptomatic for carotid artery stenosis, whereas 336 (55%) were identified as asymptomatic. As embolism protection methods, distal protection, proximal protection, and double (distal + proximal) protection was used in 52%, 43%, and 0.3% of patients, respectively. RESULTS: The success rate of the CAS procedure was 96%. Procedure-related death was reported in 4 (0.6%) patients who successfully underwent the CAS procedure. Moreover, acute carotid artery stent thrombosis, hyperperfusion syndrome, periprocedural major stroke, and periprocedural minor stroke was observed in 4 (0.6%), 2 (0.3%), 2 (0.3%), and 12 (1.9%) patients, respectively. The total clinical complication rates during the first 30 periprocedural days were 1.6% (10 patients) and 3.1% (19 patients) in the asymptomatic and symptomatic groups, respectively. On cranial magnetic resonance imaging performed, asymptomatic ipsilateral cranial microembolism, asymptomatic contralateral cranial microembolism, and bilateral asymptomatic cranial microembolism was detected in 61 (11.6%), 20 (3.8%), 23 (4.4%) patients, respectively. Asymptomatic restenosis was observed in 24 (3.9%) patients. CONCLUSION: The CAS procedure is a reliable treatment option applicable with acceptable complication and success rates as outlined in the guidelines, when performed following a multidisciplinary evaluation, in the treatment of symptomatic and asymptomatic carotid artery stenosis, including high-risk patient groups.

Transcatheter aortic valve implantation through the brachial artery.

Transcatheter aortic valve implantation (TAVI) has been increasingly used in patients with severe aortic stenosis. The femoral artery is the most commonly used entry site for TAVI; however, other entry sites were also reported as transapical, transaortic, transaxillary/subclavian, and transcarotid in patients with occlusive peripheral arterial disease. In this report, a case of TAVI procedure through the brachial artery is presented.

Increased Intima-Media Thickness of the Ascending Aorta May Predict Neurological Complications Associated with TAVI.

OBJECTIVES: Neurological complications associated with transcatheter aortic valve implantation (TAVI) are important due to its morbidity and mortality risks. The purpose of this study was to investigate the importance of the features of the aortic valve and ascending aorta to predict the neurological complications associated with TAVI. METHODS: The patients for whom the heart team decided to perform TAVI were included in the study. In order to assess possible neurological complications, cerebral diffusionweighted magnetic resonance imaging(MRI) was performed pre- and post-operatively. The diameter of the patients' aortic root and ascending aorta, aortic valve scores, intima media thickness of the ascending aorta were measured from their transesophageal echocardiography records. RESULTS: A total of 108 patients constituted the study population. 31 patients were found to develop a new lesion (MR+) detected on MRI after TAVI, while 76 patients did not have any new lesions (MR-). The groups did not have any significant differences in their aortic valve features and scores. However, AA-IMT was found to be higher in the MR+ group (1.8mm [1.6-2.3] vs 1.4mm [1.2-1.8] interquartile range). The multivariate logistic regression analysis conducted to detect new lesions revealed that AA-IMT led to a significantly increased risk. CONCLUSION: The features of the ascending are more important than the demographic characteristics of patients and features of the native valve in predicting new lesions on MRI scans and thus neurological events after TAVI.

Visceral fat index: a novel predictor for coronary collateral circulation.

