Cengiz Ermis

Comparison of automatic and patient-activated arrhythmia recordings by implantable loop recorders in the evaluation of syncope

The implantable loop recorder (ILR) has become an important tool for evaluating patients with recurrent syncope. Second generation ILRs have the ability to record events either automatically (auto activated) or by manual activation (patient activated). In an attempt to evaluate the relative utility of the auto-activation feature, this study stratified ILR events based on a grading system designed to classify detected arrhythmias in terms of the likelihood that they provide a diagnostic basis for syncope. Data from 50 patients (27 men, mean age 64 ± 22 years) who underwent ILR implantation for investigation of recurrent syncope were assessed. The arrhythmia syncope grading system used 5 levels, ranging from grade 0 (rhythm recorded during syncope) to grade IV (rhythm unlikely to provide a diagnostic basis for syncope). Thirty-six patients (72%) demonstrated ≥1 auto-activated or patient-activated recording during a follow-up of 14.3 ± 7.9 months. Of the total of 529 recordings, 223 (194 after auto activation [86.9%]) from 30 patients showed a rhythm abnormality. Auto activation was more effective for documenting arrhythmias that were recorded during syncope or those with highest probability of providing a syncope diagnosis (grade 0 or I arrhythmias: auto activated, 19 patients, patient activated, 3 patients). Times from ILR implantation to first grade 0 and grade I arrhythmias were 13.4 and 7.8 months, respectively. The ILR auto-activation feature proved effective in providing a high probability basis for syncope (196 arrhythmia recordings [87.1%] in 27 patients) and enhanced the diagnostic effectiveness of the device compared with patient activation alone (29 arrhythmia recordings [12.9%] in 6 patients).

Oxidative Stress and Asymmetric Dimethylarginine Is Independently Associated with Carotid Intima Media Thickness in Peritoneal Dialysis Patients

Backgrounds: Oxidative stress (OS) and asymmetric dimethylarginine (ADMA) are accepted as nonclassical cardiovascular risk factors in end-stage renal disease patients. To clarify the role of these factors in the atherosclerotic process, we investigated if OS and ADMA are associated with common carotid artery intima media thickness (CIMT) in peritoneal dialysis (PD) patients. Methods: Thirty PD patients without known atherosclerotic disease and classical cardiovascular risk factors as well as age- and gender-matched 30 healthy individuals were included. We measured serum thiobarbituric acid-reactive substances (TBARS), malondialdehyde (MDA), advanced glycation end product (AGE), pentosidine, advanced oxidation protein products (AOPP), ADMA and CIMT in each subjects. Results: TBARS, MDA, AOPP, AGE, pentosidine and ADMA levels were significantly higher in PD patients than in controls (p < 0.001). CIMT in patients was higher than in the control group (0.83 ± 0.09 vs. 0.77 ± 0.06 mm; p < 0.01). CIMT was independently correlated with TBARS (β = 0.33, p < 0.01), MDA (β = 0.27, p < 0.01), AOPP (β = 0.22, p < 0.02), AGE (β = 0.45, p < 0.01), pentosidine (β = 0.56, p < 0.01) and ADMA (β = 0.54, p < 0.01). Conclusions: OS markers and serum ADMA levels independently predict the CIMT level in PD patients.

Biventricular implantable cardioverter defibrillators improve survival compared with biventricular pacing alone in patients with severe left ventricular dysfunction.

Introduction: Biventricular cardiac pacemakers provide important hemodynamic benefit in selected patients with heart failure and severe left ventricular (LV) dysfunction. Nevertheless, these patients remain at high mortality risk. To address this issue, we examined mortality outcome in patients with heart failure treated with biventricular pacemakers alone and those treated with biventricular implantable cardioverter defibrillators (ICDs).

Relationship of paroxysmal atrial tachyarrhythmias to volume overload: assessment by implanted transpulmonary impedance monitoring.

