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Objective: Catheter ablation following electrophysiologic study (EPS) is the mainstay of diagnosis and treatment for patients with atrioventricular reentrant tachycardia (AVRT), demonstrating excellent long-term outcome and a low rate of complications. In this study, our aim was to assess our experience in patients with accessory pathway (AP) and to compare our data with the literature. Methods: We included 1,437 patients who were diagnosed and treated for AP in our hospital between 1998 and 2020. The demographic data of all the patients, AP location, and periprocedural results were recorded. Results: Of the 1,437 patients, 1,299 (90.4%) were men; and the mean age of the population was 26.67 years. The location of 1,418 APs were along the left free wall (647 [45.6%] patients), in the posteroseptal region (366 [25.3%] patients), in the anteroseptal region (290 [20.4%] patients), and along the right free wall (115 [8.1%] patients). The ratio of the second AP existence was 3.0% and AVNRT co-existence was 2.0%. A total of 55 (3.8%) patients had recurrent sessions for relapse. Our center’s total success rate was 95.5%, and total complication rate was 0.26%. Conclusion: According to our retrospective analysis, EPS is a highly functional tool in the diagnosis and management of arrhythmias such as AVRT for high-risk patient groups like military personnel with the aim of risk stratifcation and medical management. Amaç: Elektrofzyolojik çalışmayı (EPS) takiben kateter ablasyonu, Atriyoventriküler Reentrant Taşikardisi (AVRT) olan hastalar için tanı ve tedavinin temel dayanağıdır ve mükemmel uzun vadeli sonuç ve düşük bir komplikasyon oranı gösterir. Çalışmamızın amacı, aksesuar yolaklı hastalardaki deneyimlerimizi değerlendirmek ve verilerimizi literatür ile karşılaştırmaktı. Yöntemler: Hastanemizde 1998-2020 yılları arasında aksesuar yol (AP) tanısı alan ve tedavisi olan 1437 hastayı dahil ettik. Tüm hastaların demografk verileri, aksesuar yolun konumu ve işlemle ilgili sonuçlar kaydedildi. Bulgular: 1437 hastanın 1299’u (%90.4) erkekti ve çalışma popülasyonun ortalama yaşı 26.67 idi. 1418 AP’nin lokasyonu; sol serbest duvar boyunca (647 hasta, %45.6), posteroseptal bölgede (366 hasta, %25.3), anteroseptal bölgede (290 hasta, %20.4) ve sağ serbest duvar boyunca (115 hasta, %8.1) idi. İkinci AP var olma oranı %3.0 ve AVNRT birlikte var olma oranı %2.0 idi. 55 (%3.8) hastada relaps sebebiyle tekrarlayan işlemler yapıldı. Merkezimizin toplam başarı oranı %95.5 ve toplam komplikasyon oranı %0.26 idi. Sonuç: Retrospektif analizimizin ışığında elektrofzyolojik çalışma, risk sınıfandırması ve tıbbi karar amacıyla askeri personel gibi yüksek riskli hasta grupları için AVRT gibi aritmilerin tanı ve yönetiminde oldukça işlevsel bir araçtır.

Permanent junctional reciprocating tachycardia (PJRT) is an infrequent form of atrioventricular re-entrant tachycardia. We report the clinical and electrophysiological properties of PJRT and outcomes of radiofrequency catheter ablation (RCA) in a large group of patients. We included 62 patients with the diagnosis of PJRT. Radiofrequency catheter ablation was performed in all. Location of accessory pathway was right posteroseptal in 37 (59,7%) cases, right midseptal in 3 (4,8%), left posterior in 7 (11,3%), left lateral in 5 (8,1%), left posterolateral in 3 (4,8%), left anterolateral in 2 (3,2%), left posteroseptal in 2 (3,2%), middle cardiac vein in 2 (3,2%), and left coronary cusp in 1 (1,6%). Single procedure success rate was 90.3%. None of patients had recurrence during follow-up after repeat ablations. Overall long-term success rate was 98.4%. Left ventricular systolic function recovered in all patients with tachycardia-induced cardiomyopathy (TIC). Retrograde decremental accessory pathways are mainly located in posteroseptal region. Radiofrequency catheter ablation is a safe and effective approach in patients with PJRT.

Background: Left ventricular aneurysm (LVA) is an important complication of acute myocardial infarction. In this study, we investigated the role of N- Terminal pro B type natriuretic peptide level to predict the LVA development after acute ST-segment elevation myocardial infarction (STEMI). Methods: We prospectively enrolled 1519 consecutive patients with STEMI. Patients were divided into two groups according to LVA development within the six months after index myocardial infarction. Patients with or without LVAs were examined to determine if a significant relationship existed between the baseline N- Terminal pro B type natriuretic peptide values and clinical characteristics. A p-value < 0.05 was considered statistically significant. Results: LVA was detected in 157 patients (10.3%). The baseline N- Terminal pro- B type natriuretic peptide level was significantly higher in patients who developed LVA after acute MI (523.5 ± 231.1 pg/mL vs. 192.3 ± 176.6 pg/mL, respectively, p < 0.001). Independent predictors of LVA formation after acute myocardial infarction was age > 65 y, smoking, Killip class > 2, previous coronary artery bypass graft, post-myocardial infarction heart failure, left ventricular ejection fraction < 50%, failure of reperfusion, no-reflow phenomenon, peak troponin I and CK-MB and NT-pro BNP > 400 pg/mL at admission. Conclusions: Our findings indicate that plasma N- Terminal pro B type natriuretic peptide level at admission among other variables provides valuable predictive information regarding the development of LVA after acute STEMI. Resumo Fundamento: O aneurisma do ventrículo esquerdo (AVE) é uma importante complicação do infarto agudo do miocárdio (IAM). Objetivo: Investigar o papel da porção N-terminal do pró-hormônio do peptídeo natriurético do tipo B (NT-proBNP) para predizer o desenvolvimento de AVE após infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCST). Métodos: Incluímos prospectivamente 1519 pacientes consecutivos com IAMCST. Os pacientes foram divididos em dois grupos de acordo com o desenvolvimento de AVE nos seis meses após o infarto do miocárdio. Os pacientes com ou sem AVE foram examinados para determinar se existia uma relação significativa entre os valores basais do NT-proBNP e as características clínicas. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados: O AVE foi detectado em 157 pacientes (10,3%). O nível basal do NT-proBNP foi significativamente maior em pacientes que desenvolveram AVE após IAM (523,5 ± 231,1 pg/mL vs. 192,3 ± 176,6 pg/mL, respectivamente, p < 0,001). Os preditores independentes da formação de AVE após IAM foram idade > 65 anos, tabagismo, classe Killip > 2, cirurgia de revascularização miocárdica anterior, insuficiência cardíaca pós-infarto do miocárdio, fração de ejeção do ventrículo esquerdo < 50%, falha de reperfusão, fenômeno de no-reflow, pico de troponina I e CK-MB e NT-proBNP > 400 pg/mL na internação. Conclusões: Nossos achados indicam que o nível plasmático do fragmento N-terminal do peptídeo natriurético tipo B na admissão, entre outras variáveis, fornece informações preditivas valiosas sobre o desenvolvimento de AVE após o IAMCST agudo.

