Serdar Bozyel

Associations Between Neutrophil Gelatinase Associated Lipocalin, Neutrophil-to-Lymphocyte Ratio, Atrial Fibrillation and Renal Dysfunction in Chronic Heart Failure

Background Atrial fibrillation (AF) and renal dysfunction are two common comorbidities in patients with chronic heart failure with reduced ejection fraction (HFrEF). This study evaluated the effect of permanent AF on renal function in HFrEF and investigated the associations of atrial fibrillation, neutrophil gelatinase-associated lipocalin (NGAL), and neutrophil-to-lymphocyte ratio (NLR) with adverse clinical outcome. Material/Methods Serum NGAL levels measured by ELISA and NLR were compared between patients with sinus rhythm (HFrEF-SR, n=68), with permanent AF (HFrEF-AF, n=62), and a healthy control group (n=50). Results Mean eGFR levels were significantly lower, and NLR and NGAL levels were significantly higher in the HFrEF patients than in the control patients but the difference between HFrEF-SR and HFrEF-AF was not statistically significant (NGAL: 95 ng/mL in HFrEF-SR, 113 ng/mL in HFrEF-AF and 84 ng/mL in the control group; p<0.001). Independent associates of baseline eGFR were age, hemoglobin, NLR, triiodothyronine, and pulmonary artery systolic pressure. In a mean 16 months follow-up, adverse clinical outcome defined as progression of kidney dysfunction and composite of all-cause mortality and re-hospitalization were not different between HFrEF-SR and HFrEF-AF patients. Although NGAL was associated with clinical endpoints in the univariate analysis, Cox regression analysis showed that independent predictors of increased events were the presence of signs right heart failure, C-reactive protein, NLR, triiodothyronine, and hemoglobin. In ROC analysis, a NLR >3 had a 68% sensitivity and 75% specificity to predict progression of kidney disease (AUC=0.72, 95% CI 0.58–0.85, p=0.001). Conclusions Presence of AF in patients with HFrEF was not an independent contributor of adverse clinical outcome (i.e., all-cause death, re-hospitalization) or progression of renal dysfunction. Renal dysfunction in HFrEF was associated with both NLR and NGAL levels, but systemic inflammation reflected by NLR seemed to be a more important determinant of progression of kidney dysfunction.

Clinical ventricular tachycardia and surgical epicardial ICD implantation in a patient with a Fontan operation for double-inlet left ventricle : online article - case report

The Fontan operation is the primary surgical technique used for palliation of patients with single-ventricle physiology. Arrhythmias are frequently observed and associated with morbidity and mortality in Fontan patients. The frequency of arrhythmias after the Fontan procedure increases over time and it was reported to reach 50% in a 20-year follow up. Atrial tachyarrhythmias, especially atrial tachycardia and sinus bradycardia, are most frequently observed in these patients. Ventricular arrhythmias are rarely observed. Generally, medical therapy, catheter ablation, pacemaker or implantable cardioverter defibrillator (ICD) implantation are options in the treatment of these arrhythmias. It may be difficult to implant either a pacemaker or an ICD in patients on whom the Fontan procedure has been performed. In conditions where access to the right ventricle is from the venous system, it is anatomically impossible. Where there is no functional right ventricle, device implantation can be performed with alternative methods other than the conventional transvenous approach. In this report, we discuss a middle-aged woman with a Fontan operation performed 14 years earlier, who presented with ventricular tachycardia (VT) and in whom an epicardial ICD was implanted. The literature on this issue is also reviewed.

What is the Lowest Value of Left Ventricular Baseline Ejection Fraction that Predicts Response to Cardiac Resynchronization Therapy