Background— Clinical experience suggests that atrial tachyarrhythmias (ATs) are a frequent comorbidity in heart failure patients with left ventricular systolic dysfunction and that volume overload may increase AT susceptibility. However, substantiating this apparent relationship in free-living patients is difficult. Recently, certain implantable cardioverter-defibrillators provide, by measuring transpulmonary electric bioimpedance, an index of intrathoracic fluid status (OptiVol index [OI]). The goal of this study was to determine whether periods of greater intrathoracic fluid congestion (as detected by OI) correspond with increased AT event frequency. Methods and Results— This analysis retrospectively assessed the relation between AT events and OI estimate of volume overload in patients with left ventricular systolic dysfunction and OI-capable implantable cardioverter-defibrillators. OI values were stratified into 3 levels: group 1, 60. An OI threshold-crossing event was defined as OI≥60, a value previously associated with clinically significant volume overload. Findings in 59 patients (mean left ventricular ejection fraction, 24%) with 225 follow-up visits (mean, 3.8 visits per patient) were evaluated. AT prevalence was 73%. AT frequency (percent of patients visits with at least 1 episode of AT since previous device interrogation) was greater in group 3 versus group 1 ( P =0.0342). Finally, in terms of temporal sequence, AT episodes preceded OI threshold-crossing event in 43% of incidences, followed threshold-crossing event in 29%, and was simultaneous or indeterminate in the remainder. Conclusions— These findings not only support the view that worsening pulmonary congestion is associated with increased AT frequency in patients with left ventricular dysfunction but also suggest that AT events may be responsible for triggering episodic pulmonary congestion more often than previously suspected. Received February 24, 2009; accepted August 24, 2009. # CLINICAL PERSPECTIVE {#article-title-2}Background—Clinical experience suggests that atrial tachyarrhythmias (ATs) are a frequent comorbidity in heart failure patients with left ventricular systolic dysfunction and that volume overload may increase AT susceptibility. However, substantiating this apparent relationship in free-living patients is difficult. Recently, certain implantable cardioverter-defibrillators provide, by measuring transpulmonary electric bioimpedance, an index of intrathoracic fluid status (OptiVol index [OI]). The goal of this study was to determine whether periods of greater intrathoracic fluid congestion (as detected by OI) correspond with increased AT event frequency. Methods and Results—This analysis retrospectively assessed the relation between AT events and OI estimate of volume overload in patients with left ventricular systolic dysfunction and OI-capable implantable cardioverter-defibrillators. OI values were stratified into 3 levels: group 1, <40; group 2, 40 to 60; and group 3, >60. An OI threshold-crossing event was defined as OI≥60, a value previously associated with clinically significant volume overload. Findings in 59 patients (mean left ventricular ejection fraction, 24%) with 225 follow-up visits (mean, 3.8 visits per patient) were evaluated. AT prevalence was 73%. AT frequency (percent of patients visits with at least 1 episode of AT since previous device interrogation) was greater in group 3 versus group 1 (P=0.0342). Finally, in terms of temporal sequence, AT episodes preceded OI threshold-crossing event in 43% of incidences, followed threshold-crossing event in 29%, and was simultaneous or indeterminate in the remainder. Conclusions—These findings not only support the view that worsening pulmonary congestion is associated with increased AT frequency in patients with left ventricular dysfunction but also suggest that AT events may be responsible for triggering episodic pulmonary congestion more often than previously suspected.

Efficacy of biphasic waveform cardioversion for atrial fibrillation and atrial flutter compared with conventional monophasic waveforms