Background . Platelet to lymphocyte ratio (PLR) has been demonstrated as a risk and prognostic marker in many of cardiovascular diseases. A relationship between PLR and severity of carotid stenosis has been shown. The aim of our study was to investigate the relationship between PLR and all cause mortality in patients with carotid arterial disease. Methods . This retrospective study included 146 patients who had been performed selective carotid angiography. Carotid stenosis were graded by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Platelet to lymphocyte ratio was calculated as the ratio of platelets to lymphocytes. The end point of the study was all-cause mortality. Results . During median follow-up of 16 months (0-65 months) 15 (10.3%) patients suffered all-cause mortality. 50 patients (34.2%) underwent carotid endarterectomy and 69 patients (47.3%) had non-carotid cardiac surgery. 38 patients (26.02%) had cerebrovascular events (stroke/transient ischemic attack) at admission. NASCET grades were not different between survivors and non-survivors. Non-survivors had significantly lower hemoglobin (Hb) levels (12.7 ± 1.6 g/dL vs. 13.7 ± 1.7 g/dL, p = 0.031) and they were older than survivors (74.2 ± 8.4 years vs. 68.6 ± 8.5 years, p = 0.029). Non-survivors had significantly higher PLR values compared with survivors (190.3 ± 85.6 and 126.8 ± 53.8, p = 0.017). In multivariate analysis, only PLR predicted all-cause mortality in patients with carotid artery stenosis. Conclusion . In our study, higher PLR was associated with increased all-cause mortality.

Objective Fibrinogen-to-albumin ratio (FAR) is an inexpensive and easily measurable novel inflammatory index that has been found to be associated with atherosclerosis. In this study, we aimed to investigate the association between the FAR and coronary artery disease (CAD) severity in patients with stable CAD. Methods In total, 356 consecutive patients with CAD were classified into three groups, those with a low Synergy between percutaneous coronary intervention and the Taxus and Cardiac Surgery Study (SYNTAX) score (?22), those with an intermediate SYNTAX score (23? SYNTAX score ?32) and those with a high SYNTAX score (>32). Results We determined that there were significant differences in the mean age (P < 0.001), male gender (P = 0.008), serum fibrinogen (P = 0.03), low-density lipoprotein cholesterol (P < 0.001) and FAR (P < 0.001) among the SYNTAX score groups. A strong positive correlation was detected between FAR and SYNTAX score (r = 0.899; P < 0.001), and the cutoff level of FAR for high SYNTAX score was 82 (sensitivity of 82%, specificity of 88.3% and an area under the curve of 0.826). Conclusion The novel inflammatory index, FAR, is significantly associated with the severity of CAD in patients with stable CAD.

Lower-extremity peripheral artery disease (LEAD) is associated with increased rates of mortality and morbidity. The aim of this study was to evaluate the associations among inflammatory and thrombotic markers and lower-extremity peripheral disease. A total of 280 patients were enrolled in this study. Of these patients, 152 patients had LEAD on peripheral angiography that was performed because of suspected lower-extremity peripheral disease based on history, physical examination, and non-invasive tests. The control group consisted of 128 patients without LEAD on peripheral angiography. Patients with LEAD were classified according to trans-atlantic inter-society consensus (TASC) II classification. Subsequently, patients in TASC A to B were defined as having mild to moderate peripheral artery disease, and those in TASC C to D were defined as having advanced peripheral artery disease. Thrombotic and inflammatory markers, such as the neutrophil-to-lymphocyte ratio (NLR), the high-sensitivity C (hs-C) reactive protein level, the monocyte-to-high-density lipoprotein-cholesterol ratio, the fibrinogen to albumin ratio (FAR), and whole-blood viscosity at high shear rate (HSR) and low shear rate (LSR), were evaluated in this population. The NLR, the monocyte-to-high-density lipoprotein-cholesterol ratio, the FAR, and whole-blood viscosity, both at a LSR and a HSR, were significantly higher in patients with lower-extremity peripheral disease compared with patients without lower-extremity peripheral disease. We determined that lower-extremity peripheral disease severity was correlated with the NLR, monocyte-to-high-density lipoprotein-cholesterol ratio, FAR, whole-blood viscosity at LSR, and whole-blood viscosity at HSR (r = 0.719, P =.004; r = 0.25, P =.008; r = 0.691, P =.002; r = 0.546, P

Blood group types are associated with coronary artery disease. However, data are scarce about the impact of blood group types on coronary collateral circulation. In this study, we aimed to investigate the relationship between the blood group types and coronary collateral circulation. Two hundred and twelve patients who underwent coronary angiography in our department and had a stenosis of ≥ 90% in at least one major epicardial vessel were included in our study. Collateral degree was graded according to Rentrop-Cohen classification. After grading, patients were divided into poor coronary collateral circulation (Rentrop grade 0 and 1) and good coronary collateral circulation (Rentrop 2 and 3) groups. The ABO blood type of all participants was determined. The incidence rates of O blood group type were significantly higher in the good coronary collateral group compared to the poor collateral group (37.9% vs 17.1%, P < .001). The O type blood group was an independent predictor of good coronary collateral circulation (odds ratio = 1.83, 95% confidence interval = 1.56-6.18, P = .015). Coronary collateral circulation is associated with blood group types. The O blood group predicts good coronary collateral development among patients with coronary artery disease.

