Fatih Mehmet Uçar

Programming Implantable Cardioverter-Defibrillator Therapy Zones to High Ranges to Prevent Delivery of Inappropriate Device Therapies in Patients With Primary Prevention: Results from the RISSY-ICD (Reduction of Inappropriate ShockS bY InCreaseD zones) trial

Inappropriate shock is a frequently seen clinical problem despite advanced technologies used in modern implantable cardioverter-defibrillator (ICD) devices. Our aim was to investigate whether simply raising the ICD detection zones can decrease inappropriate therapies while still providing appropriate therapy. We randomized 223 patients with primary prevention to either the conventional programming group with 3 zones as VT1 (167 to 182 beats/min) with discriminators, VT2 (182 to 200 beats/min) with discriminators, and ventricular fibrillation (>200 beats/min) (n=100) or the high-zone programming group with 3 zones as VT1 (171 to 200 beats/min) with discriminators, VT2 (200 to 230 beats/min) with discriminators, and ventricular fibrillation (>230 beats/min; n=101). Twenty-two patients were lost to follow-up. The primary objectives were the first episode of appropriate and inappropriate therapies. The secondary objectives were all-cause mortality and hospitalization for heart failure. During 12-month follow-up, the first episode of appropriate therapy was higher (22% vs 10%, hazard ratio [HR] 2.18, 95% confidence interval [CI], 1.09 to 4.36, p=0.028) and the first episode of inappropriate therapy was lower (5% vs 28%, HR 0.18 [95% CI 0.07 to 0.44], p<0.001) in the high-zone group compared with the conventional group. Although all-cause mortality did not differ (2% for the high-zone group vs 3% for the conventional group, HR 0.65 [95% CI 0.11 to 3.99], p>0.05), hospitalization for heart failure was significantly higher in the conventional group (13% vs 4%, HR 0.28 [95% CI 0.09 to 0.88], p=0.021). In conclusion, in a real-world population, high-zone settings of the single-, dual-, and triple-chamber ICDs were associated with reduction in inappropriate therapy while still providing appropriate therapy.

Gamma-glutamyl transferase predicts recurrences of atrial fibrillation after catheter ablation.

Background Catheter ablation is a popular therapy of atrial fibrillation (AF). Gamma-glutamyl transferase (GGT) is known as a marker of oxidative stress. The objective of this study was to ascertain the relationship between levels of GGT and recurrence of AF after catheter ablation. Methods A total of 102 paroxysmal AF patients who underwent cryoballoon catheter ablation were enrolled. Serum samples were obtained to evaluate GGT levels before catheter ablation. Cox regression analysis was used to estimate the predictors of AF recurrence. Results Mean age of the cohort was 49.9 ± 11.7 and 63% of the patients were male. After a mean follow-up of 20 months, 19 (23%) patients had AF recurrences. The baseline GGT levels were significantly higher in patients who had AF recurrence [27 U/L (17-36) vs 18 U/L (13-22), P= 0.002]. The optimal cut-off value of GGT to predict AF recurrence was 23.5 U/L according to receiver operating characteristic curve analysis (area under the curve 0.72, P= 0.002). In the multivariable Cox regression analysis, baseline GGT > 23.5 was the only independent predictor of AF recurrence (hazard ratio (HR) 4.47, 95% confidence interval [1.66-12.09], P= 0.003). Conclusions Our results indicate that elevated GGT is associated with AF recurrence. A simple measurement of GGT may help us to identify high-risk patients undergoing catheter ablation for AF.

Tako-tsubo cardiomyopathy may lead to permanent changes in left ventricular geometry: Potential implications in the setting of pre-existing myocardial disease?

Article history: Received 9 September 2015 Accepted 3 October 2015 Available online 9 October 2015 dimensions, volumes and wall thickness, etc. might be encountered in a portion of subjects with TTC despite full convalescence as demonstratedwith normalized systolic functions. Moreover, these potential changes in left ventricular geometry due to the impact of a TTC attack might possibly go undetected in previously healthy subjects, but might be associated with significant clinical and echocardiographic changes in the

Apical pouches with hypertrophic cardiomyopathy

An 18-year-old man is admitted to the emergency department after an episode of syncope at school. His family history showed that the elder brother had hypertrophic cardiomyopathy (HCM), and another elder brother died suddenly at age 52. On physical examination, the patient’s vital signs were normal. A grade 2/6 systolic murmur was heard at the cardiac apex. The remainder of the findings on physical examination was normal. Electrocardiography revealed sinus rhythm and deep symmetrical T-wave inversions in leads I, II, aVL, and V3-V6 (Figure A). His laboratory findings including serum electrolytes were within normal limits. Two-dimensional transthoracic echocardiography showed typical of massive HCM (Figure B) with apical pouches (star in Figure C, and Video 1*) and color Doppler transthoracic echocardiography at apical four chamber view showing apical HCM with coronary artery-left ventricular micro-fistulas (Video 2*). Development of the apical pouches are also rare finding in HCM. The mechanisms contributing to the formation of apical pouches in HCM are multiple and still to be clarified. Possible causes include the increased afterload and high apical pressure, ventricular remodeling, the increased oxygen demand due to increased myocardial thickness and decreased oxygen supply due to the decreased capillary network and apical myocardial infarction. Investigators have suggested that the progression of myocardial disease in the left ventricular apex causing apical aneurysm or apical pouches could be a mechanism for the disappearance of negative T-waves during the course of the disease. 589

Coronary artery-left ventricular micro-fistulas associated with apical hypertrophic cardiomyopathy.

