Fatih Bayrak

Pulmonary vein ostium shape and orientation as possible predictors of occlusion in patients with drug-refractory paroxysmal atrial fibrillation undergoing cryoballoon ablation

AIMS No specific data are available on the influence of pulmonary vein (PV) anatomy and shape on cryoballoon ablation (CA) catheter efficacy in delivering cryothermal energy and, consequently, in obtaining PV isolation. METHODS AND RESULTS Among a larger series of patients (68) with drug-refractory paroxysmal atrial fibrillation who underwent CA in our department, 52 patients were included in our study. All of them had a multislice cardiac computed tomography (MSCT) before the procedure. We retrospectively evaluated their MSCT scans focusing our attention on PV ovality and orientation in the frontal plane. A fair inverse association was documented between the ovality index of the left PVs and the degree of occlusion (r=-0.486 and P<0.003 for the LSPV and r=-0.360 and P=0.033 for the LIPV), whereas no association was found between the ovality index of the right PVs and the degree of occlusion (r=-0.283 and P=0.083 for the RSPV and r=0.235 and P=0.093 for RIPV). Nevertheless, a strong inverse association was found between the orientation of the PV ostia and the degree of occlusion in each vein (r=-0.804 and P<0.001 for the LSPV, r=-0.415 and P=0.013 for LIPV, r=-0.798 and P<0.001 for the RSPV, and r=-0.867 and P<0.001 for RIPV). CONCLUSION Pulmonary vein ostium shape and orientation evaluated by MSCT proved to be useful in predicting the degree of occlusion obtained during CA.

Safety and efficacy of patient preparation with intravenous esmolol before 64-slice computed tomography coronary angiography.

ObjectiveTo evaluate the safety and efficacy of heart rate reduction by intravenous esmolol in patients who are assigned for coronary angiography with 64-slice computed tomography (CT). MethodsFive hundred consecutive patients were prospectively analyzed. Patients with an initial heart rate less than 65 beats per minute (bpm) did not receive esmolol. Patients with a heart rate between 65 and 80 bpm received a bolus dose of 1 mg/kg intravenous esmolol. Patients with an initial heart rate between 80 and 90 bpm received a bolus dose of 2 mg/kg intravenous esmolol. An additional 1 mg/kg intravenous esmolol was given to the patients when the target heart rate was not reached with the first bolus dose. Patients with an initial heart rate more than 90 bpm received 50 mg atenolol PO, and were reevaluated after 1 h. ResultsA total of 391 patients with a heart rate ≥65 bpm before multislice computed tomography (MSCT) examination received intravenous esmolol with a mean dose of 158±55 mg. Initial and final mean heart rates were 80±11 bpm and 63±7 bpm, respectively (P<0.0001). Heart rate below 65 bpm was reached in 265 (65%) of these 391 patients. Only four patients (1%) had a final heart rate above 80 bpm before MSCT imaging. Four of the 391 patients (1%) had a final heart rate below 50 bpm. ConclusionIntravenous esmolol is safe and effective to reach the optimum heart rate in patients assigned for MSCT.

Acute myocardial infarction in a young woman with severe ulcerative colitis

In this report we present a case of a 28-year-old woman who was admitted to our emergency room complaining of chest pain. Her clinical ECG and biochemical evaluation was consistent with acute nonatherogenic myocardial infarction. Subsequent work is revealed that she was suffering from ulcerative colitis with acute exacerbation since last week. We discussed triggering factors for thrombogenic and inflammatory tendency of patient with comprehensive review of literature to clarify the causal relationship.

Isolating the pulmonary veins as first-line therapy in patients with lone paroxysmal atrial fibrillation using the cryoballoon.

AIMS Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Nowadays, catheter-based ablative approaches are mainly reserved for drug-refractory patients. However, the value of an ablative therapy as a first-line alternative remains elusive. The aim of our study was to analyse the acute procedural success and clinical outcome of patients with lone paroxysmal AF undergoing cryoballoon ablation (CBA) as first-line treatment. METHODS AND RESULTS Eighteen individuals (mean age 44 ± 9 years, range 23-61 years, 15 males) with lone paroxysmal AF preferring a catheter-based treatment to drug treatment as first-line therapy were consecutively enrolled in our study. Mean left atrial size was 39 ± 4 mm and mean left ventricular ejection fraction 58 ± 3%. After a mean of 2.4 CBA (range 2-4) applications pulmonary vein (PV) isolation could be demonstrated in 70 (97%) PVs. Additional lesions with a focal ablation catheter were needed to isolate one right inferior pulmonary vein and one left superior pulmonary vein in two different patients. At the end of the procedure, all (100%) PVs were isolated. After a 2-month blanking period, 16 patients (89%) were free of symptomatic AF recurrence at a mean follow-up of 14 ± 9 months and without antiarrhythmic drugs (AADs). CONCLUSION Cryoballoon ablation in patients with lone paroxysmal AF yields a high acute efficacy rate with a great chance of being free of symptomatic AF recurrence without antiarrhythmic drugs on a mid-term follow-up period, when offered as a first-line treatment.