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.

Focal atrial tachycardia arising from the right atrial appendage usually responds well to radiofrequency ablation; however, successful ablation in this anatomic region can be challenging. Surgical excision of the right atrial appendage has sometimes been necessary to eliminate the tachycardia and prevent or reverse the resultant cardiomyopathy. We report the case of a 48-year-old man who had right atrial appendage tachycardia resistant to multiple attempts at ablation with use of conventional radiofrequency energy guided by means of a 3-dimensional mapping system. The condition led to cardiomyopathy in 3 months. The arrhythmia was successfully ablated with use of a 28-mm cryoballoon catheter that had originally been developed for catheter ablation of paroxysmal atrial fibrillation. To our knowledge, this is the first report of cryoballoon ablation without isolation of the right atrial appendage. It might also be an alternative to epicardial ablation or surgery when refractory atrial tachycardia originates from the right atrial appendage. © 2015 by the Texas Heart ® Institute, Houston

WOS: 000356266000034, PubMed: 24671663, …

Hyperthyroidism often causes tachyarrhythmia. Reversible atrioventricular block caused by hyperthyroidism is rare occurrence. Presently described is a case of atrioventricular block due to hyperthyroidism and recovery after antithyroid treatment.

Purpose: Vasovagal syncope is a common and challenging problem that may result in injury and causes susbstantial anxiety among patients and their relatives. However, treatment of vasovagal syncope with standard pharmacologic approaches is not satisfactory. The aim of this study is to investigate the effect of amitriptyline, a tricyclic antidepressant drug, by using its anticholinergic effects in preventing syncopal episodes in patients with vasovagal syncope. Methods: In this study, 74 patients (mean age 24 ± 1.9 years, 26 male) with a history of recurrent syncope and baseline positive head-up tilt table test (syncope or presyncope) were included. Oral amitriptyline treatment was given to all patients, with a starting dose of 10 mg once a day. Head-up tilt table test was performed in all patients 4 weeks after the treatment started. Patients were followed up clinically for 6 months. Results: After 4 weeks, during head-up tilt table test in 69 patients (93%), syncope or presyncope was not seen and test was assumed as negative. At the end of the 6th month, 67 patients (91%) were free of symptoms. Only two patients (0.3%) did not tolerate amitriptyline due to side effects. Conclusions: Oral amitriptyline can be used in the prevention of recurrent episodes of vasovagal syncope safely. However, randomized controlled studies are essential to assess the real effectiveness of this therapy.

Objective In this retrospective study, we investigated the association between air pollution and weather conditions with the incidence of acute myocardial infarction (AMI) in the city of Kutahya. Methods A total of 402 patients who were admitted with acute ST segment elevation MI and non-ST segment elevation MI were included in the study in 1 year. Daily maximum, minimum, and mean ambient temperature and mean barometric pressure data were obtained from the Kutahya Meteorology Department. Daily air pollution data were obtained from the Web site of National Air Quality Observation Network (http://www.havaizleme.gov.tr). Results Increase in ambient air temperature in the day of MI and 2 days before the day of MI according to their control days was correlated with increase in number of MI cases. When we grouped the patients according to ages as 30-54, 55-65, and > 65 years, we found that there was a relation between sulfur dioxide (SO 2 ) and the occurrence of AMI for the age group of 30-54 for the same day (D0) (P

Objective: Since visual estimation of the extent of vessel stenosis may vary between operators, we aimed in this study to investigate both inter-observer variability and consistency between the estimation of an operator and quantitative coronary analysis (QCA) measurements. Methods: A total of 147 elective percutaneous coronary intervention patients with 155 lesions between them were consecutively enrolled in the study. These patients were evaluated for visual estimation of lesion severity by three operators. The lesions were also evaluated with QCA by an operator who was blinded to the visual assessments. Reference diameter, minimal lumen diameter, percentage diameter of stenosis, percentage area of stenosis and diameter of lesion length from the proximal lesion-free segment to the distal lesion-free segment were calculated using a computerised QCA software program. Results: There was a moderate degree of concordance in the categories 70–89% (kappa: 0.406) and 90–99% (?: 0.5813), whereas in the categories < 50% and 50–69% there was a low degree of concordance between the visual operators (?: 0.323 and ?: 0.261, respectively). There was a low to moderate grade of concordance between visual estimation and percentage area of stenosis by QCA (?: 0.30) but there was no concordance between visual estimation and percentage diameter of stenosis by QCA (?: –0.061). Also, there was a statistically significant difference between QCA parameters of percentage diameter of stenosis and percentage area of stenosis (58.4 ± 14.5 vs 80.6 ± 11.2 %, p < 0.001). Conclusion: Visual estimation may overestimate a coronary lesion and may lead to unnecessary coronary intervention. There was low concordance in the categories < 50% and 50–69% between the visual operators. Percentage area of stenosis by QCA had a low to moderate grade of concordance with visual estimation. Percentage area of stenosis by QCA more closely reflected the visual estimation of lesion severity than percentage diameter of stenosis. © 2018 Clinics Cardive Publishing (PTY)Ltd. All rights reserved.

Obesity-associated alterations in coagulation and fibrinolytic factors in favor of thrombosis are well known. Observations suggest that leptin, a recently discovered obesity gene product, in addition to being a satiety factor, induces platelet aggregation, accelerates formation of firm thrombi, and is associated with abnormal fibrinolysis. The authors studied the influence of plasma leptin concentrations on admission within 6 hours of acute myocardial infarction (MI) on the outcome of thrombolytic therapy (TT). Forty-one patients with acute MI who underwent TT were enrolled into the study. Levels of plasma leptin were determined with radioimmunoassay method in samples obtained just before initiation of TT. Patients were initially classified according to the admission plasma leptin concentrations, and it was observed that failure of reperfusion therapy with streptokinase was significantly higher in patients with admission plasma leptin concentrations ≥14 ng/mL (group 2) as compared to patients with admission plasma leptin concentrations

Permanent form of junctional reciprocating tachycardia (PJRT) is an uncommon form of atrioventricular re-entrant tachycardia due to an accessory pathway characterized by slow and decremental retrograde conduction. The majority of accessory pathways in PJRT are localized in the posteroseptal zone. Despite the high success rate, failure may occur during endocardial radiofrequency catheter ablation due to epicardial insertion of the accessory pathway. We report a case of PJRT in a 25-year-old man in whom the accessory pathway was located epicardially in the posteroinferior region and ablated from within the middle cardiac vein by radiofrequency catheter ablation.

