- Email: [email protected]
OP-091 Cardioneuroablation in the Treatment of Reflex Syncope: The Results of One Year Follow up: Single Center Experience
MARCH 10e13, 2016
O R A L A B S T R A C T S
Objective: The incidence of the usage of synthetic cannabinoids (SC) have increased all over the world as well as in our country. In our study, we aimed to evaluate if bonsai cause ventricular repolarization abnormalities or not with using initial and 12th hour electrocardiogram in patients with acute toxication of ’Bonsai’. Therefore we examined the change of QTc and cTp-e parameters to show the ventricular repolarization effects of the usage of bonsai. Methods: A retrospective study design was used. Twenty patients included the study presenting with clouding of consciousness after the usage of bonsai to the emergency department of Bursa State Hospital. The QT,QTc,Tp-e intervals and several other electrocardiographic parameters were measured at baseline and 12 hours afterusage of ’Bonzai’. Results: QRS duration was significantly decreased (102.115.5 ms vs 95.010.7 ms p¼0.022 ). When cQT measurements were evaluated, significant decrease was found at the end of the 12th hour(426.647.2 ms vs 390.442.9 ms p¼0.002). Similarly, Tp-e and cTp-e values were decreased significantly when bonsai lost the acute effect.(93.421.1 ms vs 77.421.0 ms p¼0.014,105.328.5 ms vs 88.1 21.5 ms p¼0.01 ). Conclusion: The usage of bonzai effects ventricular repolarization heterogenity as assesses by the QTc and Tp-e intervals. Table 1 Hemodynamic and electrocardiographic findings on admission and at the 12th hour
patients with MB. In addition, HRR1 was lower in patients with left anterior descending (LAD) MB than non-LAD MB (28.513.2 vs 37.111.4, p¼0.013). Presence of MB, deep MB, LAD MB and multivessel MB were predictors of HRR1 (p<0.01 for all). In multivariate analysis, LAD MB was only significant independent predictor of HRR1 (b ¼-8.524, p¼0.009). Conclusions: Patients with MB has impairment in HRR indices which is more pronounced among patients with LAD MB. Cardiac autonomic dysfunction in MB might be due to recurrent myocardial ischemia.
(A) Measurement of heart rate recovery and (B) myocardial bridging causing luminal compression is shown
Baseline mean 12th hour later mean p value SD (n¼20) SD (n¼20) Heart rate (bpm) Ca2þ (mg/dL) Kþ (mmol/L) Systolic BP(mmhg) Diastolic BP (mmhg) PR interval (ms) QRS duration (ms) QTinterval (ms) QTc interval (ms) Tp-e (ms) cTp-e (ms)
76.2 10.1 4.1 128 78 149.0 102.1 382.1 426.6 93.4 105.3
15.5 1.3 0.3 6.9 6.1 27.7 15.5 42.2 47.2 21.1 28.5
71.8 9.9 4.2 121 72 140.1 95.0 376.0 390.4 77.4 88.1
13.3 0.9 0.3 6.1 5.9 20.4 10.7 36.0 42.9 21.0 21.5
NS NS NS NS NS NS 0.022 NS 0.002 0.014 0.01
Approaches in Diagnosis and Non-Invazive and Invasive Treatment of Arrhythmias Saturday, March 12, 2016 02:15 PM w 03:15 PM, Hall 6 (Abstract nos. OP-091 w OP-099)
BP:blood pressure, bpm:beats per minute, ms: millisecond, NS:nonsignificant.
