Entrapment of focal atrial tachycardia using cryoballoon ablation; Sinus rhythm in the left atrium and ongoing atrial tachycardia in the left atrial appendage

Left atrial appendage (LAA) is a well-known source of focal atrial tachycardias (AT). Although radio-frequency (RF) energy is the most commonly used technique in such cases, there was an option other than epicardial approach when RF technique fails. Cryoballoon technology is primarily developed to be used for pulmonary vein isolation (PVI). Also, there was no report regarding the isolation of LAA by using cryo-balloon in patients with focal AT. In this case, for the first time in the literature, we successfully isolated the LAA because of failed attempts of RF ablation for focal AT in whom the surface electrogram showed a sinus rhythm while arrhythmia continues inside the LAA.

Exercise heart rate recovery assessment of the cardiac autonomic nervous system in workers occupationally exposed to lead

OBJECTIVE

The aim of the present study was to assess cardiac autonomic function via indices of exercise heart rate recovery (HRR) in workers occupationally exposed to lead.

METHODS

A total of 98 lead-exposed workers and 98 healthy controls were enrolled. All underwent exercise testing and transthoracic echocardiography. HRR indices were calculated by subtracting 1st- (HRR1), 2nd- (HRR2), and 3rd-minute (HRR3) heart rates from maximal heart rate (HR). Exercise test parameters- HRR in particular- were compared between groups, and correlation analysis of blood, 24-hour urine lead levels, and test parameters was performed.

RESULTS

Baseline demographic and clinical characteristics were found to be similar between groups. Mean HRR1 (26.2±3.6 vs 29.0±4.1 bpm, p<0.001), HRR2 (42.6±3.9 vs 46.9±3.7 bpm, p<0.001), and HRR3 (56.6±4.5 vs 61.8±4.3 bpm, p<0.001) values were significantly lower in the lead-exposed group than in the healthy controls. HRR1 was found to be significantly correlated with blood (r:-0.415; p<0.001) and 24-hour urine lead levels (r:-0.446; p<0.001). HRR2 and HRR3 were significantly correlated with 24-hour urine lead level (r:-0.396; p<0.001 and r:-0.233; p=0.021, respectively).

CONCLUSION

Lead-exposed workers had lower HRR indices than normal subjects. Blood and 24-hour urine lead levels were significantly associated with HRR indices. Cardiac autonomic functions may be affected by exposure to lead, and those occupationally exposed should be closely followed for adverse cardiovascular outcome.

Serum galectin-3 level as a marker of thrombogenicity in atrial fibrillation

BACKGROUND

Left atrial appendage flow velocity (LAAFV) and presence of spontaneous echo contrast (SEC) have been reported to be predictors of thromboembolism in atrial fibrillation (AF) patients. Galectin-3 is a biomarker reflecting pro-inflammatory status, whose role in AF has recently drawn attention, particularly in persistent AF population.

AIM

In this study we aimed to investigate the association between serum galectin-3 levels and echocardiographic predictors of thromboembolism in persistent AF patients.

METHODS

We included 65 persistent AF patients (55.50±10.67 years, 46.15% male). Transesophageal echocardiography (TEE) was performed to assess LAAFV and presence of left atrial (LA)/LA appendage (LAA)-located SEC and thrombus prior to direct current cardioversion or catheter ablation for AF.

RESULTS

Median galectin-3 level was 0.63 ng/mL. Serum galectin-3 levels were significantly correlated with LAAFV (r=-.440, P<.001). Serum galectin-3 levels were associated with presence of SEC (P<.001), and LA thrombus (P=.008). Receiver operating characteristic analysis revealed that a serum galectin-3 greater or equal to the cut-off value of 0.69 predicted presence of SEC with a sensitivity and specificity of 91.00% and 79.00%, respectively (P<.001).

CONCLUSION

In conclusion, in the setting of persistent AF, serum galectin-3 levels are associated with presence of SEC and LAAFV on TEE. Our findings suggest that serum galectin-3 level may have a place in thromboembolism risk stratification in persistent AF patients.