Pulmonary vein isolation during cryoballoon ablation using the novel Achieve inner lumen mapping catheter: a feasibility study.

AIMS Cryoballoon (CB) ablation has proven very effective in achieving pulmonary vein isolation (PVI). The Achieve catheter (AC) is a novel inner lumen catheter designed to be used in conjunction with the CB, which serves the double purpose of a guidewire and a mapping catheter. We aimed to evaluate the feasibility of CB ablation in conjunction with the novel AC, in terms of PVI and safety in a series of patients affected by drug resistant paroxysmal atrial fibrillation (AF). METHODS AND RESULTS Seventy patients (49 male) affected by paroxysmal AF were assigned to CB PVI using the AC as a mapping catheter. Patients underwent loop-Holter monitoring 1, 3 and 6 months after ablation. Isolation occurred in 98% of PVs with the CB-AC association without having switching to a regular guidewire. Pulmonary vein isolation could be documented by real-time (RT) recordings in 47% (132) of veins. Time to isolation was significantly longer in PVs exhibiting early left atrium-PV reconnection if compared with veins with sustained isolation (117 ± 25 s vs. 59 ± 25 s; P< 0,005). No serious complications occurred; four transient phrenic nerve palsies occurred all resolving completely before the end of the procedure. CONCLUSION Cryoballoon ablation in conjunction with the novel AC is feasible, safe, and most importantly affords PVI in nearly all veins without having to switch to a regular guidewire. However, RT recordings could be documented in only 47% of pulmonary veins.

Prevalence, Clinical Characteristics and Management of Atrial Fibrillation in Patients With Brugada Syndrome

Atrial fibrillation (AF) can be the first manifestation of latent Brugada syndrome (BS). The aim of our study was to assess the prevalence of AF as the first clinical diagnosis in patients with BS and their demographic and clinical characteristics and diagnosis management in a large cohort of patients. The patient group consisted of 611 patients with BS. The data from those with a diagnosis of AF previous to the identification of BS were analyzed (n = 35). Eleven cases were unmasked after the initiation of a class I antiarrhythmic drug and one during the establishment of general anesthesia. In the remaining population, BS was diagnosed using an ajmaline test performed mainly because of younger age in patients with lone AF (n = 13), previous syncope or sudden cardiac death (n = 3), or a clinical history of sudden cardiac death in the family (n = 5). The mean patient age was 49 ± 15 years, 21 were male patients, 14 had a family history of sudden death, 15 had had previous syncope, and 4 had survived cardiac arrest. Concomitant electrical disorder was found in 13 patients. Remarkably, 21 patients had normal findings on the baseline electrocardiogram. In conclusion, AF could be one of the first clinical manifestations of latent BS in a considerable number of patients. This identification is crucial because the treatment of these patients is subject to relevant changes. The ajmaline test plays an essential role, mainly in young patients with a family history of sudden death, despite having normal findings on a baseline electrocardiogram.

Evaluation of myocardial bridges with 64-slice computed tomography coronary angiography.

Objective — The aim of this study is to report the characteristics of myocardial bridging (MB) using 64-slice computed tomography and to demonstrate the association between atherosclerotic coronary artery disease (CAD) and MB. Methods and results — In 990 consecutive patients who underwent multi-slice computed tomography (MSCT) coronary angiography for suspected or known coronary artery disease, myocardial bridge evaluation was performed with axial, curved multiplanar reconstruction and three-dimensional volume-rendered images. 265 bridged segments were identified in 223 (22.5%) patients. Multiple MBs on left coronary arteries were found in 41patients. Most of the MBs were in the LAD (62.6%), followed by the obtuse marginal artery (14.7%) and diagonal artery (14.3%). The average length of MBs was 14±7mm, and the average depth was 1.6±1.1mm. No significant difference was observed between patients with and without MB on the middle LAD in respect of age, gender, prevalence of diabetes, hyperlipidaemia, hypertension, current smoking and prevalence of atherosclerotic plaques at the proximal LAD. On the other hand, prevalence of atherosclerotic plaques at the distal LAD were significantly lower in patients with MB on the middle LAD (3.5% vs. 19.7%, P: 0.0001). Conclusions — The presence and morphological characteristics of MB and its relation with atherosclerotic plaques in the involved coronary artery can be comprehensively analysed with 64-slice computed tomography coronary angiography.Atherosclerosis is a common finding in segments proximal to MB, but the prevalence of plaques in equivalent segments (proximal LAD in our study) is not higher than in patients under similar coronary artery disease risk and without MB. On the other hand, prevalence of atherosclerotic plaques at the distal LAD was significantly lower in our patients with MB on the middle LAD. Finally, we suggest that rather than causing proximal atherosclerosis, MB might have a more important role in the protection of distal segments of the bridged arteries from atherosclerosis.