B on extensive experience with implantable cardioverter-defibrillators and automatic external defibrillators, the utility of biphasic transthoracic shock has been demonstrated in the setting of lifethreatening ventricular tachyarrhythmias. These observations have led to the application of biphasic waveforms during elective transthoracic cardioversion for atrial fibrillation (AF). The present report compares cardioversion outcomes in 2 sequential groups of patients with AF undergoing transthoracic cardioversion. It was undertaken in an attempt to ascertain the extent to which biphasic waveform technique enhances transthoracic AF cardioversion success rates. • • • Records of 145 patients were reviewed. The patients were referred to our center for elective transthoracic cardioversion between January 1999 and September 2001, and had undergone this procedure in the electrophysiologic laboratory. Patients with atrial flutter (20 patients, 14%) were also included because of the similarity of the arrhythmia and the treatment required. Demographic and clinical data—including arrhythmia type and duration, underlying disease, and concomitant medications—were documented, along with echocardiographic data including left atrial diameter and left ventricular ejection fraction. Procedural data—including the number of cardioversion attempts made, energy levels used, and anesthetic employed— were documented. Similarly, complications were recorded, particularly skin irritation. A successful cardioversion procedure was defined as restoration of sinus rhythm for 1 cycle after energy application. Recurrence of the arrhythmia 2 hours after a successful cardioversion (i.e., before the patient left the observation unit) was deemed an “early recurrence.” The statistical significance of the efficacy of biphasic waveform cardioversion compared with monophasic waveform shock cardioversion was evaluated using chi-square and Fisher’s exact tests. A p value of 0.05 was considered statistically significant. Data were obtained in 145 sequential patients who underwent elective electrical cardioversion for AF or atrial flutter. Eighty-two patients (mean age 67 15 years) received biphasic waveform cardioversion, and the remaining 63 patients (mean age 66 14 years) underwent cardioversion with a monophasic waveform device. The ratio of men to women was 1.8:1 and 2:1 for the biphasic and monophasic waveform cardioversion study groups, respectively. The presenting arrhythmia was AF in 70 patients (85%) in the biphasic group and in 55 patients (87%) in the monophasic group. Atrial flutter was present in 12 patients (15%) in the biphasic group and in 8 patients (13%) in the monophasic group. The mean duration of patients’ treatment for the arrhythmia event was 36 56 and 60 106 days (p NS) for the biphasic and monophasic groups, respectively. Baseline clinical characteristics for patients in each treatment group are listed in Table 1. Underlying disease processes (i.e., cardiomyopathy, coronary artery disease, valvular heart disease, lung disease, and other structural heart disease) were found to be similarly prevalent in both treatment groups. Patients in the monophasic waveform group tended to use more digoxin, amiodarone, and other antiarrhythmic medications compared with biphasic group patients. The frequencies of usage of blockers, calcium channel blockers, and angiotensin-converting enzyme inhibitors were similar in both groups. The mean left atrial diameter was 46 10 mm in the biphasic group and 45 12 mm in the monophasic waveform group. Mean left ventricular ejection fraction was similar for the biphasic and monophasic groups (49 13% and 49 15%, respectively). Procedure success rate was 99% (81 patients) in the biphasic waveform cardioversion group compared with 81% (51 patients) in the group treated with monophasic waveform (p 0.001). The mean energy required for procedural success was 126 46 J and 228 83 J for the biphasic and monophasic waveform groups, respectively (p 0.001). The mean number of attempts before achieving procedural success was 1.3 0.8 for the biphasic cardioversion group and 1.2 0.4 for the monophasic cardioversion group. The treated arrhythmia recurred in 10 biphasic group patients (12%) and in 6 monophasic group patients (12%). All recurrences were in patients with AF. Skin irritation was not observed in any of the patients who received biphasic waveform shock, whereas 2 patients (3%) who received monophasic waveform shock required topical treatment for irritation at patch sites. • • • From the Cardiac Arrhythmia Center, Cardiovascular Division, Department of Medicine, Minneapolis, Minnesota. Dr. Ermis is supported in part by a grant from the Midwest Arrhythmia Research Foundation, Minneapolis, Minnesota. Dr. Benditt’s address is: Cardiac Arrhythmia Center, MMC 508, 420 Delaware Street, Minneapolis, Minnesota 55455. Manuscript received April 9, 2002; revised manuscript received and accepted June 7, 2002.

Improved survival of cardiac transplantation candidates with implantable cardioverter defibrillator therapy: role of beta-blocker or amiodarone treatment.

Introduction: Survival in patients awaiting cardiac transplantation is poor due to the severity of left ventricular dysfunction and the susceptibility to ventricular arrhythmia. The potential role of implantable cardioverter defibrillators (ICDs) in this group of patients has been the subject of increasing interest. The aims of this study were to ascertain whether ICDs improve the survival rate of patients on the waiting list for cardiac transplantation and whether any improvement is independent of concomitant beta‐blocker or amiodarone therapy.

The significance of the left atrial volume index in cardioversion success and its relationship with recurrence in patients with non-valvular atrial fibrillation subjected to electrical cardioversion: a study on diagnostic accuracy