A 58 year-old Caucasian man was admitted to the coronary care unit with angina pectoris. There were deep inverted T waves and ST segment depression at anterior precordial derivations. Coronary angiography revealed widespread coronary artery to left ventricular microfistulae arising from distal portions of both left and right coronary systems. Left ventriculography and transthoracic echocardiography revealed typical features of apical hypertrophic cardiomyopathy. Angina pectoris was alleviated by beta-blocker therapy. Both multiple coronary artery to left ventricular microfistulae and apical hypertrophic cardiomyopathy are rare conditions and little is known about pathophysiological and clinical aspects of this combination. Accumulating evidence will provide us this information so that the management of the patients will be enhanced. (Cardiol J 2011; 18, 3: 307–309)

Association between RDW and stent thrombosis in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Abstract Stent thrombosis is a rare but potentially fatal complication of percutaneous coronary interventions (PCIs). In recent years, the predictive and prognostic value of the red cell distribution width (RDW) as an indicator of inflammation has been shown in many cardiovascular diseases. Aim of this study was to examine the predictive value of RDW for stent thrombosis in patients who underwent successful stent implantation for ST-elevation myocardial infarction (STEMI). In this retrospective study, 146 patients who underwent successful PCI to native coronary artery due to STEMI previously and presented with acute coronary syndrome with stent thrombosis were included (stent thrombosis group). A total of 175 patients who had similar procedural characteristics (type, diameter, and length of stent) and not had stent thrombosis were consisted control group. Patients were divided into tertiles according to the admission RDW values (12.9 ± 0.4, 14.2 ± 0.4, and 16.3 ± 1.5, respectively). Stent thrombosis developed in 47 (40.9%) patients in the lowest tertile, 39 (37.9%) patients in mid tertile, and 60 (58.3%) patients in the highest tertile (P = 0.006). Female gender ratio was statistically significantly higher in the 3rd tertile (13 [11.3%], 8 [7.8%], 24 [23.3%], P = 0.003, respectively). RDW (OR: 1.397 [95% CI 1.177–1.657], P < 0.001) and platelet count (OR: 1.008 [95% CI 1.004–1.012], P < 0.001) remained independent predictors of stent thrombosis after multivariate logistic regression analysis. ROC curve analysis demonstrated that, admission RDW values higher than 13.9 can predict the development of stent thrombosis with a sensitivity of 57% and a specificity of 52% (The area under the ROC curve: 0.59 [95% CI 0.53–0.65] P = 0.007). High RDW values found to be independently associated with the development of stent thrombosis in patients with STEMI.

Non-Sustained Ventricular Tachycardia Episodes Predict Future Hospitalization in ICD Recipients with Heart Failure

Background Implantable cardioverter-defibrillator (ICD) therapy is well known to reduce mortality in selected patients with heart failure (HF). Objective To investigate whether monitored episodes of non-sustained ventricular tachycardia (NSVT) might predict future HF hospitalizations in ICD recipients with HF. Methods We examined 104 ICD recipients (mean age: 60 ± 10.1 years, 80.8 % male) with HF who were referred to our outpatient clinic for device follow-up. After device interrogation, patients were divided into NSVT positive and negative groups. The primary endpoint was the rate of hospitalization within the next 6 months after initial ICD evaluation. Results Device evaluation demonstrated at least one episode of monitored NSVT in 50 out of 104 patients. As expected, no device therapy (shock or anti-tachycardia) was needed for such episodes. At 6 months, 24 patients were hospitalized due to acute decompensated HF. Hospitalization rate was significantly lower in the NSVT negative as compared with positive groups (38% versus 62%; adjusted hazard ratio [HR] 0.166 ; 95% CI 0.056 to 0.492; p = 0.01). Conclusions Monitored NSVT bouts in ICD recordings may serve as a predictor of future HF hospitalizations in ICD recipients with HF suggesting optimization of therapeutic modalities in these patients along with a close supervision in the clinical setting.

