Paraschos Geleris

Comparison of Effectiveness of Ranolazine Plus Amiodarone Versus Amiodarone Alone for Conversion of Recent-Onset Atrial Fibrillation

Ranolazine, an antianginal agent with antiarrhythmic properties, prevents atrial fibrillation (AF) in patients with acute coronary syndrome. In experimental models, the combination of ranolazine and amiodarone has marked synergistic effects that potently suppress AF. Currently, the clinical effect of the ranolazine-amiodarone combination for the conversion of AF is unknown. This prospective randomized pilot study compared the safety and efficacy of ranolazine plus amiodarone versus amiodarone alone for the conversion of recent-onset AF. We enrolled 51 consecutive patients with AF (<48-hour duration) eligible for pharmacologic cardioversion. Patients (33 men, 63 ± 8 years of age) were randomized to intravenous amiodarone for 24 hours (group A, n = 26) or to intravenous amiodarone plus oral ranolazine 1,500 mg at time of randomization (group A + R, n = 25). The 2 groups were well balanced with respect to clinical characteristics and left atrial diameter. Conversion within 24 hours (primary end point) was achieved in 22 patients (88%) in group A + R versus 17 patients (65%) in group A (p = 0.056). Time to conversion was shorter in group A + R than in group A (9.8 ± 4.1 vs 14.6 ± 5.3 hours, p = 0.002). According to Cox regression analysis, left atrial diameter and A + R treatment were the only independent predictors of time to conversion (hazard ratio 5.35, 95% confidence interval 2.37 to 12.11, p <0.001; hazard ratio 0.81, 95% confidence interval 0.74 to 0.88, p <0.001, respectively). There were no proarrhythmic events in either group. In conclusion, addition of ranolazine to standard amiodarone therapy is equally safe and appears to be more effective compared to amiodarone alone for conversion of recent-onset AF.

Right Atrial and Ventricular Adaptations to Training in Male Caucasian Athletes: An Echocardiographic Study

BACKGROUND The aim of this study was to investigate the systolic and diastolic properties of the right cardiac chambers (the right ventricle and right atrium) among different subsets of athletes to unveil potential variations in right ventricular and right atrial remodeling secondary to different training modes. METHODS A cohort of Caucasian male top-level athletes (n = 108; 80 endurance athletes [EAs], mean age, 31.2 ± 10.4 years; 28 strength-trained athletes [SAs], mean age, 27.4 ± 5.7 years) and untrained controls (n = 26; mean age, 26.6 ± 5.6 years) (P = .327) were prospectively enrolled. Conventional echocardiographic parameters, including transtricuspid inflow, Doppler tissue imaging, and two-dimensionally derived peak systolic longitudinal strain and strain rate indices of the right ventricle and right atrium, were calculated. RESULTS EAs had greater internal right ventricular and right atrial dimensions compared with SAs and controls. There were no significant differences concerning strain between groups (-23.1 ± 3.7% in EAs vs -25.1 ± 3.2% in SAs vs -23.1 ± 3.5% in controls, P = .052), with SAs presenting higher global systolic strain rates (-1.42 ± 0.22 sec(-1) in SAs vs -1.21 ± 0.21 sec(-1) in EAs vs -1.2 ± 0.28 sec(-1) in controls, P = .016), as well as greater right atrial strain rate systolic and diastolic components. Training volume (highly vs moderately trained athletes) did not significantly influence deformation parameters. No significant differences concerning diastolic transtricuspid inflow and Doppler tissue imaging indices were also noted among different athlete groups and controls. CONCLUSIONS Despite the existence of right geometric alterations in athletes participating in different sport disciplines, few meaningful differences in deformation and diastolic function exist.

Brain natriuretic peptide and the athlete’s heart: a pilot study

Background:  The role of brain natriuretic peptide (BNP) in differentiating the athlete’s heart from maladaptive cardiac hypertrophy is unclear.

Efficacy of Various “Classic” Echocardiographic and Laboratory Indices in Distinguishing the “Gray Zone” between Athlete's Heart and Hypertrophic Cardiomyopathy: A Pilot Study

Left ventricular hypertrophy (LVH) with intraventricular septum thickness (IVST) between 1.2 and 1.5 cm in athletes represents a “gray zone” between physiologic adaptation and mild hypertrophic cardiomyopathy (HCM). Various echo and laboratory parameters have been reported till now in the literature to discriminate the “gray zone” entities. Aim of this study was to assess the efficacy of these “classic” parameters in differentiating physiologic LVH in athletes from mild HCM in a highly selected population. Nine highly trained athletes with IVST (1.28 ± 0.07 cm), 9 patients with mild HCM (1.38 ± 0.11 cm), and 26 athletes without LVH (1.06 ± 0.09 cm; P < 0.0005) underwent echocardiographic study, cardiopulmonary treadmill exercise stress test, and brain natriuretic peptide (BNP) measurement before and after exercise. Among all parameters tested, 7 were found to significantly differ between “gray zone” groups. After bootstrapping analysis, it was found that athletes with left ventricular end‐diastolic diameter <4.74 cm, mitral deceleration time >200 ms, isovolumic relaxation time >94 ms, tricuspid E/A < 1.63, septum Em < 9.5 cm/sec, relative wall thickness >0.445, and a BNP value at rest >9.84 pg/mL had a greater possibility for having underlying cardiomyopathy. A 10‐point score based on these parameters showed accuracy (area under the curve = 0.958 [95%CI: 0.738–1.0; P = 0.00005, standard error = 0.0342]) for revealing HCM in a gray zone athletic population. Differentiation of adaptive LVH versus HCM in a gray zone population could be facilitated by recognition of certain features referring to LV dimensions, diastolic function, and BNP.

