Hikmet Yorgun

Safety and efficacy outcomes in patients undergoing pulmonary vein isolation with second-generation cryoballoon

AIMS The second-generation cryoballoon (Arctic Front Advance™) (Arc-Adv-CB) has a redesigned injection system which distributes the refrigerant homogenously to the frontal balloon surface. The aim of this study was to compare the efficacy and safety of the Arc-Adv-CB and its predecessor (Arctic Front™) (Arc-CB) in patients who underwent pulmonary vein isolation (PVI) for atrial fibrillation (AF). METHODS AND RESULTS Three hundred and six patients (55.35 ± 10.60 years, 47.05% male) were included in the study. A total of 1205 pulmonary veins were attempted for PVI with either Arc-CB or Arc-Adv-CB. The follow-up durations were 30 (23-38) and 10 (8-13) months in Arc-CB and Arc-Adv-CB groups, respectively (P < 0.001). When the blanking period was considered, freedom from AF after a single ablation procedure was 68.53 and 90.83% in patients undergoing PVI with Arc-CB and Arc-Adv-CB, respectively. The most frequent complication was transient phrenic nerve palsy (PNP) which occurred in five(2.54%) and nine(8.26%) of patients undergoing PVI with Arc-CB and Arc-Adv-CB, respectively (P = 0.040). Left atrial (LA) diameter (hazard ratio, HR: 3.552, 95% CI: 2.034-6.201, P < 0.001), smoking history (HR:1.643, 95% CI: 1.011-2.671, P = 0.045), persistent AF (HR:1.725, 95% CI: 1.021-2.915, P = 0.041), duration of AF (HR:1.039, 95% CI: 1.000-1.080, P = 0.047), and early AF recurrence (HR:2.399, 95% CI: 1.443-3.989, P < 0.001) were associated with increased late AF recurrence. On the other hand, intraprocedural vagal reactions (HR: 0.550, 95% CI: 0.331-0.915, P = 0.021) and Arc-Adv-CB use (HR: 0.441, 95% CI: 0.225-0.866, P = 0.017) were associated with lower late AF recurrence. Left atrial diameter (HR: 3.072, 95% CI: 1.646-5.732, P < 0.001), early AF recurrence (HR: 1.906, 95% CI: 1.103-3.291, P = 0.021), and Arc-Adv-CB use (HR: 0.472, 95% CI: 0.239-0.931, P = 0.030) were independent predictors for late AF recurrence. CONCLUSION Our study has shown that Arc-Adv-CB use is associated with lower late AF recurrences at the cost of an increased risk for PNP.

Serum uric acid levels predict the severity and morphology of coronary atherosclerosis detected by multidetector computed tomography.

In this study, we aimed to evaluate whether serum uric acid (UA) was associated with the severity and morphology of coronary atherosclerotic plaques (CAP) shown by multidetector computed tomography (MDCT). The study population consisted of 982 patients (58% men) who underwent dual-source 64 slice MDCT for the assessment of coronary artery disease (CAD). Coronary arteries were evaluated on 16 segment basis and critical coronary plaque was described as luminal narrowing >50%, whereas plaque morphology was assessed on per segment basis. Serum UA levels were determined using commercially available assay kits. The critical atherosclerotic lesions were detected in 454/982 (46.2%) subjects by MDCT. Serum UA levels were found to be higher in patients with any coronary plaque (6.9 ± 1.5mg/dL vs. 5.1 ± 1.3mg/dL, p<0.01). Also UA level was higher in patients with critical stenosis compared to non-critical stenosis (6.1 ± 1.5mg/dL vs. 5.4 ± 1.3mg/dL, p<0.001). Subjects having primarily calcified plaques have higher UA levels compared to other plaque subtypes (5.5 ± 1.3 for non-calcified plaques, and 5.6 ± 1.2 for mixed plaques, 6.6 ± 1.6 for calcified plaques, p<0.001). This independent association was remained after multinominal regression analysis (OR: 1,987; 95% CI; 1.69-2.32; p<0.01). Our study demonstrated that serum UA level was significantly associated with the severity and the calcified morphology of CAP detected by MDCT. Further prospective clinical studies are needed to clarify the exact physiopathologic role of UA in CAD.

