Association of Uric Acid Albumin Ratio with Recurrence of Atrial Fibrillation after Cryoballoon Catheter Ablation

Objective: Despite improvements in the technology of catheter ablation of atrial fibrillation (AF), recurrences are still a major problem, even after a successful procedure. The uric acid/albumin ratio (UAR), which is an inexpensive and simple laboratory parameter, has recently been introduced in the literature as a predictor of adverse cardiovascular events. Hence, we aimed to investigate the relationship between the UAR and AF recurrence after catheter ablation. Methods: A total of 170 patients who underwent successful catheter ablation for AF were included. The primary outcome was the late recurrence after treatment. The recurrence (+) and recurrence (−) groups were compared for clinical, laboratory and procedural characteristics as well as the predictors of recurrence assessed by regression analysis. Results: In our study population, 53 (26%) patients developed AF recurrence after catheter ablation. Mean UAR was higher in the recurrence (+) group compared to recurrence (−) group (2.4 ± 0.9 vs. 1.8 ± 0.7, p < 0.01). In multivariable regression analysis, left atrial diameter (HR: 1.08, 95% CI: 1.01−1.16, p = 0.01) and UAR (HR:1.36, 95% CI: 1.06−1.75, p = 0.01) were found to be independent predictors of recurrence. In ROC analysis, the UAR > 1.67 predicted recurrence with a sensitivity of 77% and a specificity of 57% (AUC 0.68, p < 0.01). Conclusion: For the first time in the literature, the UAR were found to be correlated independently with AF recurrence after catheter ablation.

The use of ivabradine in a patient with idiopathic ventricular arrhythmia originating from the left ventricular summit

Idiopathic ventricular arrhythmias (VA) are common and treatment options include anti-arrhythmic drugs (AAD) or catheter ablation. Patients presenting with idiopathic VA which is originating from the left ventricular summit (LVS) poses a particular challenge as the success for catheter ablation is low and AAD's may not be used long-term due to side effects. Ivabradine is an inhibitor of funny current (If) in cardiac pacemaker cells by blocking hyperpolarization-activated cyclic nucleotide-gated (HCN). In the present case, we reported the use of ivabradine in treatment of idiopathic VA which was originated from LVS and was resistant to multiple AAD's and catheter ablation.

Predictors for Early Mortality in Patients with Implantable Cardiac Defibrillator for Heart Failure with Reduced Ejection Fraction

Implantable cardioverter defibrillators (ICD) are recommended in heart failure with reduced ejection fraction (HFrEF) patients to reduce arrhythmic deaths. This study aimed to identify risk factors associated with mortality within one-year following the ICD. The data from our hospital's electronic database system was extracted for patients who were implanted ICD secondary to HFrEF between 2009 and 2019. Overall, 1107 patients were included in the present analysis. Mortality rate at one-year following the device implantation was 4.7%. In multivariate analysis; age, atrial fibrillation, New York Heart Association classification >2, blood urea nitrogen, pro-brain natriuretic peptide and albumin independently predicted one year mortality.

The value of C-reactive protein-to-albumin ratio in predicting long-term mortality among HFrEF patients with implantable cardiac defibrillators

BACKGROUND

Patients with heart failure with reduced ejection fraction (HFrEF) who received implantable cardiac defibrillator (ICD) still remain at high risk due to pump failure and prevalent comorbid conditions. The primary aim of this research was to evaluate the predictive value of C-reactive protein-to-albumin ratio (CAR) for all-cause mortality among patients with HFrEF despite ICD implantation.

MATERIALS AND METHODS

Those who were implanted ICD for HFrEF in our institution between 2009 and 2019 were included. Data were extracted from hospital's database. CAR was calculated as ratio of C-reactive protein (CRP) to serum albumin concentration. Patients were grouped into tertiles in accordance with CAR at the time of the implantation. During follow-up duration of 38 [17-77] months, survival times of tertiles were compared by using Kaplan-Meier survival method. Forward Cox proportional regression model was used for multivariable analysis.

RESULTS

Thousand and eleven patients constituted the study population. Ischaemic cardiomyopathy was the primary diagnosis in 92.3%, and ICD was implanted for the primary prevention among 33.9% of patients. Of those, 14.5% died after the discharge. Patients in tertile 3 (T3) had higher risk of mortality (4.2% vs 11.0% vs 28.5%) compared with those in other tertiles. Multivariable analysis revealed that when patients in T1 were considered as the reference, both those in T2 and those in T3 had independently higher risk of all-cause mortality. This finding was consistent in the unadjusted and adjusted multivariable models.

