Savas Celebi

The Effect of Sinus Rhythm Restoration on High-Sensitivity C-Reactive Protein Levels and Their Association with Long-Term Atrial Fibrillation Recurrence after Electrical Cardioversion

Objective: Recent studies have shown that high-sensitivity C-reactive protein (hs-CRP) measured before cardioversion (CV) plays a significant role in predicting atrial fibrillation (AF) relapse. The time course of changes in hs-CRP after successful electrical CV remains controversial. The aim of the present study was to assess the prognostic value of pre- and post-CV hs-CRP levels in predicting the long-term risk of AF. Additionally, we evaluated changes in hs-CRP levels over time following a successful CV. Methods: This prospective study comprised 216 patients with persistent AF who underwent CV (mean age 51.94 ± 8.07 years; 55.6% men). hs-CRP levels were examined in all patients, and blood samples were taken prior to and 1, 2, 7 and 30 days after CV. AF relapse was determined by 24-hour ambulatory electrocardiogram (ECG) monitoring and 12-lead standard ECG during 12 months of follow-up. We further divided the study population into two groups according to their rhythm at the end of the follow-up period (group A: patients with AF at the end of follow-up; group B: patients with sinus rhythm at the end of the follow-up period). Results: The AF recurrence rate was 42.2% throughout the 12-month follow-up period. The basal hs-CRP levels were higher in patients with an AF relapse than in those without (1.68 ± 0.57 vs. 1.12 ± 0.53 mg/dl; p < 0.01). The hs-CRP levels were significantly decreased at 30 days in group B, whereas there was no significant decrease in group A (from 1.12 ± 0.53 to 0.69 ± 0.33 mg/dl, p < 0.01, and from 1.68 ± 0.57 to 1.69 ± 0.76 mg/dl, p > 0.05, respectively). By multivariate Cox analysis, the independent predictors of AF relapse time points were the basal and day-2 hs-CRP levels. Receiver operating characteristic curve analysis showed that the cutoff value of hs-CRP on the 2nd day for predicting AF relapse was 1.85 mg/dl, with a sensitivity of 62%, a specificity of 82%, a positive predictive value of 85.7% and a negative predictive value of 81.6%. Conclusion: The hs-CRP levels both prior to and after CV predict the long-term risk of AF relapse. In the present study, hs-CRP levels were significantly decreased in patients who remained in sinus rhythm at the end of the study. In contrast, hs-CRP levels remained high throughout the follow-up in patients with an AF relapse.

Guideline-adherent therapy for stroke prevention in atrial fibrillation in different health care settings: Results from RAMSES study

OBJECTIVE No studies have been conducted in Turkey to compare the quality of stroke prevention therapies provided in different healthcare settings in patients with atrial fibrillation (AF). Therefore, we aimed to evaluate possible differences between secondary (SH) and tertiary hospital (TH) settings in the effectiveness of implementing AF treatment strategies. METHODS Baseline characteristics of 6273 patients with non-valvular AF enrolled in the RAMSES (ReAl-life Multicentre Survey Evaluating Stroke Prevention Strategies in Turkey) study were compared. RESULTS Of the study population, 3312 (52.8%) patients were treated in THs and 2961 (47.2%) patients were treated in SHs. Patients treated in the SH setting were older (70.8±9.8 vs. 68.7±11.4years, p<0.001), had a lower socioeconomic status, had a higher CHA2DS2VASc and HASBLED scores (3.4±1.4 vs. 3.1±1.7, p<0.001 and 1.7±1.0 vs. 1.6±1.1, p<0.001 respectively), and had more comorbidities than patients treated in THs. Inappropriate oral anticoagulant use was more prevalent in SHs than THs (31.4% vs. 25.6%, p<0.001). When over- and undertreatment rates were compared among hospital types, overtreatment was more prevalent in THs (7.6% vs. 0.9%, p<0.001) while undertreatment was more common in SHs (30.5% vs. 17.9%, p<0.001). CONCLUSION This study demonstrates the marked disparity between patient groups with AF presenting at SHs and THs. The use of guideline-recommended therapy is not adequate in either type of centre, overtreatment was more prevalent in THs and undertreatment was more prevalent in SHs.