Increased epicardial fat tissue is a marker of metabolic syndrome in adult patients

BACKGROUND Human epicardial adipose tissue (EAT) is a type of visceral adipose tissue functioning as a metabolically active endocrine organ by secreting several hormones and adipocytokines. In this study, we aimed to assess the relationship between EAT measured by dual source multidetector computed tomography (MDCT) and the presence and components of metabolic syndrome (MS). METHODS A total of 83 patients (43.4% male, mean age 56.1 ± 11.9) who underwent MDCT for suspected coronary artery disease were enrolled in this study. Thickness of the EAT was measured on contrast enhanced multiplanar reformat images with parasternal short axis view at basal, mid-ventricular and apical levels and horizontal long axis view. RESULTS The mean EAT thickness was significantly increased in patients with MS compared to those without MS (8.49 ± 1.43 mm vs 7.39 ± 2.10 mm, p<0.001). Additionally there was a graded relationship between increasing number of MS components and mean total EAT and pericoronary fat thickness (p<0.05). Simple regression analysis revealed that the presence of MS, age and body mass index (BMI) were correlated with mean EAT thickness (r=0.398, r=0.376 and r=0.371 respectively, p<0.001). Multiple regression analysis revealed that the presence of MS, age and BMI were the strongest independent variables related to EAT. CONCLUSION In this study we demonstrated that EAT and pericoronary fat thickness were associated with the presence of MS. Those findings may implicate that, EAT and pericoronary fat may be a novel and useful indicator for MS.

Fragmented QRS Complex Predicts the Arrhythmic Events in Patients with Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia

Fragmented QRS (frQRS) complex, with various morphology, has been recently described as a diagnostic criterion of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). However, there are little data regarding the prognostic role of frQRS in these patients. Therefore, we aimed to investigate the association of frQRS with arrhythmic events in patients with ARVC/D.

Cryoballoon Ablation for Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation: One-Year Outcome Using Second Generation Cryoballoon.

Background—Data regarding the freedom from atrial fibrillation (AF) in the follow-up of persistent AF patients is limited. The second-generation cryoballoon has better cooling properties compared with first-generation cryoballon. In this study, we aimed to assess the medium-term efficacy of second-generation cryoballoon in patients with persistent AF. Methods and Results—A total of 100 patients (63±10 years, 80% male) with symptomatic persistent AF, despite ≥1 antiarrhythmic drug(s), who were scheduled for pulmonary vein isolation using second-generation cryoballoon were enrolled in this study. Follow-up was based on outpatient clinic visits, including Holter ECGs. Recurrence was defined as a symptomatic or documented arrhythmia episode of >30 seconds excluding a 3-month blanking period. As a result, 393 pulmonary veins (7 patients with common ostium) were successfully isolated. Mean procedural and fluoroscopy times were 96.2±21.3 and 19.7±6.7 minutes, respectively. Phrenic nerve palsy occurred in 3% (3/100) of the patients. At a mean follow-up duration of 10.6±6.3 months, 67% of the patients were in sinus rhythm. Stepwise multivariable Cox proportional hazard regression analysis showed that early AF recurrence (hazard ratio 3.83, 95% confidence interval 1.91–7.68, P<0.001) was the only independent predictor for late AF recurrence apart from other clinical and echocardiographic variables. Conclusions—Our findings indicated that second-generation cryoballoon use is associated with favorable outcomes in patients with persistent AF. Recurrence at blanking period was the only predictor of long-term AF recurrence.