CONCLUSION

Among patients with HFrEF and ICD, elevated CAR increased the risk of all-cause mortality at long term.

Prognostic nutritional index as the predictor of long-term mortality among HFrEF patients with ICD

BACKGROUND

The benefit of implantable cardiac defibrillator (ICD) in patients with heart failure and reduced ejection fraction (HFrEF) could be limited in a particular group of patients. Low prognostic nutritional index (PNI) indicates malnutrition and proinflammatory condition. We sought to investigate the value of PNI in predicting long-term mortality among HFrEF patients with ICD.

METHODS

Electronic database was searched for identifying patients with HFrEF who were implanted ICD in our institution between 2009 and 2019. Demographic and clinical characteristics of included patients were recorded. PNI was calculated according to the formula: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm³ ). Patients were divided into the quartiles according to PNI values. Differences between the groups were analyzed by the log-rank test. A forward Cox proportional regression model was used for multivariable analysis.

RESULTS

One thousand and hundred patients were included to the study. The underlying heart failure etiology was ischemic and nonischemic in 77.3% and 22.7% of patients, respectively. Mortality rate in Q1 (5.1%) was considered as the reference. In the unadjusted model the mortality rate was 9.5% (hazard ratio [HR] 1.76, 95% confidence interval [95% CI] [0.92-3.38]) in Q2, 10.2% (HR 1.88, 95% CI 0.99-3.58) in Q3, and 39.6% (HR 8.12, 95% CI 4.65-14.17) in Q4. The same trend was consistent in the age- and sex-adjusted, comorbidities-adjusted, and covariates-adjusted models.

CONCLUSION

Among patients who were implanted with ICD secondary to HFrEF, lower PNI value predicted all-cause mortality during long-term follow-up. This is the first study demonstrating the value of PNI in this population.

Lifestyle intervention using mobile technology and smart devices in patients with high cardiovascular risk: A pragmatic randomised clinical trial

BACKGROUND AND AIMS

Mobile technology-based solutions present promising effects against cardiovascular diseases. Long-term follow-up in mobile phone-based interventions has not yet been elucidated as a primary prevention technique for cardiovascular diseases. The objective of the present trial is to evaluate the effectiveness of lifestyle intervention on the change in the atherosclerotic cardiovascular disease (ASCVD) risk score in a 1-year follow-up using smart phone technology in patients with high cardiovascular risk.

METHODS

This prospective, randomised, single-centre clinical investigation enrolled 242 and 241 patients to the intervention plus usual care and usual care arms, respectively. The primary outcome of this study was the 1-year ASCVD risk score adjusted to baseline ASCVD risk score. ASCVD risk scores were calculated for every study participant at the randomisation and final stages.

RESULTS

After a 1-year follow-up, the intervention plus usual care reduced the ASCVD score by 2.7% (adjusted treatment effect -2.7, 95% confidence interval (CI): -2.2,-3.3, p<0.0001). An improvement was observed in favour of the intervention plus usual care arm in the majority of the pre-specified secondary endpoints. The high sensitive troponin and high sensitive C-reactive protein levels at 1 year were similar between the two arms. The treatment effect was homogenous for diabetes mellitus, gender, systolic blood pressure, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides and body mass index; however, heterogeneity in the treatment effect was observed for age.

CONCLUSIONS

The lifestyle intervention using smart phone technology compared to usual care alone in patients with high cardiovascular risk reduced the ASCVD score at 1-year follow-up.

Comparison of apolipoprotein-A1 levels between paroxysmal atrial fibrillation patients and healthy subjects

Introduction: Studies found that the inflammation plays a key role in the pathogenesis of paroxysmal atrial fibrillation (PAF). It is well-known that apolipoprotein-A1 (Apo-A1) demonstrates antiinflammatory and anti-oxidant properties in a healthy physiological system. In the present study, we aimed to determine whether there is any difference of Apo-A1 levels in patients with PAF and healthy subjects.

Methods: In this prospective cohort study, we enrolled a total of 35 PAF patients and 34 comparable healthy participants. Apo-A1 levels were measured from each subject using an immunophelometric method. All enrolled subjects were followed-up for one year during the study period. Results: Serum high-sensitivity C-reactive protein (hs-CRP) levels were statistically higher in PAF patients compared to healthy subjects (1.54±1.99 vs. 1.06±2.01, P = 0.016, respectively). Of note, patients with PAF had lower Apo-A1 levels (1.84±0.74 vs. 2.55±0.44, P = 0.001, respectively). There was no statistical difference between the groups in terms of apolipoprotein-B levels (1.08±0.36 vs. 0.99±0.38, P = 0.339, respectively). We did not find any correlation between Apo-A1 levels and PAF attacks in the study.