Background: Reduced heart rate recovery (HRR) in coronary artery disease (CAD) is predictive of increased cardiovascular mortality and is related to reduced parasympathetic tonus. Objective: To investigate HRR and heart rate variability (HRV) measured at steady state condition and the relationship between these two parameters in CAD. Materials and Methods: In our study, we enrolled 33 (28 males, mean age 52.4 ± 9.6 years) patients with CAD who did not have heart failure, atrial fibrillation, pacemaker, and any disease state that could affect the autonomic functions and 38 age-matched healthy subjects (21 males, mean age 48.3 ± 7.8 years). All the patients underwent submaximal treadmill exercise testing (Bruce protocol). HRR was calculated by subtracting the heart rate values at the 1st, 2nd, and 3rd minutes of the recovery phase from the peak heart rate (HRR1, HRR 2, HRR3). Before exercise testing, short-term steady state HRV analyses of all subjects were obtained with the time- and frequency-domain methods and were correlated to HRR. For frequency-domain analysis, low-frequency HRV (LF, 0.004-0.15 Hz), high-frequency HRV (HF, 0.15-0.5 Hz), and LF/HF ratio were measured for 5 minutes in the morning. For time-domain analysis, standard deviation of the normal-to-normal NN intervals (SDNN), square root of the mean squared differences of successive N-N intervals (RMSSD), and proportion derived by dividing the number of interval differences of successive N-N intervals greater than 50 ms by the total number of N-N intervals (pNN50) were obtained. Only HRR3 was used for the correlation analysis. Results: In CAD groups, the HF, an indicator of parasympathetic activation, was significantly reduced, whereas the LF and LF/HF values, which are indicators of sympathetic activity, were increased (P = 0.0001 for each parameter). The time-domain parameters SDNN, RMSSD, and pNN50 were significantly reduced in the patient group (P = 0.0001, P = 0.009, and P = 0.0001, respectively). Similar to the HRV parameters, the HRR1, HRR2, and HRR3 values were significantly reduced in the patient group (P = 0.0001 for each parameter). We observed a significant negative correlation between HRR3 and LF (r =-0.67, P = 0.0001) and between HRR3 and LF/HF (r =-0.62, P < 0.0001), while there was a significant positive correlation between HRR 3 and HF, SDNN, RMSSD, and pNN50 (r = 0.69, P = 0.0001; r = 0.41, P = 0.0001; r = 0.31, P = 0.008; and r = 0.44, P = 0.0001). Conclusions: HRR and HRV are significantly reduced in CAD. The reduction in HRR is parallel to the changes in HRV parameters. HRR, which can be measured easily in the recovery phase of exercise testing, can be used to detect the depression of parasympathetic tonus and to evaluate the basal autonomic balance in this patient group. ©2006, Copyright the Authors.

QRS voltage and cycle length alternation can be seen during supraventricular re-entrant tachycardias, especially in atrioventricular (AV) re-entrant tachycardia. We present a case of a 20-year-old man, in which AV nodal re-entrant tachycardia (AVNRT) shows alternation of QRS voltage and cycle length, as well as right bundle branch block aberration due to a re-entrant circuit using two distinct, beat-to-beat alternating slow AV nodal pathways antegradely and a single fast pathway retrogradely. Although more than one antegrade slow pathway exists, creation of a single lesion at the right posterior atrial septum using the conventional right-sided approach successfully eliminated AVNRT.

The incidence of atrial fibrillation is higher in patients with VVI pacing mode than DDD pacing mode, but the likely mechanism is not clearly understood. We aimed to evaluate whether short-term VVI pacing increases inhomogeneous atrial conduction by using P-wave dispersion. Forty-seven patients (32 men, 15 women, mean age 54 +/- 13 years) with DDD pacemakers were enrolled in this study. Twelve-lead surface ECGs were obtained in all patients during VDD pacing after an observation period of 1 week. The mode was then changed to VVI and 12 lead surface ECGs were obtained after another 1-week observation period. P-wave durations were calculated in all 12 leads in both VDD and VVI pacing modes. The difference between the maximum and the minimum P-wave duration was defined as the P-wave dispersion (PWD = P(max) - P(min)). P-wave maximum duration (P(max)) calculated in VVI pacing mode was significantly longer than in VDD pacing mode (128 +/- 19 vs 113 +/- 16 ms, P0.001). There was no significant difference in the P-wave minimum durations (80 +/- 13 ms vs 79 +/- 12 ms, P = 0.7) between VVI pacing and VDD pacing. The P-wave dispersion value was higher in the VVI pacing mode than in the VDD pacing mode (48 +/- 8 ms vs 34 +/- 7 ms, P0.001). Short-term VVI pacing induces prolongation of P(max) and results in increased P-wave dispersion, which might be responsible for the development of atrial fibrillation more frequently in these patients than in those with the VDD pacing mode.

Clinical and electrophysiological characteristics of patients with atrioventricular nodal reentrant tachycardia (AVNRT) and paroxysmal atrial fibrillation (AF) have not been studied in a large patient cohort. We aimed to define the clinical features and cardiac electrophysiological characteristics of these patients, and to examine the incidence and identify predictors of AF recurrences after elimination of AVNRT.Thirty-six patients with AVNRT and documented paroxysmal AF (Group 1) and 497 patients with AVNRT alone undergoing ablation in the same period (Group 2) were studied. There were no significant differences between groups regarding clinical features, except age, which was higher in Group 1 (p0.001). Presence of atrial vulnerability (induction of AF lasting30 seconds) and multiple AH jumps (or=50 ms) before ablation were significantly more prevalent in Group 1 (p0.001, p=0.010 respectively). During follow-up of 34 +/- 11 months, AF recurred in 10 patients (28%) in Group 1, while 2 patients in Group 2 (0.4%) developed paroxysmal AF (p0.001). Univariate predictors of AF were: left atrial diameter40 mm (p=0.001), presence of mitral or aortic calcification (p=0.003), atrial vulnerability after ablation (p=0.015) and valvular disease (p=0.042). However, independent predictors of AF recurrences were left atrial diameter40 mm (p=0.002) and the presence of atrial vulnerability after ablation (p=0.034).In patients with both AVNRT and paroxysmal AF, the recurrence rate of AF after elimination of AVNRT is 28%. Left atrial diameter greater than 40 mm and atrial vulnerability after elimination of AVNRT are independent predictors of AF recurrences in the long term.