The role of preprocedural monocyte-to-high-density lipoprotein ratio in prediction of atrial fibrillation recurrence after cryoballoon-based catheter ablation

AIMS Previous studies evidenced that increased monocyte count or activity and lower high-density lipoprotein (HDL) cholesterol levels were associated with more prevalent atrial fibrillation (AF) which attributed to pro-inflammatory and pro-oxidant effects. Monocyte-to-HDL ratio (M/H ratio) is a recently emerged indicator of inflammation and oxidative stress which have been only studied in patients with chronic kidney disease. We aimed to investigate the prognostic impact of M/H ratio on AF recurrence after cryoballoon-based catheter ablation. METHODS AND RESULTS A total of 402 patients (43.5% female, age 53.5 ± 10.9 years, and 80.8% paroxysmal AF) with symptomatic AF underwent initial cryoablation procedure. Patients were categorized into quartiles on the basis of their pre-procedural M/H ratio. Post-ablation blanking period was observed for 3 months. At a mean follow-up of 20.6 ± 6.0 months, 95 patients (23.6%) had developed AF recurrence. Atrial fibrillation recurrence rates from the lowest to the highest M/H ratio quartiles were 7.4, 7.4, 16.8, and 68.4%, respectively (P < 0.001). On multivariate Cox regression analysis, the preablation M/H ratio (HR: 1.20, 95% CI: 1.15-1.25, P < 0.001), left atrial diameter, duration of AF history, and early AF recurrence were independent predictors of AF recurrence. Using a cut-off level of 11.48, the pre-ablation M/H ratio predicted AF recurrence during follow-up with a sensitivity of 85% and a specificity of 74%. CONCLUSION Elevated pre-ablation M/H ratio was associated with an increased recurrence of AF after cryoballoon-based catheter ablation. Our results support the role of pre-ablation pro-inflammatory and pro-oxidant environment in AF recurrence after ablation therapy but suggest that other factors are also important.

Percutaneous extraction of cardiac pacemaker and implantable cardioverter defibrillator leads with evolution mechanical dilator sheath: a single-centre experience

AIMS The growing problem with endocardial lead infections and lead malfunctions has increased the interest in percutaneous lead removal technology. In this report, we present our initial experience in percutaneous lead extraction with a novel hand-powered sheath, the Evolution mechanical dilator sheath. METHODS AND RESULTS During 13 months between June 2009 and July 2010, 41 leads in 23 patients were removed. All of the extracted leads were >12 months old, and indications for extraction were based on the recommendations of the Heart Rhythm Society. The leads were removed by using the Evolution mechanical dilator sheath (Cook Medical) with the rotational cutting force only, without laser or radiofrequency energy. Indications for lead removal included cardiac device infection in 7 (30.4%) cases, lead malfunction in the 15 (65.2%) cases, and lead displacement in the remaining 1 case (4.4%). In 14 (60.9%) cases, the extracted device was a pacemaker, and implantable cardioverter defibrillators (ICD) in 9 (39.1%) of them. Among 41 leads, 25 (60.9%) were right ventricular, 14 (34%) were atrial, and 2 (4.8%) were coronary sinus electrode. The median time from the preceding procedure was 74 months (25-180 months). Complete procedural success with Evolution system alone was achieved in 19 (82%) patients (35 leads). Four leads were completely removed with snaring and in two leads, partial success was achieved with a remaining ventricular tip smaller than 1.5 cm. Clinical success was 100%, and all of the patients discharged uneventfully without a major complication. CONCLUSIONS Our experience confirms that the mechanical technique with Evolution system is an effective first-line method for chronically implanted pacemaker/ICD leads. Continued investigation is required to evaluate success and complication rates in comparison with other techniques.