Conclusion: The main finding of this study was that Apo-A1 levels were significantly lower in PAF patients compared to healthy participants. Based on our results, we considered that Apo-A1 may have a key role in the pathogenesis of PAF.

Diastolic Electrocardiographic Parameters Predict Implantable Device Detected Asymptomatic Atrial Fibrillation

Background:

Atrial fibrillation is the most common clinically significant arrhythmia. It is now established that atrial high-rate episodes are highly correlated with atrial fibrillation.

Aims:

To investigate the relation between diastolic electrocardiographic parameters and subclinical atrial fibrillation detected by cardiac implantable electronic devices.

Study Design:

Ccross-sectional study.

Methods:

A total of 203 patients who had a dual-chamber, rate-modulated pacing pacemaker implanted due to sinus node dysfunction were prospectively enrolled in this study. Atrial high-rate episodes were defined as any lasting more than 5 min with an atrial rate of ≥220 beats per minute during the previous year. Patient groups were categorized on the basis of pacemaker interrogation as the absence of atrial high-rate episodes [atrial high-rate episodes (-)] and the presence of atrial high-rate episodes [atrial high-rate episodes (+)]. Episodes related to atrial over sensing were excluded. Twelve-lead surface electrocardiography was independently analyzed by two experienced readers for the measurement of diastolic electrocardiography parameters.

Results:

Among 203 patients (mean age: 67.5±9.1, 60.1% male), 51 (25.1%) with atrial high-rate episodes were defined as group 1 and 152 (74.9%) without atrial high-rate episodes were defined as group 2. Both groups were similar in terms of demographic characteristics and cardiovascular risk factors. Tend-Q and Tend-P were significantly longer in group 2. PQ interval was statistically longer in group 1. Corrected QT interval was significantly longer in group 1. Diastolic electrocardiography index, heart rate and PQ and QT intervals were the only independent predictors of atrial high-rate episodes in patients with dual pacemakers in multivariate analysis.

Conclusion:

Abnormal diastolic electrocardiography parameters are powerful predisposing factors for the initiation of incident atrial fibrillation. Diastolic electrocardiography parameters and a novel diastolic index predict atrial high-rate episodes. Evaluating these parameters enables clinicians to identify patients who are at high risk and who may benefit from prophylactic treatment.

Management and outcome of topical beta-blocker-induced atrioventricular block

BACKGROUND

Topical beta-blockers have a well-established role in the treatment of glaucoma. We aimed to investigate the outcome of patients who developed symptomatic atrioventricular (AV) block induced by topical beta-blockers.

METHODS

All patients admitted or discharged from our institution, the Siyami Ersek Training and Research Hospital, between January 2009 and January 2013 with a diagnosis of AV block were included in the study. Subjects using ophthalmic beta-blockers were recruited and followed for permanent pacemaker requirement during hospitalisation and for three months after discontinuation of the drug. A permanent pacemaker was implanted in patients in whom AV block persisted beyond 72 hours or recurred during the follow-up period.

RESULTS

A total of 1 122 patients were hospitalised with a diagnosis of AV block and a permanent pacemaker was implanted in 946 cases (84.3%) during the study period. Thirteen patients using ophthalmic beta-blockers for the treatment of glaucoma and no other rate-limiting drugs were included in the study. On electrocardiography, eight patients had complete AV block and five had high-degree AV block. The ophthalmic beta-blockers used were timolol in seven patients (55%), betaxolol in four (30%), and cartelol in two cases (15%). The mean duration of ophthalmic beta-blocker treatment was 30.1 ± 15.9 months. After drug discontinuation, in 10 patients the block persisted and a permanent pacemaker was implanted. During follow up, one more patient required pacemaker implantation. Therefore in total, pacemakers were implanted in 11 out of 13 patients (84.6%). The pacemaker implantation rate did not differ according to the type of topical beta-blocker used (p = 0.37). The presence of infra-nodal block on electrocardiography was associated with higher rates of pacemaker implantation.

CONCLUSION

Our results indicate that topical beta-blockers for the treatment of glaucoma may cause severe conduction abnormalities and when AV block occurs, pacemaker implantation is required in a high percentage of the patients.

Pacemaker implantation complication rates in elderly and young patients

Aims

To evaluate the complication rate differences between elderly and younger patients who receive a permanent pacemaker implantation.

Methods

We reviewed all cases admitted to our institution between January 2008 and June 2009 with symptomatic bradyarrhythmia for whom a permanent pacemaker was implanted. Beginning in June 2009, we prospectively collected data from all patients with the same diagnosis and procedure. The frequency of complications due to the pacemaker implantation procedure was evaluated and compared between young (<70 years old) and elderly (≥70 years old) patients.

