Emin Evren Özcan

Effect of cardiac resynchronization therapy with implantable cardioverter defibrillator versus cardiac resynchronization therapy with pacemaker on mortality in heart failure patients : results of a high-volume, single-centre experience

There are limited and contradictory data on the effects of CRT with implantable cardioverter defibrillator (CRT‐D) on mortality as compared with CRT with pacemaker (CRT‐P).

Ablation of the Epicardial Substrate in the Right Ventricular Outflow Tract in a Patient With Brugada Syndrome Refusing Implantable Cardioverter Defibrillator Therapy

Brugada syndrome is associated with a high risk of sudden cardiac death. Currently, the cornerstone of therapy is implantation of an implantable cardioverter defibrillator (ICD). Recently, a novel approach to preventively ablate the substrate located in the anterior epicardial region of the right ventricular outflow tract showed promising results by reducing the number of ventricular fibrillation episodes in patients with ICD. Here we report on a patient with Brugada syndrome who refused ICD therapy in whom a successful epicardial right ventricular outflow tract substrate ablation was performed. In some special cases, ablation therapy might be considered as the sole therapeutic option for these patients.

Aortic stiffness and flow-mediated dilatation in normotensive offspring of parents with hypertension.

OBJECTIVES Although hypertension has been shown to be one of the most important risk factors for atherosclerosis, data about the presence of subclinical atherosclerosis in normotensive offspring with parental history of hypertension are scarce. Accordingly, the current study was designated to evaluate flow-mediated dilatation and aortic stiffness, which are early signs of atherosclerosis in young subjects with parental history of hypertension. METHODS A total of 140 [corrected] healthy, non-obese subjects in the age group of 18-22 years were included in this study and divided into two groups. The first group included 70 offspring of hypertensive parents and the second group included 70 offspring of normotensive parents as controls. In all subjects, endothelium-dependent and endothelium-independent vasodilatation of the brachial artery and aortic elastic parameters were investigated using high-resolution Doppler echocardiography. RESULTS Offspring of hypertensive parents demonstrated higher values of aortic stiffness (7.1 plus or minus 1.88 and 6.42 plus or minus 1.56, respectively) but lower distensibility (9.47 plus or minus 1.33 and 11.8 plus or minus 3.36 square centimetres per dyne per 106) and flow-mediated dilatation (4.57 plus or minus 1.3 versus 6.34 plus or minus 0.83 percent, p equals 0.0001, respectively) than offspring of hypertensive parents. CONCLUSION We observed blunted endothelium-dependent dilatation and aortic stiffness in offspring of hypertensive parents compared with offspring of normotensive [corrected] parents. This is evident in the absence of overt hypertension and other diseases, suggesting that parental history of hypertension is a risk for subclinical atherosclerosis and it may contribute to the progression to hypertension and overt atherosclerosis in later life.

Longer right to left ventricular activation delay at cardiac resynchronization therapy implantation is associated with improved clinical outcome in left bundle branch block patients.

Abstract Aims Data on longer right to left ventricular activation delay (RV-LV AD) predicting clinical outcome after cardiac resynchronization therapy (CRT) by left bundle branch block (LBBB) are limited. We aimed to evaluate the impact of RV-LV AD on N-terminal pro–B-type natriuretic peptide (NT-proBNP), ejection fraction (EF), and clinical outcome in patients implanted with CRT, stratified by LBBB at baseline. Methods and results Heart failure (HF) patients undergoing CRT implantation with EF ≤ 35% and QRS ≥ 120 ms were evaluated based on their RV-LV AD at implantation. Baseline and 6-month clinical parameters, EF, and NT-proBNP values were assessed. The primary endpoint was HF or death, the secondary endpoint was all-cause mortality. A total of 125 patients with CRT were studied, 62% had LBBB. During the median follow-up of 2.2 years, 44 (35%) patients had HF/death, 36 (29%) patients died. Patients with RV-LV AD ≥ 86 ms (lower quartile) had significantly lower risk of HF/death [hazard ratio (HR): 0.44; 95% confidence interval (95% CI): 0.23–0.82; P = 0.001] and all-cause mortality (HR: 0.48; 95% CI: 0.23–1.00; P = 0.05), compared with those with RV-LV AD < 86 ms. Patients with RV-LV AD ≥ 86 ms and LBBB showed the greatest improvement in EF (28–36%; P<0.001), NT-proBNP (2771–1216 ng/mL; P < 0.001), and they had better HF-free survival (HR: 0.23, 95% CI: 0.11–0.49, P < 0.001) and overall survival (HR: 0.35, 95% CI: 0.16–0.75; P = 0.007). There was no difference in outcome by RV-LV AD in non-LBBB patients. Conclusion Left bundle branch block patients with longer RV-LV activation delay at CRT implantation had greater improvement in NT-proBNP, EF, and significantly better clinical outcome.