The Association between Platelet/Lymphocyte Ratio and Coronary Artery Disease Severity in Asymptomatic Low Ejection Fraction Patients

Background and Objectives Coronary angiography (CAG) is generally needed in the setting of systolic heart failure (HF) with an unidentified etiology as a part of diagnostic strategy. On the other hand, the clinical value of this invasive strategy is largely unknown. Platelet-lymphocyte ratio (PLR) has recently emerged as a novel inflammatory index that may serve as an important predictor of inflammatory state and overall mortality. The present study aimed to search the predictive value of PLR in determining the extent of coronary atherosclerosis in asymptomatic low ejection fraction (EF) patients. Subjects and Methods 156 asymptomatic heart failure (HF) subjects (without angina or HF symptoms, mean age: 58 years; to male: 71.2%) were enrolled, and thereafter a CAG was performed. Gensini Score was used to determine the severity of coronary artery disease (CAD) on CAG. According to this scoring system, the overall study group was categorized into three distinct subgroups: control group with the score 0, mild atherosclerosis group with the score 0 to 20 and severe atherosclerosis group with the score of >20. Thereafter, a comparison was made among groups with regard to mean values of PLR. Results The severe atherosclerosis group had a substantially higher level of mean PLR in comparison to other groups (p<0.001). Pre-CAG PLR levels as well as a variety of clinical variables including age, low density lipoprotein (LDL)-cholesterol demonstrated an independent correlation with Gensini score through a multivariate analysis. Conclusion These findings suggest the potential association of high PLR levels with severe atherosclerosis in the setting of asymptomatic systolic HF. A simple measurement of PLR helps to identify the severity of coronary atherosclerosis prior to conducting coronary angiography.

USEFULNESS OF ELECTROCARDIOGRAPHIC MARKERS TO PREDICT VENTRICULAR ARRHYTHMIAS IN ACUTE MYOCARDITIS PATIENTS

Aims: Acute myocarditis is an inflammatory disease of the myocardium and is characterized by a large heterogeneity of clinical presentation. Myocarditis is becoming to be recognized as a contributor to unexplained mortality, and is thought to be a major cause of sudden cardiac death in the first two decades of life. Myocardial inflammation, ion channel dysfunction, electrophysiological and structural remodelling may play important roles in life-threatening arrhythmias. We aimed to investigate the ventricular arrhythmia predictors in myocarditis patients by using electrocardiographic markers. Methods: A total of 56 patients (mean age 22.5 ± 3.7 years; 89% males) with acute myocarditis were enrolled in the study. Tpeak-Tend intervals, Tpeak-Tend/QT and Tpeak-Tend/corrected QT (QTc), cardio-electrophysiological balance (QT/QRS) and heart rate-corrected QT(QTc)/QRS ratios were calculated from 12-lead electrocardiogram. Results: Heart rate, QT and QTc values were similar between groups. QRS complexes were lower in arrhythmia positive group than arrhythmia negative group (p=0.004). Tpeak-Tend intervals, Tpeak-Tend/QT, Tpeak-Tend/ QTc, cardio-electrophysiological balance and heart rate-corrected QT(QTc)/QRS values were significantly higher in arrhythmia positive group (< 0.001, < 0.001, p=0.03, p=0.04 and < 0.001, respectively). Conclusion: In this study, we observed that higher Tpeak-Tend, Tpeak-Tend/QT, Tpeak-Tend/QTc , cardio-electrophysiological balance (ICEB) and heart rate-corrected QT(QTc)/QRS ratio are associated with ventricular arrhythmic episodes in acute myocarditis patients. These electrocardiographic markers may be beneficial to identify high risk patients for arrhytmias complicating myocarditis.

Neutrophil to lymphocyte ratio predicts appropriate therapy in idiopathic dilated cardiomyopathy patients with primary prevention implantable cardioverter defibrillator

Objectives: To investigate whether an inflammatory marker of neutrophil to lymphocyte ratio (NLR) predicts appropriate implantable cardioverter defibrillator (ICD) therapy (shock or anti tachycardia pacing) in idiopathic dilated cardiomyopathy (IDC) patients. Methods: We retrospectively examined IDC patients (mean age: 58.3 ± 11.8 years, 81.5% male) with ICD who admitted to outpatient clinic for pacemaker control at 2 tertiary care hospitals in Ankara and Edirne, Turkey from January 2013-2015. All ICDs were implanted for primary prevention. Hematological and biochemical parameters were measured prior procedure. Results: Over a median follow-up period of 43 months (Range 7-125), 68 (33.1%) patients experienced appropriate ICD therapy. The NLR was increased in patients that received appropriate therapy (4.39 ± 2.94 versus 2.96 ± 1.97, p<0.001). To identify independent risk factors for appropriate therapy, a multivariate linear regression model was conducted and age (β=0.163, p=0.013), fasting glucose (β=0.158, p=0.017), C-reactive protein (CRP) (β=0.289, p<0.001) and NLR (β=0.212, p<0.008) were found to be independent risk factors for appropriate ICD therapy. Conclusions: Before ICD implantation by using NLR and CRP, arrhythmic episodes may be predictable and better antiarrhythmic medical therapy optimization may protect these IDC patients from unwanted events.