Results

Among 574 patients with a permanent pacemaker, 259 patients (45.1%) were below and 315 patients (54.9%) were above or at 70 years of age. There were 240 (92.7%) and 19 (7.3%) dual-chamber pacemaker (DDD) and single-chamber pacemaker (VVI) implanted patients in the younger group, and 291 (76.8%) and 73 (23.2%) DDD and VVI pacemaker implanted patients in the elderly group, respectively. The complication rate was 39 (15.1%) out of 259 young patients and 24 (7.6%) out of 315 elderly patients. Postprocedural complications were statistically lower in the elderly patients than in younger patients (P = 0.005).

Conclusion

A pacemaker implantation performed by an experienced operator is a safe procedure for patients of advanced age. The patients who are above 70 years old may have less complication rates than the younger patients.

Alzheimer's disease: is pacemaker implantation safe?

AIM

To evaluate the safety of pacemaker implantation in patients with Alzheimer's disease (AD).

METHODS

We reviewed all cases admitted to our institution between January 2008 and June 2009, with symptomatic bradyarrhythmia for whom a permanent pacemaker was implanted. Beginning in June 2009, we prospectively collected data from all patients with the same diagnosis and procedure. Patients with a diagnosis of AD were included in the study. The risks and frequency of complications due to the pacemaker implantation were evaluated. Because of the older age of patients, they were divided into 2 groups to define the effect of age on complication rate. Group 1 consisted of patients aged <75 years, and group 2 consisted of those who are ≥75 years.

RESULTS

Among the 574 patients with permanent pacemaker, 20 patients (3.4%) had a diagnosis of AD. Three patients with an AD experienced a complication and all were in group 2. However, the rate of complication was not significant within groups (P = 1.000). Reoperation was needed for all of them, and it was significantly higher in patients with AD than in patients without a concomitant disease (P = .006). Patients in group 2 had 3 times higher rate of complication (21.4%) than those without an AD and aged ≥75 years (7.1%; P = .125).

CONCLUSION

Pacemaker implantation may be of risk in patients with AD, especially in those aged ≥75 years.

Effect of cardiac resynchronization therapy on mean platelet volume

OBJECTIVE

Cardiac resynchronization therapy (CRT) increases cardiac performance and decreases morbidity and mortality in patients with heart failure. Mean platelet volume (MPV), a marker of platelet hyperreactivity, was found to be increased in both chronic heart failure and thromboembolic events. Systemic and pulmonary thromboembolism is a frequent complication of heart failure.The aim of this study is to determine the effects of cardiac resynchronization therapy on MPV values.

METHODS AND RESULTS

Fifty-six heart failure patients with increased QRS duration underwent biventricular pacemaker implantation. Blood samples were collected the morning before implantation and at six months follow-up. Response criteria were: an increase in ejection fraction of more than 10% from baseline at six months or no hospitalization for major cardiac events during the first six months.The mean MPV values were decreased from 9.3 +/- 0.5 fl to 8.3 +/- 0.5 fl. Patients with recorded major cardiac events in the follow-up period had no statistically significant decrease in MPV values.

CONCLUSIONS

In our study we found that cardiac resynchronization therapy leads to a decreased MPV and clinical improvement in patients with heart failure that is accompanied with a decrease in MPV.

The relationship between nonalcoholic fatty liver disease and the severity of coronary artery disease in patients with metabolic syndrome

OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is an important complication of metabolic syndrome (MS). We investigated the possible relationship between NAFLD and angiographical severity of coronary artery disease (CAD) in patients with MS.

STUDY DESIGN

This prospective study included 80 patients (35 men, 45 women; mean age 63+/-10 years; range 42 to 80 years) with a diagnosis of MS according to the ATP III criteria. All patients underwent abdominal ultrasonography to detect NAFLD. Coronary angiography was performed for stable angina pectoris (n=48), unstable angina pectoris (n=21), and prognostic reasons (n=11). The severity of CAD was assessed by the number of vessels involved (vessel score) and the severity score (Gensini score). Significant stenosis was defined as 70% or greater reduction in lumenal diameter.