- OP-090 Assessment of Cardiac Autonomic Functions by Heart Rate Recovery Indices in Patients with Myocardial Bridge. Sercan Okutucu1, Mustafa Aparci2, Hakan Aksoy1, Begum Yetis Sayin1, Cengiz Ozturk3, Mehmet Karaduman4, Zafer Isilak2, Ebru Akgul Ercan1, Ali Oto1. 1Memorial Ankara Hospital, Department of Cardiology, Ankara, Turkey; 2 Haydarpasa Training Hospital, Department of Cardiology, Istanbul, Turkey; 3Department of Cardiology, Gulhane Military Medical Faculty, Ankara, Turkey; 4Department of Internal Medicine, Gulhane Military Medical Faculty, Ankara, Turkey. Objective: Heart rate (HR) recovery (HRR) reflects autonomic activity and predicts cardiovascular events. The aim of this study was to assess HRR in patients with myocardial bridge (MB). Methods: Medical recordings of 93 patients with MB and age, sexmatched 78 healthy subjects were analyzed. MB was diagnosed via coronary computed tomography angiography after a positive exercise stress test (EST). HRR indices were calculated by subtracting 1st (HRR1), 2nd (HRR2) and 3rd (HRR3) minute HR from the maximal HR during EST. Results: HRR1 (30.213.3bpm vs 35.810.4bpm, p¼0.001) and HRR2 (52.313.3bpm vs. 57.111.6bpm, p¼0.013) were lower in
- OP-091 Cardioneuroablation in the Treatment of Reflex Syncope: The Results of One Year Follow up: Single Center Experience. Tolga Aksu1, Tumer Erdem Guler1, Kivanc Yalin2, Sukriye Ebru Golcuk2. 1Kocaeli Derince Education and Research Hospital, Department of Cardiology, Kocaeli, Turkey; 2Bayrampasa Kolan Hospital, Department of Cardiology, Istanbul, Turkey. Aims: Neurally meditated reflex syncope (NMS) is usually associated with excessive vagal reflex. This study reports one year follow-up outcome of endocardial radiofrequency (RF) catheter ablation of the paracardiac ganglia and cardiac vagal nervous system calling as cardioneuroablation. Methods: A total of 8 patients (1M/7FM, 33.4þ12.8 years) with normal left ventricular systolic function (Ejection fraction % 60.6þ5%) were included. Patients were classified with VASIS classification. All patients had at least 3 episodes of syncope (8.7þ3.4). Intracardiac electrocariograms were recorded 30-500 Hz with a sweep speed of 150-400 mm/s. Atrial mapping was performed via Ensite Velocity electronatomical mapping system. The sites showing fragmented potentials were identified by electrical mapping and verified by high-frequency stimulation and ablated until atrial electrical potential was completely eliminated (<0.1 mV) (Figure 1). The followup consisted of clinical evaluation, ECG (1 month/every 3 months/or
S36 The American Journal of Cardiologyâ MARCH 10e13, 2016 12th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Oral
MARCH 10e13, 2016 patients had presyncopal complaints but did not have syncope during tilt table. One patient had symptoms of EHRA class 1 palpitation at 11th month.The average heart rate in the holter was 96/min. The patients were prescribed 50 mg metoprolol daily and diagnosed inapporiate sinus tachycardia. The patients complaints improved after drug treatment. Conclusion: Cardioneuroablation is associated with decreased risk of syncope in selected cases with NMS and associated with decreased incidence of asystole on tilt table. Due to complex pathopyhsiology of syncope, 1 year follow up of these patients may not be enough to predict long term outcome of these patients. Another limitations of the study is the absence of follow-up with event recorders Further studies are needed to clarify this issues.
- OP-093
Figure 1. The three-dimensional electroanatomical mapping of the right atrium and left atrium and intracardiac electrograms. Red dots show radiofrequency shots. All fibrillar atrial potentials were targeted in both atria as the procedure was performed for neurally mediated reflex syncope. Compare red dots with the red spheres in Figure 1 and note that red dots are seen in both atria. In intracardiac electrograms, fragmented (fibrillar) and compact atrial endocardial potentials are seen on distal electrode of the ablation catheter. CS ¼ coronary sinus; IVC ¼ inferior vena cava; LIPV ¼ left inferior pulmonary vein; LSPV ¼ left superior pulmonary vein; MA ¼ mitral annulus; RAA ¼ right atrial appendix; RIPV ¼ right inferior pulmonary vein; RSPV ¼ right superior pulmonary vein; SVC ¼ superior vena cava.