A rare presentation of cystic echinococcosis: aortic involvement

Cystic echinococcosis is an endemic parasitic infestation caused by the larval stage of Echinococcus granulosus. Although infestation of any part of human body can occur, isolated cardiac involvement is uncommon. We present a case of isolated hydatidosis involving the ascending aorta.

New horizon for ventricular pacing

Dear Editor, We read the article entitled “His-bundle pacing as a standard approach in patients with permanent atrial fibrillation and bradycardia’’ by Jastrzębski et al.1 with great interest. The authors reported that His bundle pacing (HBP) was safe and feasible in a patient with atrial fibrillation and bradycardia. Although it was non-inferior to standard right ventricular pacing, long-term pacing thresholds and battery current data were in an acceptable range. This study presents valuable data about the long-termsafety and feasibility ofHBP.Wehave further comments about the study: First, optimal pacing side is still a matter of debate. Several studies have reported that right ventricular apical pacing is associatedwith left ventricular dyssynchrony and progressive left ventricular myocardial dysfunction.2,3 HBP activates the ventricles via the native HisPurkinje system, resulting in true physiological pacing, and, therefore, is a promising alternate method for ventricular pacing. Although it is technically challenging and associatedwith high-pacing thresholds and higher current drain, clinical trials determine promising results.4,5 The main problem of HBP is to find the optimal His bundle (HB) potential. Moreover, a large right atrium or tricuspid valve regurgitation makes the implantation process difficult. Improved dedicated catheters anddelivery systems try toovercome theseproblems.6 Additionally, 3Dmapping is useful to achieve the lowest pacing threshold.7 We want to learn the opinion of the authors for the feasibility of 3D mapping in patients with inability to find HB potential. Furthermore, did they determine any association between the right atrial diameter and difficulty to fix the lead? Second, HB injury current recorded during HB lead placement implies good tissue contact and is associated with low-pacing thresholds. Therefore, HB injury current is a useful marker to evaluate the success of HBP. Although it is not an essential target at the time of implantation, clinical data show that it predicts lower pacing thresholds.8 Did the authors evaluate the HB injury current in their study population? If yes, was HB current injury associated with longterm pacing thresholds? We would like to thank the authors for their valuable data about HBP. ORCID

An unusual cause of angina pectoris due to dynamic coronary artery compression and successful treatment with cardiac surgical reconstruction

Extrinsic compression of coronary arteries causing angina pectoris is very unusual. No data regarding the optimal treatment for coronary artery compression due to dilated cardiac chambers have been reported. In this case report, we describe a man with severe mitral valve stenosis and the dilated left atrium, which resulted in coronary artery compression, and the successful management of his condition by surgical reconstruction.

Beyond Lipids: Antiarrhythmic Effects of Statins

We read the article entitled “Lower in-hospital ventricular tachyarrhythmia in patients with acute myocardial infarction receiving prior statin therapy” by Park et al with interest. They reported that previous statin therapy was associated with a reduced risk of ventricular arrhythmias in percutaneous coronary intervention patients (n 1⁄4 1177) with acute myocardial infarction (MI). Moreover, all-cause death at follow-up (12 months) was lower (hazard ratio: 0.191, 95% confidence interval: 0.059-0.618, P 1⁄4 .006) in patients on previous statin treatment. However, there were no significant differences in cardiac death, repeat revascularization, or recurrent MI during follow-up. Prior studies have shown an antiarrhythmic benefit of statin use in various settings. Statins, in addition to low-density lipoprotein cholesterol lowering, exhibited properties of improved endothelial homeostasis, anti-inflammatory, and antioxidant effects and normalization of sympathetic outflow. Experimental studies determined that statin use shortened the duration of the action potential and suppressed trigger activity, thereby reducing the incidence of ventricular arrhythmias. These effects may be dose dependent. Park et al determined similar results. However, we have some concerns about the study. First, there are no data about previous antiarrhythmic and/or b-blocker treatment of patients. Second, the duration and doses of statin treatment are not clear. Finally, there are no data about serum electrolyte levels. References