Background Statins exert a variety of favourable effects on the vascular system not directly related to their lipid lowering function known as pleiotropic effects. There are not enough data regarding the effects of prior statin use on coronary blood flow after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Accordingly, in the present study, we aimed to investigate the effects of prior statin use on coronary blood flow after primary PCI in patients with AMI using the Thrombolysis In Myocardial Infarction (TIMI) frame count method. Methods The study population consisted of 200 patients (161 men; mean age = 62 ′ 7 years) referred to cardiology clinics with AMI who subsequently underwent successful primary PCI. The study population was divided into two groups according to statin use before primary PCI. Group 1 consisted of 98 patients (75 men; mean age = 63 ′ 7 years) not taking statin and group 2 consisted of 102 patients (86 men; mean age = 61 ′ 7 years) taking daily dose of at least 40 mg atorvastatin for at least 6 months. Coronary blood flow was determined by TIMI frame count method using the angiographic images obtained just after PCI and stenting. Results Only mean TIMI frame count was detected to be significantly lower in patients taking at least 40 mg atorvastatin for at least 6 months compared with that of the patients taking no statin (P

Onset of atrial fibrillation in hypertensive patients is usually associated with a high occurrence of cardiovascular complications. Therefore, it is important to assess non-invasively the risk of developing paroxysmal atrial fibrillation (PAF) in hypertensive patients during sinus rhythm. This study was undertaken to determine if hypertensive patients with history of PAF could be identified while in sinus rhythm by measurement of signal-averaged ECG P-wave duration.Signal-averaged electrocardiography (SAECG) P-wave recording was performed in 44 hypertensive patients (30 men and 14 women; mean age 60+/-11 years, group A) who had a history of paroxysmal AF and in 50 hypertensive patients without history of AF (33 men and 17 women; mean age 57+/-12, group B). All patients were also evaluated by using echocardiography to measure left ventricular ejection fraction (LVEF) and left atrial diameter (LAD).SAECG P-wave duration was found to be significantly higher in group A than in group B (146+/-14 ms vs. 128+/-11 ms, p0.001). Left atrial diameter was not significantly different (40.1+/-3.4 mm vs. 39.3+/-3.0 mm, p0.05), whereas LVEF was significantly lower in group A than group B (63+/-5% vs. 67+/-4%, p=0.03). There was a correlation between SAECG P-wave duration and age (r=0.32, p0.05). In univariate analysis, SAECG P-wave duration and LVEF were significant predictors of PAF, but only SAECG P-wave duration remained a significant independent predictor of PAF in multivariate analysis.The results of this study indicate that hypertensive patients with history of PAF can be detected while in sinus rhythm by signal-averaged ECG P-wave duration.

The onset of recurrent or sustained atrial fibrillation (AF) is common during electrophysiological (EP) studies of accessory pathways (AP). We report our experience in patients with Wolff-Parkinson-White (WPW) syndrome in whom AF with rapid antegrade conduction over the AP occurred during an EP study and mapping and ablation were done during sustained AF, as compared to patients ablated during sinus rhythm. The study group consisted of 18 patients (group 1) with WPW syndrome who underwent catheter ablation during pre-excited AF. Two hundred and sixty-three patients, comparable for clinical characteristics, whose manifest APs were ablated under sinus rhythm formed the control group (group 2). Bipolar electrogram criteria recorded from the ablation catheter showing early ventricular activation relative to the delta wave on the surface ECG and AP potentials preceding the onset of ventricular activation were used as targets for ablation. Clinically documented atrial fibrillation was significantly more frequent and antegrade ERP of AP was significantly shorter in group 1 than in group 2 (39% vs 14%, P=0.014 and 268+/-37 vs 283+/-16, P0.001, respectively). Procedure-related variables, acute success rates (17/18 [94%] in group 1, 251/263 [95%] in group 2; P0.05) and late recurrence rates (0/18 [0%] in group 1 vs 5/263 [2%] in group 2; P0.05) during a mean follow-up of 25+/-9 months (range 8-52 months) did not differ significantly. Our results show that both right- and left-sided accessory pathways can be mapped and ablated safely during pre-excited AF without delay, and that acute success and recurrence rates and long-term follow-up results are similar to those of pathways ablated during sinus rhythm.

Background: Several studies demonstrated that P wave dispersion (PWD) increased after coronary occlusion. The effect of primary percutaneous coronary intervention (PCI) on PWD needs to be elucidated. Methods: The study consisted of 125 patients with acute myocardial infarction (110 men, mean age 59.8 ′ 7.8 years) undergoing primary PCI. The patients were divided into three groups according to thrombolysis in myocardial infarction myocardial perfusion grade (TMPC) after successful PCI. Groups 1 (n = 12), 2 (n = 9), and 3 (n = 104) included the patients with TMPC 0/1, 2, 3, respectively. Electrocardiograms were obtained before and approximately 66 ′ 18 minutes after PCI. Results: PWD and P m a x i m u m after PCI were significantly lower than the preintervention values (P < 0.001 for both). When PWD and P m a x i m u m values after PCI were compared among groups, PWD and P m a x i m u m in groups 1 and 2 were found to be higher than those of group 3 (P < 0.001 for PWD and P m a x i m u m ). Atrial fibrillation (AF) occurred in 14 patients. P m a x i m u m and PWD in patients with AF were higher compared to those of the patients without AF (P < 0.001 for both P wave parameters). Also more frequent AF attacks were observed in group 1 compared to group 3 (P < 0.001). Conclusions: PWD and P m a x i m u m after primary PCI were lower compared to the preintervention values. Prolonged PWD in patients with poor myocardial perfusion can contribute to increased mortality, and also it can can be combined with ST segment resolution to predict clinical reperfusion and might help in predicting AF.