Coronary Atherosclerosis: Pathophysiologic Basis for Diagnosis and Management.

Coronary atherosclerosis is a long lasting and continuously evolving disease with multiple clinical manifestations ranging from asymptomatic to stable angina, acute coronary syndrome (ACS), heart failure (HF) and sudden cardiac death (SCD). Genetic and environmental factors contribute to the development and progression of coronary atherosclerosis. In this review, current knowledge related to the diagnosis and management of coronary atherosclerosis based on pathophysiologic mechanisms will be discussed. In addition to providing state-of-the-art concepts related to coronary atherosclerosis, special consideration will be given on how to apply data from epidemiologic studies and randomized clinical trials to the individual patient. The greatest challenge for the clinician in the twenty-first century is not in absorbing the fast accumulating new knowledge, but rather in applying this knowledge to the individual patient.

Sinus nodal response to adenosine relates to the severity of sinus node dysfunction.

AIMS It is unknown as to whether the result of adenosine testing for the diagnosis of sinus node dysfunction (SND) depends on the clinical presentation. We investigated whether syncope or presyncope are associated with a more pronounced sinus nodal inhibition by adenosine in SND. METHODS AND RESULTS We studied 46 patients with SND, 33 with syncope or presyncope and 13 without such history. Controls were 30 subjects undergoing electrophysiological studies for supraventricular tachycardia or unexplained syncope. We calculated the corrected sinus node recovery time after intravenous adenosine 0.15 mg/kg (ADSNRT) as well as after atrial pacing (CSNRT). Corrected sinus node recovery time values >525 ms were considered abnormal. Corrected sinus node recovery time after adenosine injection was more prolonged in SND patients with syncope or presyncope as compared with those without such history [median: 4900 inter-quartile range (IQR): 920-8560 ms vs. median: 280 IQR: 5-908 ms; P< 0.005]. In SND patients with syncope or presyncope ADSNRT was more prolonged than CSNRT (median: 4900 IQR: 920-8560 ms vs. median: 680 IQR: 359-1650 ms, P< 0.01). In SND patients without syncope or presyncope no statistical difference was noted between ADSNRT and CSNRT (median: 280 IQR: 5-908 ms vs. median: 396 IQR: 270-600 ms, P = 0.80). The sensitivity of CSNRT for SND diagnosis was 57% and the specificity was 100%. A cut-off of 1029 ms for ADSRNT yields the same sensitivity with a specificity of 96.6%. CONCLUSION In patients with SND syncope or presyncope relate to an exaggerated sinus nodal suppression by adenosine. Prolonged ADSNRT can diagnose cases with severe underlying SND where a more aggressive management strategy is probably warranted.

Brugada Syndrome Masked by Ibutilide Treatment in a Patient with Atrial Flutter

We present a case of Brugada syndrome in a young patient whose typical ECG pattern was ‘masked’ after ibutilide was administered for atrial flutter cardioversion. Ibutilide, a class III antiarrhythmic agent used for the treatment of atrial fibrillation and flutter, prolongs the action potential duration plateau phase by augmenting the slow component of the inward Na+ current and by blocking the rapid component of the delayed rectifier potassium current. Insights into the pathophysiology of Brugada syndrome and this first-reported action of ibutilide are supplied, providing a plausible scientific basis for the masking effect of ibutilide. Furthermore, issues concerning the safety of ibutilide administration in patients with Brugada syndrome along with the importance of programmed ventricular stimulation and especially short-long-short sequence protocol in inducing ventricular fibrillation in these patients are also discussed.

Right atrial thrombus as a complication of supraventricular tachycardia ablation resolved by anticoagulation.

Figure 1. Course of a large right atrioventricular thrombus after supraventricular tachycardia ablation. A. demonstrates catheters used during electrophysiology study and concomitant ablation procedure. B. shows a short-axis view at the level of aortic valve demonstrating a snake-like clot coiled inside right atrium (transparent arrows), freely protruding in the right ventricle through tricuspid valve during diastole as seen in C. Fifteen days later, transoesophageal echocardiography D. as well as transthoracic twodimensional echocardiography (E. short-axis view and F. apical-four chamber view) show no signs of thrombus demonstrating only a prominent Chiari network (white head arrows) on which the initial thrombus had probably anchored. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle. A 40-year-old man underwent successful radiofrequency ablation of slow pathway [two applications (35 W, 55◦C, 60 seconds) using a 4-mm-tip catheter] (Fig. 1A). Procedure lasted