Uğur Canpolat

Association of serum total bilirubin level with severity of coronary atherosclerosis is linked to systemic inflammation.

OBJECTIVE Although cardiovascular protective action of bilirubin has been attributed to its antioxidant effect, there was scarce data regarding the anti-inflammatory properties. Herein, we aimed to assess the relationship between serum total bilirubin level and severity of coronary artery disease (CAD) in association with the direct inflammatory marker such as C-reactive protein (CRP), the other indirect markers included in inflammation process such as neutrophil to lymphocyte ratio (NLR) and red cell distribution width (RDW) in patients with stable CAD. METHODS Angiographic data of 1501 patients were analyzed in this retrospective cross-sectional study. Patients were categorized according to Gensini scores as control, mild CAD and severe CAD groups. The association of clinical and laboratory parameters with the severity of CAD were determined by multivariable linear regression analysis. RESULTS Total bilirubin level in the control group was significantly higher than those of the other groups. After multivariable linear regression analysis total bilirubin [β=-3.131 (-4.481, -1.782), p<0.001] was significantly associated with the severity of CAD. Futhermore, there was a moderate and significant inverse correlation between serum total bilirubin level and the severity of CAD (r=-0.173, p<0.001), CRP (r=-0.112, p<0.001), NLR (r=-0.070, p=0.026) and RDW (r=-0.074, p=0.027). CONCLUSION Serum total bilirubin level was independently and inversely associated with the severity of coronary atherosclerosis in patients with stable CAD. In addition, total bilirubin level was inversely correlated with CRP, NLR and RDW. These results suggest that besides its already known effect on the oxidative stress, higher serum total bilirubin level may exhibit an anti-inflammatory effect in the coronary atherosclerotic process.

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.

Association of Monocyte-to-HDL Cholesterol Ratio with Slow Coronary Flow is Linked to Systemic Inflammation.

Background: Previous studies proposed that both inflammation, oxidative stress, and impaired endothelial dysfunction have a significant role in occurrence of slow coronary flow (SCF). monocyte-to-high density lipoprotein cholesterol ratio (MHR) is a recently emerged indicator of inflammation and oxidative stress, which have been studied only in patients with chronic kidney disease. Hypothesis: We aimed to assess the relationship between MHR and SCF. Methods: Patients who had angiographically normal coronary arteries were enrolled in this retrospective study (n = 253 as SCF group and n = 176 as control group). Patients who had corrected thrombolysis in myocardial infarction frame counts (cTFCs) above the normal cutoffs were defined as with SCF. Results: The MHR and high-sensitivity C-reactive protein (hsCRP) were significantly higher in the SCF group. In correlation analysis, MHR has a significantly positive correlation with cTFC and serum hsCRP levels (P < .001). In multivariate logistic regression analysis, MHR was found as independently associated with the presence of SCF (odds ratio: 1.24, P < .001). Conclusion: Higher MHR which indicates an enhanced inflammation and oxidative stress was significantly and independently associated with the presence of SCF. Besides, MHR was positively correlated with serum hsCRP level as a conventional marker for systemic inflammation.

Association of Platelet to Lymphocyte Ratio With Inflammation and Severity of Coronary Atherosclerosis in Patients With Stable Coronary Artery Disease

The platelet to lymphocyte ratio (PLR) has recently emerged as a potential inflammatory biomarker. Hence, we assessed the relationship between PLR and the extent/severity of coronary artery disease (CAD) using the Gensini score in association with the inflammatory marker C-reactive protein (CRP) in patients with stable CAD. Angiographic data of 1646 patients were analyzed in this cross-sectional study. Patients were categorized according to Gensini scores as no CAD (control), mild, and severe CAD groups. The PLR in the control group was significantly lower than those of mild and severe CAD groups. In multivariate logistic regression analysis, PLR was found to be an independent predictor of the presence of severe CAD (odds ratio: 1.043 [1.036-1.049], P < .001). Furthermore, there was a significant correlation between PLR and the severity of CAD (r = .370, P < .001) and CRP levels (r = .312, P < .001). In conclusion, PLR was independently and positively associated with the severity of coronary atherosclerosis. These results suggest that PLR is an easily available and cheap inflammatory indicator that can be used in predicting the severity of CAD.

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.

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.

Diabetic Cardiomyopathy; Summary of 41 years

Patients with diabetes have an increased risk for development of cardiomyopathy, even in the absence of well known risk factors like coronary artery disease and hypertension. Diabetic cardiomyopathy was first recognized approximately four decades ago. To date, several pathophysiological mechanisms thought to be responsible for this new entity have also been recognized. In the presence of hyperglycemia, non-enzymatic glycosylation of several proteins, reactive oxygen species formation, and fibrosis lead to impairment of cardiac contractile functions. Impaired calcium handling, increased fatty acid oxidation, and increased neurohormonal activation also contribute to this process. Demonstration of left ventricular hypertrophy, early diastolic and late systolic dysfunction by sensitive techniques, help us to diagnose diabetic cardiomyopathy. Traditional treatment of heart failure is beneficial in diabetic cardiomyopathy, but specific strategies for prevention or treatment of cardiac dysfunction in diabetic patients has not been clarified yet. In this review we will discuss clinical and experimental studies focused on pathophysiology of diabetic cardiomyopathy, and summarize diagnostic and therapeutic approaches developed towards this entity.