Objective This study was designed to investigate the role of visceral adiposity along with other clinical parameters in predicting poor coronary collateral circulation (CCC) among patients with severe obstructive coronary artery disease (CAD). Subjects and methods A total of 135 patients with severe obstructive CAD and good (n = 70) or poor (n = 65) CCC were included. Data on angiographically detected CCC, the quality criteria for CCC (Rentrop scores) and visceral fat index (VFI) obtained via bioelectrical impedance were compared between good and poor CCC groups. Independent predictors of poor CCC, the correlation between VFI and Rentrop score and the role of VFI in the identification of CCC were analyzed. Results A significant negative correlation was noted between VFI and Rentrop scores (r = -0.668, < 0.001). The presence of hypertension (OR 4.244, 95% CI 1.184 to 15.211, p = 0.026) and higher VFI (OR 1.955, 95% CI 1.342 to 2.848, p < 0.001) were shown to be independent predictors of an increased risk for poor CCC. ROC analysis revealed a VFI > 9 (AUC [area under the curve] (95% CI): 0.898 (0.834-0.943), p < 0.0001) to be a potential predictor of poor CCC with a sensitivity of 95.38% and specificity of 85.71%. Conclusion In conclusion, our findings revealed comorbid hypertension and higher VFI to significantly predict the risk of poor CCC in patients with severe obstructive CAD.

Visceral fat index: a novel predictor for coronary collateral circulation

ABSTRACT Objective This study was designed to investigate the role of visceral adiposity along with other clinical parameters in predicting poor coronary collateral circulation (CCC) among patients with severe obstructive coronary artery disease (CAD). Subjects and methods A total of 135 patients with severe obstructive CAD and good (n = 70) or poor (n = 65) CCC were included. Data on angiographically detected CCC, the quality criteria for CCC (Rentrop scores) and visceral fat index (VFI) obtained via bioelectrical impedance were compared between good and poor CCC groups. Independent predictors of poor CCC, the correlation between VFI and Rentrop score and the role of VFI in the identification of CCC were analyzed. Results A significant negative correlation was noted between VFI and Rentrop scores (r = -0.668, < 0.001). The presence of hypertension (OR 4.244, 95% CI 1.184 to 15.211, p = 0.026) and higher VFI (OR 1.955, 95% CI 1.342 to 2.848, p < 0.001) were shown to be independent predictors of an increased risk for poor CCC. ROC analysis revealed a VFI > 9 (AUC [area under the curve] (95% CI): 0.898 (0.834-0.943), p < 0.0001) to be a potential predictor of poor CCC with a sensitivity of 95.38% and specificity of 85.71%. Conclusion In conclusion, our findings revealed comorbid hypertension and higher VFI to significantly predict the risk of poor CCC in patients with severe obstructive CAD.

Echocardiographic assessment of right ventricular function in peritoneal dialysis patients.

OBJECTIVE: Cardiovascular disease is the leading cause of mortality in patients undergoing dialysis. Most of the available studies focus on left ventricular (LV) function in peritoneal dialysis (PD) patients; data about the effect of PD on right ventricular (RV) function are scarce. The aim of this study was to evaluate echocardiographic parameters of the RV in patients with end-stage renal disease (ESRD) undergoing PD. METHODS: A total of 73 individuals were grouped as follows: PD patients (n=36) and healthy controls (n=37). Echocardiography of the RV was performed in all of the patients using tissue Doppler imaging (TDI). RESULTS: The LV mass index (LVMI), left atrial (LA) diameter, posterior wall, and interventricular septum thicknesses were significantly greater in the PD group. The LV peak late diastolic atrial contraction (A) velocity was higher, and the peak early diastolic (E) velocity and the early diastolic velocity of the lateral mitral annulus (Em) were lower in the PD group compared with the control group. The right atrial (RA) diameter, RA area, RV fractional area change, RV myocardial performance index, and pulmonary vascular resistance values were similar in both groups, whereas the tricuspid annular plane systolic excursion (TAPSE) value was lower in the PD patients. The RV E; early diastolic (Ea), late diastolic (Aa), and systolic (Sa) velocities; deceleration time; and tricuspid regurgitation velocity were also similar in the 2 groups. Only the RV A velocity and the Ea/Aa ratio were significantly higher in the PD group, and the E/A ratio was lower in the PD group than in the control group. CONCLUSION: The results of conventional and TDI echocardiography indicated that RV systolic and diastolic functions were preserved in PD patients.