Ventricular pre-excitation and cardiac hypertrophy mimicking hypertrophic cardiomyopathy in a Turkish family with a novel PRKAG2 mutation

Mutations in PRKAG2, the gene for the γ2 regulatory subunit of AMP‐activated protein kinase, cause cardiac hypertrophy and electrophysiological abnormalities. We identified a novel mutation in PRKAG2 causing familial ventricular pre‐excitation and severe cardiac hypertrophy.

Added value of transoesophageal echocardiography during transseptal puncture performed by inexperienced operators

AIMS Transseptal puncture (TP) appears to be safe in experienced hands; however, it can be associated with life-threatening complications. The aim of our study was to demonstrate the added value of routine use of transoesophageal echocardiography (TEE) for the correct positioning of the transseptal system in the fossa ovalis, thus potentially preventing complications during fluoroscopy-guided TP performed by inexperienced operators. METHODS AND RESULTS Two hundred and five patients undergoing pulmonary vein isolation procedure (PVI) for drug-resistant paroxysmal or persistent atrial fibrillation were prospectively included. When the operator (initially blinded to TEE) assumed that the transseptal system was in a correct position according to fluoroscopical landmarks, the latter was then checked with TEE unblinding the physician. If necessary, further refinement of the catheter position was performed. Refinement >10 mm, or in case of catheter pointing directly at the aortic root or posterior wall were considered as major repositioning. Thirty-four patients required major repositioning. Regression analysis revealed age (P: 0.0001, Wald: 12.9, 95% confidence interval: 1.04-1.16), left atrial diameter (P: 0.01, Wald: 6.6, 95% confidence interval: 1.04-1.34), previous PVI (P: 0.01, Wald: 6.3, 95% confidence interval: 1.31-8.76), and atrial septal thickness (P: 0.03, Wald: 4.5, 95% confidence interval: 1.05-3.4) as independent predictors of major revision with TEE. CONCLUSION Routine 2D TEE in addition to traditional fluoroscopic TP appears to be very useful to guide the TP assembly in a correct puncture position and thus, to avoid TP-related complications. However, further randomized prospective comparative studies are necessary to support these suggestions.

Value of electrocardiogram in the differentiation of hypertensive heart disease, hypertrophic cardiomyopathy, aortic stenosis, amyloidosis, and Fabry disease.

Left ventricular hypertrophy is 1 of the most frequent cardiac manifestations associated with an unfavorable prognosis. However, many different causes of left ventricular hypertrophy exist. The aim of the present study was to assess the diagnostic value of common electrocardiographic (ECG) parameters to differentiate Fabry disease (FD), amyloidosis, and nonobstructive hypertrophic cardiomyopathy (HC) from hypertensive heart disease (HHD) and aortic stenosis (AS). In 94 patients with newly diagnosed FD (n = 17), HHD (n = 20), amyloidosis (n = 17), AS (n = 20), and HC (n = 20), common ECG parameters were analyzed and tested for their diagnostic value. A stepwise approach including the Sokolow-Lyon index, corrected QT duration, and PQ interval minus P-wave duration in lead II to overcome P-wave abnormalities was applied. A corrected QT duration <440 ms in combination with a PQ interval minus P-wave duration in lead II <40 ms was 100% sensitive and 99% specific for the diagnosis of FD, whereas a corrected QT duration >440 ms and a Sokolow-Lyon index ≤1.5 mV were found to have a sensitivity and specificity of 85% and 100%, respectively, for the diagnosis of amyloidosis and differentiation from HC, AS, and HHD. Moreover, a novel index ([PQ interval minus P-wave duration in lead II multiplied by corrected QT duration]/Sokolow-Lyon index) proved to be highly diagnostic for the differentiation of amyloidosis (area under the curve 0.92) and FD (area under the curve 0.91) by receiver operator characteristic analysis. In conclusion, a combined analysis of PQ interval minus P-wave duration in lead II, corrected QT duration, and Sokolow-Lyon index proved highly sensitive and specific in the differentiation of FD, amyloidosis, and HC compared to HHD and AS. Analysis of these easy-to-assess ECG parameters may be of substantial help in the diagnostic workup of these 5 conditions.