Role of Preablation Neutrophil/Lymphocyte Ratio on Outcomes of Cryoballoon-Based Atrial Fibrillation Ablation

The neutrophil/lymphocyte ratio (NLR) has recently emerged as better indicator of inflammation and oxidative stress and has been widely studied in several cardiovascular diseases. In the present study, we evaluated the role of the preablation NLR in atrial fibrillation (AF) recurrence after cryoballoon-based catheter ablation. A total of 251 patients (47.8% women, age 54.12 ± 10.9 years, 80.1% with paroxysmal AF) with symptomatic AF underwent cryoablation. At a mean follow-up of 19.0 ± 6.6 months, 60 patients (23.9%) had developed AF recurrence. The patients who developed AF recurrence had had a greater preablation NLR (3.53 ± 0.95 vs 2.65 ± 0.23, p <0.001) and a higher white blood cell count, neutrophil count, and high-sensitivity C-reaction protein levels. On multivariate regression analysis, the preablation NLR (hazard ratio 2.15, 95% confidence interval 1.70 to 2.73, p <0.001), left atrial diameter (hazard ratio 1.09, 95% confidence interval 1.04 to 1.14, p <0.001) and early AF recurrence (hazard ratio 2.99, 95% confidence interval 1.71 to 5.23, p <0.001) were independent predictors of AF recurrence after cryoablation. Using a cutoff level of 3.15, the preablation NLR predicted AF recurrence during follow-up with a sensitivity of 84% and specificity of 75%. Patients with a preablation NLR >3.15 had a 2.5-fold increased risk of developing AF recurrence after cryoablation. In conclusion, an elevated preablation NLR was associated with increased AF recurrence after cryoballoon-based catheter ablation. Our results support the role of a preablation inflammatory environment in the development of AF recurrence after ablation therapy but suggest that other factors are also important.

A Prospective DE-MRI Study Evaluating the Role of TGF-β1 in Left Atrial Fibrosis and Implications for Outcomes of Cryoballoon-Based Catheter Ablation: New Insights into Primary Fibrotic Atriocardiomyopathy

Transforming growth factor (TGF)‐β1 mediated atrial fibrosis plays a major role in the development of vulnerable atrial substrate for atrial fibrillation (AF). Although cryoablation effectively eliminates the triggers for AF, the impact of atrial substrate on the success of cryoablation remains unclear.

Additional benefit of cryoballoon-based atrial fibrillation ablation beyond pulmonary vein isolation: modification of ganglionated plexi

AIMS It has been known that cryoballoon-based pulmonary vein isolation (PVI) is an efficacious and a safe therapeutic option to eliminate triggers of atrial fibrillation (AF). However, the effect of cryoablation on external modifiers of AF-like ganglionated plexi (GP) has never been investigated. In this study, we aimed to investigate whether vagal reactions probably due to GP modification during cryoablation, are associated with success rates during follow-up. METHODS AND RESULTS A total of 145 patients (age: 54.5 ± 10.1, 52.4% males and 80.7% paroxysmal AF) who were symptomatic despite treatment with ≥ 1 antiarrhythmic drug underwent PVI with cryoballoon. Occurrences of intraprocedural vagal reactions were recorded in all patients. Intraprocedural vagal reaction was observed in 59 patients (40.7%). Vagal reaction characterized by bradycardia and hypotension was more common in patients free of AF recurrence as was the requirement of atropine administration or temporary pacing (46.2 vs. 15.4%, P = 0.004 and 38.7 vs. 7.7%, P = 0.002, respectively). At a median 17 (4-27) months follow-up, AF recurrence was observed in 26 (17.9%) patients. Multivariate Cox regression analysis showed that non-paroxysmal AF, left atrial diameter, and early recurrence significantly increased AF recurrence; however, requirement of atropine administration or temporary pacing (hazard ratio: 0.064; 95% confidence interval: 0.008-0.48, P = 0.008) decreased AF recurrence. CONCLUSION Our findings indicate that vagal reactions during cryoablation, as a surrogate marker of cardiac ANS modification, decrease AF recurrence in a subgroup of patients with paroxysmal and persistent AF. This finding may be attributed to the concomitant ablation of GP during antral PVI.