Background: Prolongation of P-wave times and increase of P-wave dispersion (PWD) were shown to be independent predictors of atrial fibrillation (AF). Angiotensin II receptor blockers (AARBs) and angiotensin-converting enzyme inhibitors (ACEIs) have beneficial effects on atrial conduction times. However, there are not enough data about the comparative effects of those drugs onPWD. Hypothesis: We aimed to compare the effects of telmisartan and ramipril on PWD after 6-month treatment in hypertensive patients. Methods: In all, 100 newly diagnosed hypertensive patients were enrolled in the study and were randomly assigned to two groups. Group 1 and Group 2 each consisted of 50 patients, taking daily doses of 80 mg telmisartan and 10 mg ramipril, respectively. Twelve-lead surface electrocardiograms (ECG) were recorded from all patients before and after 6-month drug therapy. The P-wave duration (Pdur) measurements were calculated from the 12-lead surface ECG. Results: When pretreatment PWD and P maximum values were compared with post-treatment values, a statistically significant decrease was found in both groups after 6 months (Group 1 and 2; p < 0.001 for PWD and Pmaximum). P-wave dispersion and Pmaximum values after treatment in Group 1 were statistically significantly lower than those in Group 2 after the 6-month treatment period (p = 0.01 for PWD; p = 0.008 for Pmaximum). Conclusions: Telmisartan has a much greater lowering effect on PWD and Pmaximum values than ramipril. This finding may be important in the prevention of AF in hypertensive patients.

Background: Atrial fibrillation is a frequent arrhythmia in patients undergoing hemodialysis. The consequences of hemodialysis on P wave durations and P wave dispersion have not been fully understood. The objective of this study was to study the effect of dialysis on P wave maximum (P m a x ), P wave minimum (P m i n ), and P wave dispersion (P d ). Methods: We studied P m a x , P m i n , and P d in 32 patients (17 men and 15 women, mean age 54 ′ 18 years) with chronic renal failure undergoing hemodialysis. The difference between maximum and minimum P wave duration was calculated and defined as P wave dispersion (P d = P m a x - P m i n ). Results: There was a significant increase in P m a x at the end of dialysis compared to the beginning (98 ′ 13 ms vs. 125 ′ 12 ms, P < 0.001). P m i n did not show any significant change (71 ′ 11 ms vs. 73 ′ 10 ms, P = 0.42). P d was significantly increased at the end of dialysis (27 ′ 9 ms vs. 52 ′ 11 ms, P < 0.001). There was a negative correlation between serum potassium, magnesium, phosphate, blood urea nitrogen, and creatinin at the end of dialysis and P m a x and P d respectively (P < 0.05). A weak positive correlation was found between serum calcium, bicarbonate at the end of dialysis and P m a x and P d (P < 0.05). Conclusion: Hemodialysis ends with significant increase in P wave maximum duration and P wave dispersion, which might be responsible for the increased occurrence of atrial fibrillation in these groups of patients.

Recent evidence has demonstrated that inflammation plays a major role in the initiation and progression of atheroma plaques. C-reactive protein (CRP) is shown to have prognostic significance in acute coronary syndromes. We investigated the influence of CRP levels before thrombolytic therapy on infarct-related artery (IRA) patency and the degree of residual stenosis.45 consecutive patients with a first attack of acute myocardial infarction (MI) who underwent streptokinase therapy and subsequently coronary angiography were enrolled into the study. Patients were divided into 2 groups according to the level of CRP on admission.Serum CRP levels wereor =0.5 mg/dL in 26 patients (Group-I) and0.5 mg/dL in 19 patients (Group-II). The patency of IRA (TIMI-2 and 3) evaluated at 90th minute after the initiation of thrombolytic therapy was similar between the two groups (62% vs. 68%, p0.05). However, the presence of TIMI-3 flow was significantly lower and TIMI-2 flow was higher in Group-I as compared to Group-II (12% vs. 53%, p=0.003 and 50% vs. 16%, p=0.018 respectively). Additionally, among patients with patent IRA, the degree of residual stenosis was significantly higher in Group-I (80 +/- 14% vs. 68 +/- 15%, p=0.032).High serum CRP levels on admission in patients within 6 hours after the start of acute ST-segment elevation MI are associated with lower TIMI flow grades and higher residual stenosis of IRA after intravenous streptokinase. Our observations imply that patients with higher CRP levels on admission require closer follow-up during and after acute MI.

*Gulhane Military Medical Academy, Department of Cardiology; *Hacettepe University School of Medicine, Department of Cardiology,Ankara, TurkeySummaryBackground: Paroxysmal atrial fibrillation (PAF) in hyper-trophic cardiomyopathy (HCM) is associated with poor prog-nosis. Previous studies have shown good correlation betweenP-wave dispersion (Pd) and occurrence of PAF. However, Pdin patients with HCM for predicting PAF has not been studied.Hypothesis:The aim of the study was to determine whetherPd could identify patients with HCM who are likely to sufferfrom PAF.Methods: Twenty-two patients with HCM with a history ofPAF (Group 1) and 26 patients with HCM without a history ofPAF (Group 2) were studied. Maximum (Pmax) and mini-mum (Pmin) P-wave durations, as well as P-wave dispersion(Pd = Pmax Pmin) were calculated from 12-lead surfaceelectrocardiograms (ECG).Results: P-wave dispersion was significantly different be-tween the groups (Group 1: 55 ±6 ms vs. Group 2: 37 ±8 ms;p

A 45-year-old Turkish male patient was admitted to our hospital for an acute myocardial infarction. He had suffered two previous acute myocardial infarctions 5 and 6 years earlier. Coronary angiography performed after the previous two acute myocardial infarctions had shown normal coronary arteries and coronary vasospasm had been suspected. The patient was treated with thrombolytic therapy (rt-PA) during the last coronary event. Five days after the current admission, the patient had postinfarct angina and underwent coronary angiography, showing only a nonobstructive lesion with irregular ulcerated edges in the left anterior descending artery after the first diagonal branch. Subsequent intravascular ultrasound confirmed the presence of an atherosclerotic lesion with plaque dissection. Stenting of this lesion was performed with successful relief of on-going chest pain. Intravascular ultrasound can provide important diagnostic information in patients presenting with acute coronary syndromes in the absence of severe angiographic stenosis. Identification of plaque dissection at mildly stenotic lesions provides pathophysiologic insights that may have therapeutic implications. However, the optimal treatment for such lesions is not known.