Background Cardiac resynchronization therapy (CRT) is an effective treatment option for patients with refractory heart failure. However, many patients do not respond to therapy. Although it has been thought that there was no relation between response to CRT and baseline ejection fraction (EF), the response rate of patients with different baseline LVEF to CRT has not been evaluated in severe left ventricular systolic dysfunction. We aimed to investigate any difference in response to CRT between the severe heart failure patients with different baseline LVEF. Material/Methods In this study, 141 consecutive patients (mean age 59±13 years; 89 men) with severe heart failure and complete LBBB were included. Patients were divided into 3 groups according to their baseline LVEF: 5–15%, Group 1; 15–25%, Group 2, and 25–35%, Group 3. NYHA functional class, LVEF, LV volumes, and diameters were assessed at baseline and after 6 months of CRT. A response to CRT was defined as a decrease in LVSVi (left ventricular end-systolic volume index) ≥10% on echocardiography at 6 months. Results After 6 months, a significant increase of EF and a significant decrease of LVESVi and LVEDVi after 6 months of CRT were observed in all groups. Although the magnitude of improvement in EF was biggest in the first group, the percentage of decrease in LVESVi and LVEDVi was similar between the groups. The improvement in NYHA functional class was similar in all EF subgroups. At 6-month follow-up, 100 (71%) patients showed a reduction of >10% in LVESVi (mean reduction: −15.5±26.1 ml/m2) and were therefore classified as responders to CRT. Response rate to CRT was similar in all groups. It was 67%, 75%, and 70% in Group 1, 2, and 3, respectively, at 6-month follow-up (p>0.05). There was no statistically significant relation between the response rate to CRT and baseline LVEF, showing that the CRT has beneficial effects even in patients with very low LVEF. Conclusions It seems there is no lower limit for baseline LVEF to predict non-response to CRT in eligible patients according to current guidelines.

A simple discharge risk model for predicting 1-year mortality in hospitalised acute decompansated heart failure patients with reduced ejection fraction

Abstract Objective: The risk stratification for prognosis in heart failure is very important for optimal disease management and decision making. The aim of this study was to establish a simple discharge 1-year mortality prediction model by integrating data obtained from demographic characteristics, clinical evaluation, laboratory biomarkers and echocardiographic evaluation of hospitalised heart failure with reduced ejection fraction (HFrEF) patients with acute decompensation. Methods and results: A risk score model was developed based on β-coefficient number of variables in a multivariable logistic regression model which was created with the use of data on clinical, laboratory, imaging and therapeutic findings of 670 patients (65.4% males, 65 ± 11 years) who was hospitalised with acute decompensated HFrEF. The mean left ventricular ejection fraction (LVEF) was 26 ± 9%. Independent predictors of mortality were: age ≥75 years, sodium <130 mEq/L, hepatomegaly at admission, unable to use beta-blocker at discharge and LVEF ≤20%. The 1-year mortality rate was 7.8% in the study population. The existence of each predictor was scored as 1 point and the discharge risk score identified patients into low (0–1 points), intermediate (2–3 points) and high (4–5 points) risk individuals with 3, 15.6 and 44.4% 1-year mortality rates, respectively. The model performance evaluated by concordance index was 0.74. Conclusions: This simple discharge risk score model for hospitalised acute decompensated HFrEF patients using easily determined demographic characteristics, clinical signs, echocardiographic and laboratory data is a valuable and an easy risk assessment tool to use at point-of-care.

Effect of Oral Nitrates on All-Cause Mortality and Hospitalization in Heart Failure Patients with Reduced Ejection Fraction: A Propensity-Matched Analysis

BACKGROUND Hydralazine-nitrate combination is recommended for patients with heart failure with reduced ejection fraction (HFrEF)/systolic heart failure who are symptomatic despite guideline-directed medical therapy (GDMT). Use of nitrates alone for this indication is not well-established. This study aims to evaluate the effect of oral nitrates on all-cause mortality and hospitalization in HFrEF patients using GDMT. METHODS AND RESULTS Nitrate prescription at discharge and its association with all-cause mortality and heart failure hospitalization were examined in a propensity-matched analysis of 648 HFrEF patients followed for a median of 56 months. A total of 269 (42%) patients died during that period. In Cox regression analysis, nitrate usage was associated with a slightly increased mortality risk compared with not using nitrates (hazard ratio 1.29; 95% confidence interval 1.01-1.65; P = .040), which continued modestly after the propensity-matched analysis (hazard ratio  1.26; 95% confidence interval 0.95-1.68; P = .102). In both prematch and propensity-matched analyses, nitrate use was not associated with risk of rehospitalization. No significant effect was detected on subgroups stratified by coronary artery disease, age, gender, and background medical therapy. CONCLUSIONS In this study, oral nitrate use alone in addition to GDMT did not affect all-cause mortality and hospitalization risk in HFrEF patients during a long-term follow-up. There was even a modest tendency for increased risk of mortality.