RESULTS

Ultrasonography revealed NAFLD in 43 patients (53.8%). Patients with NAFLD had significantly higher body mass index, waist circumference, and serum triglyceride level, and significantly lower HDL-cholesterol level (p<0.001). Coronary angiography showed significantly higher vessel (2.5+/-0.9 vs 1.0+/-1.0) and CAD severity scores (90.2+/-40.0 vs 36.4+/-28.9) in patients with NAFLD (p<0.001). Univariate analysis showed that the presence of NAFLD (r=0.61, p<0.001), grade of NAFLD (r=0.42, p<0.001), and patient age (r=0.36, p=0.002) were significantly correlated with the CAD severity score. In multivariate linear regression analysis, the presence of NAFLD was the only independent factor affecting the CAD severity score (beta: 1.35, p<0.001).

CONCLUSION

The presence of NAFLD is associated with more severe CAD, requiring that patients with MS be investigated for the presence of NAFLD and those with NAFLD be attentively followed-up for the presence and severity of CAD.

[Comparison of Doppler echocardiographic parameters before and after ablation in Wolff-Parkinson-White syndrome patients with and without atrial fibrillation]

OBJECTIVES

We compared Doppler echocardiographic features before and after radiofrequency catheter ablation (RFCA) performed for Wolff-Parkinson-White (WPW) syndrome in patients with and without atrial fibrillation (AF).

STUDY DESIGN

Forty patients with WPW syndrome were evaluated in two groups depending on the presence of AF (6 females, 14 males; mean age 33+/-15 years) and atrioventricular reciprocating tachycardia (AVRT) (8 females, 12 males; mean age 32+/-18 years). Echocardiographic examination was performed in all the patients 24 hours before and after RFCA. Doppler parameters were recorded including E and A transmitral filling velocities and their velocity-time integrals (VTI), mitral diastolic filling time (mDFT), deceleration time, isovolumic contraction and relaxation times, aortic ejection time (ET) and aortic VTI.

RESULTS

The most common localization of the accessory pathway was the left lateral wall (n=9) in patients with AF, compared to one patient in the AVRT group. During programmed electrical stimulation, orthodromic AVRT was induced in all the patients with AVRT; of the AF group, six patients had AF and 14 patients exhibited AVRT that degenerated into AF. The two groups did not differ significantly before and after RFCA with regard to two-dimensional and Doppler echocardiographic parameters (p>0.05). Significant changes observed in both groups after RFCA were as follows: increases in A velocity and A wave VTI (p<0.05), decrease in the E/A ratio (p<0.05), prolongation of mDFT (p<0.001), and shortening of aortic ET (p<0.01). Following the procedure, preexcitation disappeared in all the patients and none had tachyarrhythmia.

CONCLUSION

There were no echocardiographic parameters associated with AF in patients with WPW syndrome.

Circadian pattern of spontaneous ventricular tachyarrhythmias in patients with implantable cardioverter defibrillators

BACKGROUND

Previous studies have reported a circadian variation of ventricular tachyarrhythmias. However, there is no detailed information of the daily distribution of ventricular tachycardia (VT) and ventricular fibrillation (VF) episodes. The purpose of this study was to evaluate the daily distribution of episodes of ventricular tachyarrhythmia in patients with implantable cardioverter defibrillators.

MATERIAL/METHODS

We used data stored by last-generation implantable cardioverter-defibrillators (ICD) to retrospectively evaluate the circadian distribution of VT and VF in 70 patients with ICD. The distribution of tachyarrhythmias was categorized into four time zones: zone 1 (06:00-11:59), zone 2 (12:00-17:59), zone 3 (18:00-23:59), and zone 4 (00:00-05:59).

RESULTS

During a follow-up of a mean of 3.1+/-1.3 years, a total of 791 ventricular arrhythmias were recorded from which 631 events were VT and 160 VF. A circadian variation of episodes of ventricular tachyarrhythmia was evident. The incidence of ventricular arrhythmia sharply increased in zone 1 (8.82+/-2.13, p<0.0001). Episodes of VT had peaks in zones 1 and 2 (7.44+/-2.03 and 2.70+/-0.65, p<0.001) and episodes of VF had peaks in zones 1 and 4 (1.38+/-0.39 and 1.30+/-0.51, p<0.011). No difference was observed between patients who used betablocker and those who did not.

CONCLUSIONS

Malignant ventricular tachyarrhythmias have a circadian distribution. VT peaks occur in the morning and noon hours and VF peaks occurs at the night and morning hours. Betablocker and/or amiodarone usage do not alter this distribution.

Signal detection for page-accessoptical memories with intersymbol interference

We propose a technique for data detection in a two-dimensional page-access optical memory. The technique combines sequence detection by the use of the Viterbi algorithm with decision feedback to improve the bit-error-rate performance in a system corrupted by intersymbol interference. It has an advantage in that it can be operated on a row-by-row basis as data are output from the optical detector. Use of the proposed scheme might ease the design tolerances of the optical components or permit the use of large data pages.