symptoms), Holter (every 6 months/or symptoms), Head up Tilt Table test (1 month/every 3 months), and atropin test (end of ablation and 6 months). Clinical occurence of syncope and negative tilt table tests were defined as clinical end point. Results: The mean number of treated endocardial points was 36.8 4.7. The mean procedure and the mean fluoroscopy time were 121.2 16.4 minutes and 32.5 6.8 minutes, respectively. Based on tilt table results, 6 of the patients had VASIS type 2B and 2 of the patients had VASIS type 1 response with a >3 sceond asystole. In all patients ablation were performed succesfully. After intervention, 2 patients with VASIS type 1 syncope had hypotensive response response during tilt table but did not have a asystole or bradycardia (Table 1). These
Diagnostic Value of Horizontal ECG Method for Detecting St Segment Changes in Patients with Acute Anterolateral _ Myocardial Infarction. Alper Kepez, Bahar Dalkilic, Okan Erdogan. Department of Cardiology, Marmara University, Istanbul, Turkey. Objective: The aim of the present study is to compare the amount of ST segment elevation on horizontal electrocardiography (hECG) by placing standard precordial leads (V3-6) horizontally on the left 4th intercostal space with standard ECG (sECG) in patients with acute anterior and/or lateral ST segment elevation myocardial infarction (STEMI). Methods: Consecutive eligible patients (n¼58) who were diagnosed with acute anterior and/or lateral STEMI were included in the study. After recording simultaneous hECG and sECG ST segment changes in precordial leads (V3-6) were compared. Results: The mean ST segment changes (mm) on hECG were significantly higher than sECG in V4 (2.72 vs 2.12.1, p¼0.001), V5 (2.11.7 vs 1.21.6, p<0.001) and V6 (0.91 vs 0.41.2, p<0.001), respectively (Table-1, Figure-1). When hECG and sECG were compared in patients with BMI <30kg/m2, mean ST segment changes (mm) on hECG were significantly higher than sECG in V4 (2.92.1 vs 2.12.4, p¼0.004), V5 (2.21.9 vs 1.31.7, p<0.001) and V6 (1.11.1 vs 0.41.1, p<0.001), respectively. Conclusion: Mean ST segment changes in patients with anterior STEMI were significantly more pronounced and easily detectable on hECG compared to sECG leads. Hence, hECG may be recommended over sECG for its diagnostic superiority in detecting ST segment changes in patients suspected with acute anterior and/or lateral STEMI.
The clinical and follow up data of the patients Case Age Gender
1 2 3 4 5 6 7 8
50 18 34 38 21 19 48 39
F F M F F F F F
Follow-up Syncope Pre-syncopal Post-syncopal Post-syncopal Post-syncopal Post-syncopal duration(month) episodes before episodes before episodes after episodes after episodes after episodes after intervention intervention (/month) intervention intervention intervention intervention (/month) (/month) (/month) (/month)
22 22 21 21 16 16 15 14
12 6 8 7 5 6 12 14
25 18 12 45 54 33 21 19
1. month
3. month
6. month
12. month
3 1 0 0 4 6 3 7
5 2 0 1 8 5 7 6
4 3 0 0 12 5 8 9
5 1 1 2 6 8 4 3
The American Journal of Cardiologyâ MARCH 10e13, 2016 12th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Oral
S37
O R A L A B S T R A C T S
O R A L A B S T R A C T S
Objective: The incidence of the usage of synthetic cannabinoids (SC) have increased all over the world as well as in our country. In our study, we aimed to evaluate if bonsai cause ventricular repolarization abnormalities or not with using initial and 12th hour electrocardiogram in patients with acute toxication of ’Bonsai’. Therefore we examined the change of QTc and cTp-e parameters to show the ventricular repolarization effects of the usage of bonsai. Methods: A retrospective study design was used. Twenty patients included the study presenting with clouding of consciousness after the usage of bonsai to the emergency department of Bursa State Hospital. The QT,QTc,Tp-e intervals and several other electrocardiographic parameters were measured at baseline and 12 hours afterusage of ’Bonzai’. Results: QRS duration was significantly decreased (102.115.5 ms vs 95.010.7 ms p¼0.022 ). When cQT measurements were evaluated, significant decrease was found at the end of the 12th hour(426.647.2 ms vs 390.442.9 ms p¼0.002). Similarly, Tp-e and cTp-e values were decreased significantly when bonsai lost the acute effect.(93.421.1 ms vs 77.421.0 ms p¼0.014,105.328.5 ms vs 88.1 21.5 ms p¼0.01 ). Conclusion: The usage of bonzai effects ventricular repolarization heterogenity as assesses by the QTc and Tp-e intervals. Table 1 Hemodynamic and electrocardiographic findings on admission and at the 12th hour
patients with MB. In addition, HRR1 was lower in patients with left anterior descending (LAD) MB than non-LAD MB (28.513.2 vs 37.111.4, p¼0.013). Presence of MB, deep MB, LAD MB and multivessel MB were predictors of HRR1 (p<0.01 for all). In multivariate analysis, LAD MB was only significant independent predictor of HRR1 (b ¼-8.524, p¼0.009). Conclusions: Patients with MB has impairment in HRR indices which is more pronounced among patients with LAD MB. Cardiac autonomic dysfunction in MB might be due to recurrent myocardial ischemia.