A new and simple technique for vagal ganglia ablation in a patient with functional atrioventricular block: Electroanatomical approach

Increased parasympathetic tone may cause symptomatic functional atrioventricular block (AVB) and necessitate pacemaker implantation. In these patients, where there is no structural damage to the conduction system, removal of the vagal activity using radiofrequency ablation seems to be a theoretically rational approach. Several methods have been used to determine suitable areas for vagal ganglia ablation. The aim of this report was to describe a new method to detect parasympathetic innervation sites without the need to use additional equipment or extend procedure time. A 51-year-old man was referred to the clinic for implantation of a permanent pacemaker because of symptomatic second-degree AVB and recurrent syncope. The functional nature of the AVB and a supra-Hisian location were verified with standard electrocardiography, Holter recordings, atropine sulfate test, and a standard electrophysiological study. Using conventional recordings, the electrograms were divided into 3 subgroups and sites demonstrating a fractionated pattern were targeted. All of the fractionated electrogram sites considered suitable for usual ganglion settlement were ablated. Biatrial ablation was initiated from the left atrial side. During left atrial ablation, the intrinsic basic cycle length of sinus node accelerated to 800 milliseconds despite AVB persistence. Subsequently, 1:1 atrioventricular conduction was achieved when ablation was applied around the coronary sinus ostium. The patient was completely asymptomatic, experiencing no episodes of dizziness or syncope, and was taking no medications at the end of 9 months of follow-up. In conclusion, electroanatomically guided vagal ganglia ablation may be a good alternative to pacemaker implantation in well-selected patients with functional AVB.

Idiopathic premature ventricular contractions originating from left ventricular summit successfully ablated from the epicardial approach

Catheter ablation of ventricular arrhythmias originating from the left ventricular summit can be challenging, given the high risk of vascular injury and low success rates during radiofrequency ablation. In case of failed endocardial ablation attempt, ablation from adjacent structures such as the coronary cusps, coronary venous system, and the septal right ventricular outflow tract should be tried as effective alternative approaches, respectively. Epicardial approach is an effective alternative strategy in failed cases. We report on a 45-year-old man with VAs originated from the LVS who underwent an epicardial ablation.

Elevated levels of vitamin B12 in chronic stable heart failure: a marker for subclinical liver damage and impaired prognosis

Background Elevated vitamin B12 is a sign for liver damage, but its significance in chronic stable heart failure (HF) is less known. The present study investigated the clinical correlates and prognostic significance of vitamin B12 levels in stable systolic HF. Methods A total of 129 consecutive patients with HF and 50 control subjects were enrolled. Data regarding demographics, clinical signs, therapeutic and conventional echocardiographic measurements were recorded for all patients. Right-sided HF was defined as the presence of at least one of the typical symptoms (ankle swelling) or specific signs (jugular venous distention or abdominojugular reflux) of right HF. Cox proportional hazards regression analyses were performed to determine the independent prognostic determinants of mortality. Results Baseline B12 levels in HF patients (n=129) with and without right sided HF were significantly higher compared to healthy controls (n=50): Median 311 pg/mL and 235 pg/mL vs 198 pg/mL, respectively (P=0.005). Folic acid levels were similar between the study groups. Age, ejection fraction, left atrial size, estimated glomerular filtration rate, and direct and indirect bilirubin levels were significantly correlated to serum B12 level in univariate analysis. In multivariate analysis, independent correlates of B12 were direct bilirubin (R=0.51, P<0.001) and age (R=0.19, P=0.028). Patients with HF were followed-up for a median period of 32 months. Median B12 levels were significantly higher in patients who subsequently died (n=35) compared to survivors, but folic acid was not different between the two groups. ROC analysis showed that B12 values ≥270 pg/mL had 80% sensitivity and 58% specificity for predicting all-cause mortality (area under the curve=0.672, 95% CI=0.562−0.781; P=0.003). However, in Cox regression analysis, only left atrial diameter, level of direct bilirubin, and the presence of abdominojugular reflux were independent predictors of death. Conclusion Increased B12 in stable HF patients is associated with increased direct bilirubin due to right HF, indicating a cardiohepatic syndrome, but neither B12 nor folic acid are independently associated with mortality.