Background: There are few data related to the seasonal influences on the QT dispersion. Methods: We analyzed the effects of seasons on QT dispersion in a large group of healthy young males. We studied the seasonal variability of QT dispersion in 523 healthy male subjects aged 22 ± 4 years (ranging from 20 to 26). Four seasonal 12-lead resting electrocardiograms (ECGs) recorded at double amplitude were performed at 25 mm/s at intervals of 3 months. Subsequent ECGs were recorded within 1 hour of the reference winter recording. QT dispersion was defined as the difference between the longest and the shortest mean QT intervals. Results: There was a significant seasonal variation in QT dispersion (P = 0.001), with the largest QT dispersion in winter (71 ± 18 ms) and the smallest one in spring (43 ± 19). Conclusion: There exists a significant seasonal variation in QT dispersion of healthy subjects and such variability should be taken into consideration in the evaluation process of QT dispersion.

A 29-year-old and 17 weeks pregnant woman was admitted to the emergency room with acute pulmonary oedema. In her medical history, it was realised that she had been admitted to the emergency room wi...

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy characterized histologically by fibro-fatty replacement of heart muscle, and clinically by ventricular arrhythmias and right ventricular dysfunction. This report presents monozygotic twins with ARVC, suggesting a genetic abnormality as the most probable cause. © 2015 Turkish Society of Cardiology.

The increasing prevalence of critical lower limb ischemia is frequently associated with complex tibioperoneal obstructive disease and a high rate of amputation. In this article, we report our recent experience in order to highlight this valuable and underutilised technique, which proved successful in a complicated case where a conventional approach failed. © 2015 Turkish Society of Cardiology.

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We read with great interest the article written by Seong Woo Han and colleagues addressing the effect of atrial mass reduction on the clinical outcomes after radiofrequency catheter ablation for longstanding persistent atrial fibrillation (AF). They have compared linear ablation and defragmentation and found that only conduction block through linear lines and pulmonary vein isolation (PVI) positively influence the clinical outcomes for long-standing persistent atrial fibrillationwhile the amount of atrial mass reduction did not influence the clinical outcome [1]. Wewould like to discuss two distinct issues: complex-fractionated atrial electrogram (CFAE) and definition of atrial mass reduction. As known, after the breakthrough for AF ablation that came from Haissaguerre et al., when they described pulmonary veins as important sources of focal AF, significant advances were made in the field of catheter ablation of AF [2]. Catheter ablation approaches initially involved PVI, followed by wider areas of ablation including the antral regions, and this strategy was adopted by virtually everyone. However, ablation strategies still differ significantly among laboratories in the settings of long-standing persistent AF cases. These strategies extend from linear ablation of left atrium to ablation of regions of CFAE, ganglionic plexuses, areas outside the left atrium like the cavotricuspid isthmus, to isolation of superior vena cava and coronary sinus. One or more of these ablation approaches are accepted in different laboratories in the ablation procedures of patients with long-standing persistent AF. CFAE was first described by Nademanee et al. [3]. Subsequently, automatic software was developed to identify areas of CFAE and several different algorithms are being used to define CFAE areas in the clinical studies. Although these software programs were developed to aid in rapid and objective identification of areas of CFAE, they are handicapped with the inconsistency among different products [4]. Results of studies have also been inconsistent probably as a result of this discrepancy [4,5]. AlthoughNademanee described success rates of up to 90% in the mid-term follow-up, other studies have reported much less success rates only in the range of 30–35% [3–6]. Thus, this raises the issue if the results would have been different had Seong Woo Han and colleagues used another software. It seems that much more research is needed to improve our knowledge gap regarding CFAE. Another issue I would like to discuss is that it may be argued whether it is appropriate to calculate the proportion of atrial mass reduction during CFAE-guided ablation by dividing the total atrium size by the lesion size. The lack of reliable transmurality with catheter ablation may reduce the value of the definition of “atrial mass reduction” regarding the effectiveness in catheter ablation for AF. In the case of linear lesions, we can prove the efficacy of transmural lesions objectively through demonstration of bidirectional conduction block. However, in the case of CFAE-guided ablation, the end point of “local fractionated potentials were abolished” does not necessarily mean effective transmural lesion. Even if we completed linear ablation lines anatomically guided by 3-D mapping system, almost always there is a need to give additional energy application to create bidirectional conduction block at the ablation line. The only important issue here is effective detection and ablation of the critical substrate producing and sustaining AF, the sine qua non of the arrhythmia. These critical substrates are ganglionic plexuses for some authors, regions of CFAE, empirically created roof lines, linear lesions involving anterior or posterior walls of the atrium or the mitral isthmus for others. The important issue here is to find which definition correctly defines regions of critical substrates in situations involving complex pathophysiological features like persistent AF. Since the more aggressive and wider the ablation, the more fibrosis we leave behind, we need to find the best strategy to plan the best hit. Recent studies have found that AF ablation attempts are less likely to be successful in the presence of extensive atrial fibrosis [7]. There is the possibility that we will have iatrogenically created patients with excessive atrial fibrotic burdens unlikely to benefit from more effective novel AF ablation practices to be developed in the future, unless we develop gold standard strategies and guidance as soon as possible.

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Although amiodarone appears to have few pro-arrhythmic effects, torsade de pointes (TdP) has been observed after administration of a low dose and short term use of oral amiodarone, in the absence of predisposing factors. We describe the case of a 41-year-old woman admitted to hospital because of a cardiac arrest from TdP. On hospital admission, ECG showed sinus bradycardia 46 bpm with marked QT prolongation. © Polskie Towarzystwo Kardiologiczne.

We describe an asymptomatic 27-year-old man who presented a continuous murmur, and was found to have a tunnel between the aorta and the right atrium. Successful surgical treatment was performed. We emphasize the rarity of this condition, and discuss its major features.