Pulmonary vein anatomy and its variations in a Turkish atrial fibrillation cohort undergoing cryoballoon-based catheter ablation

OBJECTIVE

Pulmonary vein (PV) anatomy has drawn attention since assumption that atrial fibrillation (AF) may originate from PVs and that electrical isolation of PVs may be beneficial in eliminating these triggers. The present study aims to investigate PV anatomy and its variations in a sample of Turkish patients undergoing PV isolation (PVI) for AF.

METHODS

250 patients underwent multidetector computed tomography before cryoballoon-based PVI for AF. PV and left atrial (LA) anatomy were evaluated in 3-dimensional epicardial reconstructions.

RESULTS

980 PVs were observed. All PVs drained into the LA. Mean superoinferior (SI) dimension for each vein was significantly larger than mean anteroposterior (AP) dimension. Accessory PVs were only seen on right side. Accessory veins were significantly smaller in both AP and SI diameter than other veins. Right-sided PV ostia were more round. Expected anatomy of 2 atrial ostia for right upper and lower lobe veins on each side was seen in 94.8% of patients. Remainder had other variant anatomy in right PVs. Conjoined ostium in the LA was seen in 35.6% of patients.

CONCLUSION

PV variations were common in Turkish AF cohort undergoing PVI, which may be important to know about prior to ablation therapy for procedural success.

Role of Adjuvant Renal Sympathetic Denervation in the Treatment of Ventricular Arrhythmias

Ventricular arrhythmias (VAs) are known to result in significant morbidity and mortality rates in patients with both ischemic and nonischemic dilated cardiomyopathy. Although catheter ablation has emerged as an adjunct treatment strategy in the management of VAs, 1-year follow-up data have revealed that ventricular tachycardia (VT)-free survival rate is ∼50%. Up to now, a few small case series with short-term follow-up have reported reduced VT recurrence after application of renal sympathetic denervation (RSDN) in patients with refractory VAs. In this study, we aimed to investigate the safety and efficacy of RSDN as an adjunctive therapy to catheter ablation for refractory VAs in patients with dilated cardiomyopathy. For this purpose, we conducted a retrospective, propensity score-matched cohort study. A total of 32 patients with implantable cardioverter-defibrillators (ICDs) who underwent catheter ablation or both catheter ablation and RSDN for refractory VAs were included in the analysis. Patients were followed up at a median of 15 months (6 to 20 months). Patient groups did not differ regarding the mean number of VT/ventricular fibrillation episodes in the last 6 months before the procedure (35.00 ± 4.10 in catheter ablation-only group vs 43.00 ± 5.30 in catheter ablation + RSDN group, p = 0.23). There was a significant decrease in burden of both VT/ventricular fibrillation and antitachycardia pacing and shock therapies delivered from ICDs in the patient group that received RSDN as an adjunct therapy (p <0.05). Mortality rates were similar in 2 groups (p >0.05). In conclusion, our findings suggest that adjunctive RSDN is a safe and effective method for reducing the arrhythmic burden in patients with refractory VAs. In the future, it may be performed routinely in patients with ICDs and refractory VAs.

Bethesda classification is a valuable guide for fine needle aspiration reports and highly predictive especially for diagnosing aggressive variants of papillary thyroid carcinoma

BACKGROUND

A fine needle aspiration biopsy (FNAB) is the most valuable diagnostic procedure for pre-operative discrimination of benign and malignant nodules. The Bethesda System for Reporting Thyroid Cytopathology provides standardised reporting and cytomorphological criteria in aspiration smears. The aim of the present study was to determine malignancy rates in nodules with different cytology results and evaluate the diagnostic value of Bethesda for variants of papillary thyroid carcinoma (PTC).