What is better for predilatation in bioresorbable vascular scaffold implantation: a non-compliant or a compliant balloon?

Objective: The bioresorbable vascular scaffold system (BVS) is a fully absorbable vascular treatment system. In this study, we aimed to compare the periprocedural effectiveness and long term results of non-compliant balloon (NCB) and compliant balloon (CB) systems, which are used for predilatation before BVS implantation. Methods: One hundred forty-six BVS-treated lesions from 119 patients were retrospectively analyzed in the study. Patients with acute coronary syndrome, stable angina and silent ischemia were included in the study. Lesions and patients were categorized into the NCB and CB groups according to the type of balloon used for predilatation. NCB was implemented on 72 lesions (59 patients) and CB was implemented on 74 lesions (60 patients). The two groups were compared on terms of procedural features and both in-hospital and 1-year clinical follow-up results. Chi-square and independent sample t test were performed for statistical analysis. Results: There was no significant difference between the two groups in terms of patient characteristics and lesion properties. The number of postdilated lesions was significantly higher in the CB group. Procedure time, fluoroscopy time, and contrast volume were significantly lower in the NCB group. At follow-up, one patient had myocardial infarction in the CB group because of scaffold thrombosis and no mortality was observed. Conclusion: Predilatation with NCB before BVS implantation reduces the need for postdilatation. In addition, use of NCB reduces the procedure time, fluoroscopy time, and contrast volume but had no effect on 1 year clinical follow-up results compared with CB.

Non-reentrant atrioventricular nodal tachycardia

Dual ventricular response to a single supraventricular impulse through dual atrioventricular (AV) nodal pathways is an interesting and uncommon phenomenon. Rarely, some patients can exhibit sustained one-to-two conduction producing a non-reentrant AV nodal tachycardia during sinus rhythm [1–6]. We report the case of a patient whose arrhythmia was caused by this mechanism. A 44-years-old male patient who had frequent irregular palpitations was admitted to hospital. He was misdiagnosed with atrial fibrillation and referred to our institute for consideration of pulmonary vein isolation. He did not have any significant disease in his medical history. Echocardiography was normal. The electrocardiogram showed an irregular narrow QRS complex tachycardia. Careful evaluation of the electrocardiograms revealed the presence of two ventricular activations for each atrial beat (Fig. 1). On some occasions, the wide QRS complexes with right bundle branch block (RBBB) morphology not preceded by P waves simulating premature ventricular complexes (PVCs) were observed. Electrophysiological study revealed regular 1:2 AV relationship. Each ventricular signal was preceded by a His deflection with a constant HV interval (46 ms) (Fig. 2a). The AH1 interval between the atrial wave and the first His deflection was 159 ms. The AH2 interval between the atrial wave and the second His deflection was 528 ms. Both AH1 and AH2 intervals were slightly variable. When AH2 interval was shorter than 520 ms, second ventricular responses were conducted by RBBB morphology (Fig. 2a). Because of sustained double responses, we could not perform programmed atrial extra stimulation to identify a jump in AH interval. After detailed electrophysiological examination, radiofrequency (RF) energy was delivered (40 W, 55 C, 66 s) in the posterior aspect of Koch’s triangle, where the typical ‘‘slow pathway potentials’’ were observed. After first RF application, 1:2 response disappeared (Fig. 2b). During post-ablation tests, we did not observe dual AV nodal conduction properties, and we could not induce any arrhythmia. On the 6 month follow-up, the patient was asymptomatic. Non-reentrant AV nodal tachycardia (1:2 tachycardia) is a rare manifestation of dual AV nodal physiology. Persistent simultaneous conduction of P waves over a fast and a slow nodal pathways may lead irregular supraventricular tachycardia. The two major electrophysiological properties of simultaneous anterograde fast and slow conduction during sinus rhythm are: (1) Absence of retrograde ventriculoatrial conduction via fast and slow pathways and (2) Critical conduction delay in slow pathway to allow sequential conduction of impulse from both pathways [1, 2]. Delay has to be longer than the effective refractory period of infranodal conduction system. A recently published review reported just 49 cases between dates of 1950 and 2011 [3]. Nevertheless, the prevalence of AV nodal non-reentrant tachycardia is likely to be underestimated because of difficulties in differential diagnosis. Sustained cycle length alternans is the characteristic for this arrhythmia [4]. However, changes in autonomic tone affecting conduction properties may lead irregular cycle length alternans and rate-dependent aberrancy. For these reasons, it can be erroneously diagnosed as atrial fibrillation, atrial flutter or atrial tachycardia with Wenckebach periodicity [3, 5, 7, 8]. These arrhythmias, E. E. Ozcan G. Szeplaki B. Merkely L. Geller (&) Heart Center, Semmelweis University, Gaal Jozsef street 9, Budapest 1122, Hungary e-mail: laszlo.geller@gmail.com