Is There Any Clinical Significance of the Acute Antral Lesion Size After Pulmonary Vein Isolation Using Different Balloon Technologies or Ablation Energy

is clinical superiority of a wide antral ablation effect of cryoballoon to RF ablation, we compared combined cryo-PVI and RF substrate modification with RF PVI and substrate modification in patients with long-standing persistent AF.5 No difference was seen in freedom of AF between the combined and whole RF groups (80% vs. 87.0%, P=0.344). Similar to the present report, larger ablation did not bring any additional clinical benefit. In conclusion, we speculate that cryoballoon causes a larger ablation area than RF ablation and laser balloon. These ablation effects are not only detected during sinus rhythm by voltage mapping, but also during AF by using the CFAE mean tool. Larger and prospective randomized trials with adequate statistical power will be able to answer whether a larger ablation leads to more freedom from AF and whether one ablation technology is superior to another.

Rare Case of Both Left Atrial and Ventricular Compression by Dissecting Aortic Aneurysm

Address for Correspondence: Dr. Onur Argan, Clinic of Cardiology, Kocaeli State Hospital, Kocaeli, Turkey e-mail: onur_argan@yahoo.com ORCID ID: orcid.org/0000-0001-7745-7736 Received: 29 March 2018 Accepted: 22 June 2018 • DOI: 10.4274/balkanmedj.2018.0567 Available at www.balkanmedicaljournal.org Cite this article as: Argan O, Ural D, Bozyel S. Rare Case of Both Left Atrial and Ventricular Compression by Dissecting Aortic Aneurysm. Balkan Med J 2018;35:406-7 ©Copyright 2018 by Trakya University Faculty of Medicine / The Balkan Medical Journal published by Galenos Publishing House. A 75-year-old patient with a history of arterial hypertension was admitted to the emergency service in cardiac arrest. His medical history revealed a thoracic endovascular aortic repair operation that was performed about 2 years ago. According to the information received from relatives, he developed sudden cardiac arrest following chest pain and shortness of breath. The patient’s blood pressure was 70/50 mmHg and the heart rate was 125 pulses/min. ST depression in the D1-AVL-V5-V6 and left ventricular hypertrophy were detected in the electrocardiogram. Parasternal long axis and four-chamber images in the echocardiography showed aortic dissection and compression of the left atrium and the left ventricle caused due to an aneurysm when the patient was evaluated for the first time (Figure 1a). When we repeated the echocardiography before the exitus, the compression of the heart chambers progressed (Figure 1b). Thoracic computed tomography images supported the findings of echocardiography. Compression of the left atrium and ventricle due to 10×11.5 cm descending aorta, including the graft material and the thrombosed pseudolumen, was observed in the computed tomography images (Figure 2a, 2b). The patient with the deep hypotension died shortly after the admission. Written informed consent was obtained from the patients parents. Large dissecting aortic aneurysm compressing the heart chambers sufficient to cause hemodynamic deterioration is a rare condition. Studies have reported about the compression related to the right atrium (1), the left atrium (2), and the right ventricle (3) caused by the aortic aneurysm. To our knowledge, this is the first case of both left atrial and left ventricular compression caused due to the dissecting aortic aneurysm. In a patient with aortic dissection, ischemia, aortic valve insufficiency, and tamponade may cause hypotension. The echocardiographic findings of the present case revealed an additional mechanism that may lead to hemodynamic instability. The descending aorta is very near to the left atrium. Compression of the left atrium and ventricle due to the enlarged aorta results in decreased cardiac output and hypotension. The pleural effusion observed in this case suggests the presence of congestive 1Clinic of Cardiology, Kocaeli State Hospital, Kocaeli, Turkey 2Department of Cardiology, Kocaeli University School of Medicine, Kocaeli, Turkey 3Clinic of Cardiology, Kocaeli University of Health Sciences, Derince Training Research Hospital, Kocaeli, Turkey Onur Argan1, Dilek Ural2, Serdar Bozyel3 Rare Case of Both Left Atrial and Ventricular Compression by Dissecting Aortic Aneurysm Balkan Med J 2018;35:406-7