MATERIALS AND METHODS

A retrospective analysis of 2534 cases with 5784 thyroid nodules, who underwent FNAB followed by surgery, were included in this study. FNAB was performed with ultrasonography guidance. Cytological diagnoses were classified as: non-diagnostic (ND), benign, atypia of undetermined significance/follicular lesions of undetermined significance (AUS/FLUS), follicular neoplasm/suspicious for follicular neoplasm (FN/SFN), suspicious for malignancy (SUS) and malignant. Histopathological diagnoses were classified into four groups: benign, PTC, follicular thyroid cancer and other types of thyroid cancer (including medullary thyroid cancer, undifferentiated thyroid cancer and thyroid tumours of uncertain malignant potential). Cases with PTC were further divided into four categories: conventional variant, follicular variant, aggressive variants (tall cell, diffuse sclerosing and columnar variant) and other variants (oncocytic, solid/trabecular and warthin-like variants). FNAB results were compared with histopathological results.

RESULTS

Malignancy rates were 6.3%, 3.2%, 20.7%, 33.3%, 74.2% and 95.6% in the nodules with ND, benign, AUS/FLUS, FN/SFN, SUS and malignant cytology results, respectively. Pre-operative cytology was malignant or SUS in 56.6% of conventional, 24.3% of follicular, 92% of aggressive and 41.7% of other variants of histopathologically confirmed PTC. The difference between the groups was significant (P < 0.001).

CONCLUSION

The Bethesda classification is a reliable indicator of malignancy in nodules with different cytology results and seems to be very effective in predicting the malignancy for the nodules diagnosed with aggressive variant PTC on the final histological examination.

Transcatheter aortic valve implantation in patients with a mitral prosthesis; single center experience and review of literature

OBJECTIVES

Following the encouraging results of several registries and trials, transcatheter aortic valve implantation (TAVI) has been recognized as a valid option in patients with severe aortic stenosis deemed at high or prohibitive risk for surgical treatment. Good procedural success and good clinical outcomes have been showed and very limited data exist on TAVI in the setting of a preexisting mitral prosthesis regarding the technique, potential complications, and outcomes.

METHODS

Here, we report six cases of transfemoral TAVI with a self-expanding bioprosthesis (CoreValve; Medtronic, Inc) in patients who had previously undergone mitral valve replacement. Preprocedural, intraprocedural ve postprocedural outcome and data were analyzed and a brief literature review is also presented.

RESULTS AND CONCLUSION

Our experiences show that transfemoral CoreValve implantation can be performed successfully in patients with mechanical and bioprosthetic mitral valves.

Initial experience with the TightRail™ Rotating Mechanical Dilator Sheath for transvenous lead extraction

AIMS

In parallel with increasing implantation rates and patients' longer life expectancy, the need for transvenous lead extraction (TLE) as a specialized procedure has shown a significant growth over years. Herein, we aimed to present our initial experience in TLE by using a novel TightRail™ Rotating Mechanical Dilator Sheath.

METHODS AND RESULTS

Between October 2014 and March 2015, a total of 42 leads in 23 patients were removed at our tertiary referral centre. All of the extracted leads were >12 months old and indications for extraction were based on the recommendations of the Heart Rhythm Society. The leads were removed by using the TightRail™ Mechanical Dilator Sheath (Spectranetics Corporation) with the rotational cutting force only. Indications for lead removal included cardiac device infection in 12 (52.2%) cases, lead malfunction in the 10 (43.5%) cases, and upgrade to cardiac resynchronization therapy-defibrillator (CRT-D) in the remaining 1 case (4.3%). The extracted devices were pacemaker in 10 (43.4%) cases, implantable cardioverter-defibrillator (ICD) in 7 (30.4%) cases, and CRT in the remaining 6 (26.0%) subjects. Among 42 leads, 10 (23.8%) were right ventricular, 14 (33.3%) were atrial, 13 (31.0%) were defibrilator, and 5 (11.9%) were coronary sinus electrodes. The median time from implantation was 72 (18-216) months. Complete procedural success with TightRail™ system alone was achieved in 22 (95.7%) patients (41/42 leads) and overall clinical success was 100%. One right ventricular lead was completely removed with the help of femoral snare. All the patients were discharged uneventfully without any complication.