(A) Measurement of heart rate recovery and (B) myocardial bridging causing luminal compression is shown
Baseline mean 12th hour later mean p value SD (n¼20) SD (n¼20) Heart rate (bpm) Ca2þ (mg/dL) Kþ (mmol/L) Systolic BP(mmhg) Diastolic BP (mmhg) PR interval (ms) QRS duration (ms) QTinterval (ms) QTc interval (ms) Tp-e (ms) cTp-e (ms)
76.2 10.1 4.1 128 78 149.0 102.1 382.1 426.6 93.4 105.3
15.5 1.3 0.3 6.9 6.1 27.7 15.5 42.2 47.2 21.1 28.5
71.8 9.9 4.2 121 72 140.1 95.0 376.0 390.4 77.4 88.1
13.3 0.9 0.3 6.1 5.9 20.4 10.7 36.0 42.9 21.0 21.5
NS NS NS NS NS NS 0.022 NS 0.002 0.014 0.01
Approaches in Diagnosis and Non-Invazive and Invasive Treatment of Arrhythmias Saturday, March 12, 2016 02:15 PM w 03:15 PM, Hall 6 (Abstract nos. OP-091 w OP-099)
BP:blood pressure, bpm:beats per minute, ms: millisecond, NS:nonsignificant.
- OP-090 Assessment of Cardiac Autonomic Functions by Heart Rate Recovery Indices in Patients with Myocardial Bridge. Sercan Okutucu1, Mustafa Aparci2, Hakan Aksoy1, Begum Yetis Sayin1, Cengiz Ozturk3, Mehmet Karaduman4, Zafer Isilak2, Ebru Akgul Ercan1, Ali Oto1. 1Memorial Ankara Hospital, Department of Cardiology, Ankara, Turkey; 2 Haydarpasa Training Hospital, Department of Cardiology, Istanbul, Turkey; 3Department of Cardiology, Gulhane Military Medical Faculty, Ankara, Turkey; 4Department of Internal Medicine, Gulhane Military Medical Faculty, Ankara, Turkey. Objective: Heart rate (HR) recovery (HRR) reflects autonomic activity and predicts cardiovascular events. The aim of this study was to assess HRR in patients with myocardial bridge (MB). Methods: Medical recordings of 93 patients with MB and age, sexmatched 78 healthy subjects were analyzed. MB was diagnosed via coronary computed tomography angiography after a positive exercise stress test (EST). HRR indices were calculated by subtracting 1st (HRR1), 2nd (HRR2) and 3rd (HRR3) minute HR from the maximal HR during EST. Results: HRR1 (30.213.3bpm vs 35.810.4bpm, p¼0.001) and HRR2 (52.313.3bpm vs. 57.111.6bpm, p¼0.013) were lower in
- OP-091 Cardioneuroablation in the Treatment of Reflex Syncope: The Results of One Year Follow up: Single Center Experience. Tolga Aksu1, Tumer Erdem Guler1, Kivanc Yalin2, Sukriye Ebru Golcuk2. 1Kocaeli Derince Education and Research Hospital, Department of Cardiology, Kocaeli, Turkey; 2Bayrampasa Kolan Hospital, Department of Cardiology, Istanbul, Turkey. Aims: Neurally meditated reflex syncope (NMS) is usually associated with excessive vagal reflex. This study reports one year follow-up outcome of endocardial radiofrequency (RF) catheter ablation of the paracardiac ganglia and cardiac vagal nervous system calling as cardioneuroablation. Methods: A total of 8 patients (1M/7FM, 33.4þ12.8 years) with normal left ventricular systolic function (Ejection fraction % 60.6þ5%) were included. Patients were classified with VASIS classification. All patients had at least 3 episodes of syncope (8.7þ3.4). Intracardiac electrocariograms were recorded 30-500 Hz with a sweep speed of 150-400 mm/s. Atrial mapping was performed via Ensite Velocity electronatomical mapping system. The sites showing fragmented potentials were identified by electrical mapping and verified by high-frequency stimulation and ablated until atrial electrical potential was completely eliminated (<0.1 mV) (Figure 1). The followup consisted of clinical evaluation, ECG (1 month/every 3 months/or
S36 The American Journal of Cardiologyâ MARCH 10e13, 2016 12th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Oral
MARCH 10e13, 2016 patients had presyncopal complaints but did not have syncope during tilt table. One patient had symptoms of EHRA class 1 palpitation at 11th month.The average heart rate in the holter was 96/min. The patients were prescribed 50 mg metoprolol daily and diagnosed inapporiate sinus tachycardia. The patients complaints improved after drug treatment. Conclusion: Cardioneuroablation is associated with decreased risk of syncope in selected cases with NMS and associated with decreased incidence of asystole on tilt table. Due to complex pathopyhsiology of syncope, 1 year follow up of these patients may not be enough to predict long term outcome of these patients. Another limitations of the study is the absence of follow-up with event recorders Further studies are needed to clarify this issues.