OBJECTIVE The aim of this study was to assess the predictive value of the left atrial volume index (LAVI) in electrical cardioversion (ECV) and observe the recurrence rate of atrial fibrillation (AF) after a successful ECV in patients with non-valvular atrial fibrillation. METHOD This study was designed as a diagnostic accuracy and prospective cohort study. Eighty patients (mean age 62±12 years; 52.5% female) were enrolled in study. LAVI was measured using the area-length method and the indexed body surface area. Patients in whom the sinus rhythm (SR) was established following the ECV were assessed according to the clinical and electrocardiography (ECG) findings at the first month and grouped as those with continued SR or recurrent AF. The Students t, Mann-Whitney U, Fishers exact, Chi-square tests, ROC and logistic regression analyses were used for statistical analysis. RESULTS Subsequent to the ECV, SR was achieved in 62.5% (n=50) of the patients. In those where SR was established, the AP-Lad (4.32±0.62 vs. 4.77±0.4 cm/p=0.002) and LAVI (35.3±11.5 vs. 53.1±10.1 mL/m2/p<0.001) values were observed to be lower. ECV success was found to be associated only with the LAVI (OR:1.122, 95%CI: 1.058-1.191, p<0.001). The AUC was found as 0.892±0.041 for the LAVI (95% CI:0.075-0.285, p<0.001). During the controls at the end of the 1st month, SR was maintained in 72% (n=36) of the successful ECV group. Among the patients with maintained SR, the antero-posterior left atrial dimension (4.17±0.62 vs. 4.72±0.5 cm/p=0.004) and LAVI (30.8±6.2 vs. 46.8±13.9 mL/m2/p<0.001) values were also observed to be lower. Only the LAVI was found to be associated with the recurrence of the AF (OR:1.355, 95% CI: 1.154-1.591, p<0.001). The AUC was found as 0.950±0.029 for the LAVI (95% CI:0.063-0.313, p=0.003) CONCLUSION Lower LAVI values before the ECV are strong and independent predictors of the success of the ECV and the maintenance of SR after a successful ECV.

Red cell distribution width and neutrophil-to-lymphocyte ratio predict left ventricular dysfunction in acute anterior ST-segment elevation myocardial infarction

Objectives Red cell distribution width (RDW) and neutrophil-to-lymphocyte ratio (NLR) are the two markers used to determine risk of mortality and adverse cardiovascular outcomes in patients with acute myocardial infarction. The relationship between RDW, NLR, and left ventricular (LV) systolic functions has not been reported. In this report, we aimed to investigate the relationship between RDW, NLR, and LV systolic function in anterior ST-segment elevation myocardial infarction (STEMI) patients who underwent primary percutaneous coronary intervention (PCI). Methods RDW and NLR were measured on admission in 106 STEMI patients treated with primary PCI. Patients were divided into two groups according to left ventricular ejection fraction (LVEF), as Group I (systolic dysfunction, LVEF <50%) and Group II (preserved global left ventricle systolic function, LVEF ⩾50%). The first group included 47 patients and the second group included 59 patients. Results Mean RDW and NLR were significantly higher in Group I compared to Group II [13.7 ± 0.9% vs. 13.4 ± 0.7%, p = 0.03 and 5.86 (range, 0.66–40.50) vs. 2.75 (range, 0.51–39.39), p = 0.013, respectively]. Conclusion Increased RDW and NLR on admission, in anterior STEMI patients treated with primary PCI are associated with LV systolic dysfunction.

Ruptured Aneurysm of Noncoronary Sinus of Valsalva: Demonstration with Magnetic Resonance Imaging

There are few published reports regarding imaging findings of sinus of Valsalva aneurysms (SVA) with magnetic resonance imaging (MRI). We present an unusual form of ruptured SVA, emphasizing the diagnostic importance of MRI among a range of imaging techniques. This case report describes a case of idiopathic (thought to be congenital in origin), acutely symptomatic ruptured noncoronary SVA diagnosed by MRI and confirmed with conventional angiography and surgery. MRI accurately showed aneurysm size, location, and rupture into the right atrium and provided valuable information about this rare lesion.

Head-up Tilt Table Testing

Head-up tilt has been used for more than 50 years by physiologists and physicians. The procedure has been used to study heart rate and blood pressure adaptations to changes in position, for modeling responses to hemorrhage, to assess orthostatic hypotension, and to evaluate hemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension. During the course of such studies, incidental observations included the fact that some test subjects developed neural reflex-mediated hypotension and bradycardia, resembling vasovagal reactions. Based on these observations, and largely beginning with the report by Kenny and colleagues in 1986, 1 passive head-up tilt table testing began to be examined as a diagnostic method for provocation of vasovagal syncope in susceptible individuals. Initially the head-up tilt posture was used as the sole means for provoking vasovagal events. Subsequently, pharmacologic provocation was introduced in an attempt to enhance the diagnostic yield. Currently, isoproterenol and nitroglycerin are the most widely used pharmacologic provocateurs.