CONCLUSION

Our preliminary data with small sample size show that TightRail™ Mechanical Dilator Sheath is a new useful tool for chronically implanted pacemaker (PM)/ICD leads. Continued investigation including large patient cohort is required to evaluate success and complication rates in comparison to other tools and techniques.

Periatrial epicardial adipose tissue thickness is an independent predictor of atrial fibrillation recurrence after cryoballoon-based pulmonary vein isolation

BACKGROUND

Epicardial adipose tissue (EAT) is a metabolically active fat depot. Studies have investigated the effect of EAT thickness on outcomes of radiofrequency catheter ablation of atrial fibrillation (AF). However, data on the relationship between EAT thickness and outcome of cryoballoon-based pulmonary vein isolation (PVI) are lacking.

OBJECTIVE

In this study, we investigate the association between EAT thickness and AF recurrence after cryoballoon-based PVI.

METHODS

Patients with symptomatic paroxysmal or persistent AF despite ≥1 antiarrhythmic drug(s) were scheduled for cryoballoon-based PVI for AF per the recent recommendations. Periatrial, periventricular, and total EAT thickness measurements were obtained from preprocedural multidetector CT scans.

RESULTS

A total of 249 patients (55.6 ± 10.7 years; 48.2% male; 18.5% persistent AF) were involved in the study. Patients were followed-up for 29 months (8-48 months). When blanking period was considered, freedom from AF after the ablation procedure was 75.9% at a median follow-up of 29 months. Total periatrial EAT thickness (18.1 ± 6.2 vs. 14.7 ± 4.7 mm; P < .001) was greater in patients with late AF recurrence when compared to those without. On the other hand, periventricular or total EAT thickness measurements did not differ between both groups (P > .05). Multivariate Cox proportional hazard regression analysis showed that periatrial EAT thickness (hazard ratio, 1.086; P = .001) and left atrial volume index (hazard ratio, 1.144; P < .001) were independent predictors for late AF recurrence.

CONCLUSION

Quantification of EAT thickness from preprocedural multidetector CT scans may serve as a beneficial parameter for prediction of AF recurrence after cryoballoon-based PVI.

The Association of Serum Galectin-3 Levels with Atrial Electrical and Structural Remodeling

INTRODUCTION

Left atrial (LA) interstitial fibrosis is known to have a role in the initiation and maintenance of atrial fibrillation (AF). The role of galectin-3 in the pathogenesis of cardiac fibrosis has been demonstrated in previous studies. We aimed to determine whether serum galectin-3 level is associated with markers of atrial remodeling, including the extent of LA fibrosis detected by delayed enhancement magnetic resonance imaging (DE-MRI) and atrial electromechanical delay (AEMD) in paroxysmal AF patients with preserved left ventricular (LV) functions.

METHODS AND RESULTS

Thirty-three patients (58 [28-74] years, 51.5% male) with paroxysmal AF who underwent DE-MRI prior to cryoballoon-based AF ablation were included in the study. Serum galectin-3 levels were measured with ELISA. LA volume index (B ± SE: 0.424 ± 0.504, 95% CI: 0.560-2.627, P = 0.004) and serum galectin-3 levels (B ± SE: 0.549 ± 7.745, 95% CI: 16.874-47.550, P < 0.001) were found to be independently correlated with extent of LA fibrosis detected with DE-MRI in paroxysmal AF patients with preserved LV function. Correlation analysis between AEMD parameters and baseline characteristics showed that galectin-3 was significantly correlated with intra-left (ρ = 0.432, P = 0.012) and inter-AEMD (ρ = 0.395, P = 0.023). Duration of AF, LAD, and extent of LA fibrosis were also found to be significantly correlated with AEMD parameters.

CONCLUSION

This is a hypothesis-generating study pointing out that serum galectin-3 level is significantly associated with atrial remodeling in paroxysmal AF patients with preserved LV function. Further studies are necessary to provide exact pathophysiological mechanisms.