- OP-093
Figure 1. The three-dimensional electroanatomical mapping of the right atrium and left atrium and intracardiac electrograms. Red dots show radiofrequency shots. All fibrillar atrial potentials were targeted in both atria as the procedure was performed for neurally mediated reflex syncope. Compare red dots with the red spheres in Figure 1 and note that red dots are seen in both atria. In intracardiac electrograms, fragmented (fibrillar) and compact atrial endocardial potentials are seen on distal electrode of the ablation catheter. CS ¼ coronary sinus; IVC ¼ inferior vena cava; LIPV ¼ left inferior pulmonary vein; LSPV ¼ left superior pulmonary vein; MA ¼ mitral annulus; RAA ¼ right atrial appendix; RIPV ¼ right inferior pulmonary vein; RSPV ¼ right superior pulmonary vein; SVC ¼ superior vena cava.
symptoms), Holter (every 6 months/or symptoms), Head up Tilt Table test (1 month/every 3 months), and atropin test (end of ablation and 6 months). Clinical occurence of syncope and negative tilt table tests were defined as clinical end point. Results: The mean number of treated endocardial points was 36.8 4.7. The mean procedure and the mean fluoroscopy time were 121.2 16.4 minutes and 32.5 6.8 minutes, respectively. Based on tilt table results, 6 of the patients had VASIS type 2B and 2 of the patients had VASIS type 1 response with a >3 sceond asystole. In all patients ablation were performed succesfully. After intervention, 2 patients with VASIS type 1 syncope had hypotensive response response during tilt table but did not have a asystole or bradycardia (Table 1). These
Diagnostic Value of Horizontal ECG Method for Detecting St Segment Changes in Patients with Acute Anterolateral _ Myocardial Infarction. Alper Kepez, Bahar Dalkilic, Okan Erdogan. Department of Cardiology, Marmara University, Istanbul, Turkey. Objective: The aim of the present study is to compare the amount of ST segment elevation on horizontal electrocardiography (hECG) by placing standard precordial leads (V3-6) horizontally on the left 4th intercostal space with standard ECG (sECG) in patients with acute anterior and/or lateral ST segment elevation myocardial infarction (STEMI). Methods: Consecutive eligible patients (n¼58) who were diagnosed with acute anterior and/or lateral STEMI were included in the study. After recording simultaneous hECG and sECG ST segment changes in precordial leads (V3-6) were compared. Results: The mean ST segment changes (mm) on hECG were significantly higher than sECG in V4 (2.72 vs 2.12.1, p¼0.001), V5 (2.11.7 vs 1.21.6, p<0.001) and V6 (0.91 vs 0.41.2, p<0.001), respectively (Table-1, Figure-1). When hECG and sECG were compared in patients with BMI <30kg/m2, mean ST segment changes (mm) on hECG were significantly higher than sECG in V4 (2.92.1 vs 2.12.4, p¼0.004), V5 (2.21.9 vs 1.31.7, p<0.001) and V6 (1.11.1 vs 0.41.1, p<0.001), respectively. Conclusion: Mean ST segment changes in patients with anterior STEMI were significantly more pronounced and easily detectable on hECG compared to sECG leads. Hence, hECG may be recommended over sECG for its diagnostic superiority in detecting ST segment changes in patients suspected with acute anterior and/or lateral STEMI.
The clinical and follow up data of the patients Case Age Gender
1 2 3 4 5 6 7 8
50 18 34 38 21 19 48 39
F F M F F F F F
Follow-up Syncope Pre-syncopal Post-syncopal Post-syncopal Post-syncopal Post-syncopal duration(month) episodes before episodes before episodes after episodes after episodes after episodes after intervention intervention (/month) intervention intervention intervention intervention (/month) (/month) (/month) (/month)
22 22 21 21 16 16 15 14
12 6 8 7 5 6 12 14
25 18 12 45 54 33 21 19
1. month
3. month
6. month
12. month
3 1 0 0 4 6 3 7
5 2 0 1 8 5 7 6
4 3 0 0 12 5 8 9
5 1 1 2 6 8 4 3
The American Journal of Cardiologyâ MARCH 10e13, 2016 12th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Oral
S37
O R A L A B S T R A C T S