Successful ablation of atrioventricular nodal re-entrant tachycardia in a patient with interruption of inferior vena cava and azygos continuation.

Congenital anomalies of the venous system are a challenge for cardiac catheterization and radiofrequency ablation. This article describes ablation of atrioventricular nodal re-entrant tachycardia performed solely through the azygos continuation in a patient with inferior vena cava interruption.

Comparison of the Effects of Epicardial and Endocardial Cardiac Resynchronization Therapy on Transmural Dispersion of Repolarization.

Despite significant improvements in cardiac output and functional capacity with cardiac resynchronization therapy (CRT), incidence of sudden cardiac death still remains high. Reversal of physiological myocardial activation sequence during epicardial pacing increases the transmural dispersion of repolarization (TDR). The aim of this study was to compare the effects of endocardial and epicardial biventricular pacing on repolarization parameters in the same patient group.

Comparison of floating wire and single wire techniques in right coronary ostial lesions in terms of procedural features and one-year clinical follow-up results.

Objective: The floating wire technique is a special technique for solving interventional problems in aortaostial lesions. There are no long-term data in the literature for the floating wire technique in right aorto-ostial lesions. Methods: One hundred twenty six patients were retrospectively analyzed in this study. All of these patients had a critical right coronary aortoostial lesion. The floating wire technique was performed on 64 patients, and the single wire technique was performed on 62 patients. The two groups were compared with each other in terms of lesional and procedural properties. Additionally, 1-year clinical follow-up results were compared between the two groups. Results: There was no significant difference in terms of lesion properties between the groups. In the floating wire group, mean stent length, number of stents, mean procedure time, mean contrast volume, and mean fluoroscopy time were significantly lower than in the single wire group. At 1 year, 1 patient from each group had myocardial infarction, and no mortality was observed. In the floating wire group, the number of patients who experienced angina and the target lesion revascularization rate were both significantly lower than in the single wire group. Conclusion: The floating wire technique in right coronary ostial lesions provides a significant advantage over the single wire technique according to procedural and clinical follow-up results.

Medical treatment of an adult with uncorrected isolated interrupted aorta resulted in no complications after 4 years of follow-up.

Patient: Female, 56 Final Diagnosis: Isolated adult interrupted aortic arch Symptoms: Headache • hypertension • left ventricular hypertrophy Medication: — Clinical Procedure: — Specialty: Surgery Objective: Congenital defects/diseases Background: Interrupted aorta is a rare congenital malformation defined as the lack of continuity between the ascending and descending parts of the aorta. Case Report: This malformation was first described by Steidele in 1778. To date a few isolated adult interrupted aortic arch patients have been reported and most of them were treated surgically. However, there is not data about outcome of patients who decline surgery or who are not good candidates for surgery because of excessive risks, and there is not a data about how to follow these patients. Conclusions: Herein we present a case of adult type A isolated interrupted aorta followed-up for 4 years by medical therapy without complications.