Subclinical hyperthyroidism is a difficult entity to diagnose because of silent clinical features and it may be easily underdiagnosed unless it is suspected and thyroid hormone levels are examined. Although atrioventricular (AV) conduction abnormalities such as complete heart block may occasionally be seen in hyperthyroidism, its association with subclinical hyperthyroidism has not been reported previously. We report on a 50-year-old female patient who did not have any systemic or cardiovascular disease or history of drug use that could affect AV conduction and presented with presyncope and complete heart block with narrow QRS complexes. Thyroid function tests showed subclinical hyperthyroidism and an electrophysiological study showed the supra-His level as the site of complete AV block. After initiation of antithyroid treatment (propylthiouracil), the patient's rhythm improved to second-degree AV block on the third day and returned to normal sinus rhythm on the fourth day.

Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common form of paroxysmal regular supraventricular tachycardia in adults. It is typically induced with an anterograde block over the fast pathway (FP) and conduction over the slow pathway (SP), with subsequent retrograde conduction over the FP. Rarely, a simultaneous conduction of a premature atrial complex occurs over the FP and SP to induce AVNRT and is called "one for two phenomenon". We present a 46-year-old woman with atrioventricular nodal rhythm with a rate of 95 beats per minute with distinct electrophysiological characteristics showing simultaneous conduction over the FP and SP during induction of tachycardia and an infra-His block after radiofrequency ablation of the SP.

It has been demonstrated that abnormalities of the sympathetic nervous system strongly contribute to the development and/or maintenance of multiple disease states such as hypertension, heart failure, diabetes mellitus, sleep apnea, kidney disease and arrhythmias [1]. When we look through the window of hypertension, the renal nerves have been identified as important contributors in both development and maintenance of hypertension [2]. We read with great enthusiasm the article written by Ott and colleagues evaluating the effect of renal denervation (RDN) on elevated urinary albumin-to-creatinine ratio (UACR) in patients with resistant hypertension [3]. They have subdivided the patients according to their UACR at baseline into micro(30–300 mg/g, n = 37) and macroalbuminuria (300–2200 mg/g, n = 22) and found a significant reduction in UACR in all patients (p b 0.001) and in both subgroups (p b 0.001). They have implicated that, following RDN, the magnitude of albuminuria as well as the prevalence of microand macroalbuminuria decreased in patients with treatment-resistant hypertension and concluded that, since albuminuria is an independent renal and cardiovascular risk factor, a reduction of renal and cardiovascular risk could be achieved by RDN in these patients. The effect of catheter-based RDN on resistant hypertension in humans was assessed clinically in 2009, by the first proof-of-principle multicenter study from 45 patients with treatment-resistant hypertension [4]. The initial cohort was subsequently expanded from 45 to 153 patients, and the follow-up durationwas increased to a minimum of 2 years (Symplicity HTN-1) [5]. Both studies reported promising results favoring RDN. As it was an unblinded prospective cohort study without a control group, it was soon followed by the Symplicity HTN-2 trial to further assess RDN in a randomized fashion [6]. The Symplicity HTN-2 included 106 patients with severe resistant hypertensionwhowere randomized to RDN and conventional medical therapy versus conventional medical therapy alone. RDN was found to bemore effective thanmedical therapy alone in reducing blood pressure (BP), causing a reduction of 32 mmHg in systolic and 12 mm Hg in diastolic BP in the RDN group and no significant change in the control group. However, no changes in renal function or UACRwere identified in either group. The studywasdesigned such that patients from the control group were allowed to crossover to RDN therapy after six months, provided that the BP remained uncontrolled with a systolic BP greater than 160mmHg. Interestingly, the crossover group consisting of 35 patients experienced a significant drop in BP similar to that observed in the initial RDN group at 6 months' follow-up [7]. Recently published long-term results of the Symplicity HTN-1 study also imply that the efficacy gradually increases in 3 years' follow-up [7]. There is also evidence that patients with milder forms of hypertension may benefit from RDN [8]. Furthermore, there is emerging evidence that RDN may have a role in the treatment of heart failure, obstructive sleep apnea, insulin resistance, atrial fibrillation, hypertension associatedwith end-stage renal disease and, as shown recently, even in patients with ventricular storm where sympathetic nervous system seems to have a crucial role [9–13]. Thus, given the fact that resistant hypertension and other diseases associated with elevated sympathetic tone have significant morbidity and mortality rates, RDN therapy might be expected to have a crucial role on public health. However, the results of the Symplicity-3 trial overturned this optimistic mood about the RDN [14]. In the Symplicity HTN-3 study, RDN had no significant effect on office or 24-hour ambulatory systolic BP, findings that contradict most published studies on RDN. A recent trial even suggested inferiority of RDN as compared to adjusted drug treatment [15]. There is now growing evidence of lack of BP response following RDN in up to 50% of cases in some reports [16,17]. Clinical use of RDN had significantly increased after the encouraging results of Symplicity HTN-1 trial [5]. Afterwards, clinical studies with encouraging results appeared in the literature [18–20]. Parallel to these developments, medical device companies fancied RDN as the next big innovation and as a blockbuster therapy for millions of patients with resistant hypertension. But, what exactly happened that suddenly reversed this optimistic mood? Actually, it seems like there is no significant change; only the puzzle pieces are beginning to fall into place. Possibly because of the methodological problems involved in the initial studies, exaggerated interpretations led to heightened expectations from this exciting new treatment modality. There are three crucial points which need to be discussed.

A patient was referred for evaluation of repeated episodes of syncope with loss of consciousness and convulsions. A dual-chamber pacemaker with rate-drop feature was implanted.

Coronary-subclavian steal through the left internal mammary graft is a rare cause of myocardial ischemia in patients who have had a coronary bypass surgery. We report a 70-year-old man who presented with sustained monomorphic ventricular tachycardia 5 years after the surgical creation of a left internal mammary to the left anterior descending artery. Cardiac catheterization illustrated that the left subclavian artery was occluded proximally and that the distal course was visualized by retrograde filling through the left internal mammary graft. Clinical ventricular tachycardia was reproducibly induced with a single ventricular extrastimulus, and antitachycardia pacing terminated the tachycardia. Restoration of blood flow by way of a Dacron graft placed between the descending aorta and the subclavian artery resulted in the total relief of symptoms. Ventricular tachycardia could not be induced during the control electrophysiologic study after surgical revascularization.