This is an editorial comment on the European Society of Cardiology Guidelines on atrial fibrillation that has been revised in 2016.

Objective: Patent foramen ovale (PFO) is commonly encountered in patients with cryptogenic stroke. Mean platelet volume (MPV), an indicator of platelet reactivity, has been reported in recent trials to be higher in patients with PFO than in normal population. The aim of this study was to investigate whether there is a difference in MPV between patients with PFO and stroke or transient ischemic attack (TIA) and that of patients with asymptomatic PFO.
Methods: Patients with PFO who were younger than 55 years of age were enrolled in this retrospective study. Hemogram parameters of patients with ischemic stroke or TIA (symptomatic group) were obtained during hospitalization once they had stable clinical status.
Results: Total of 108 patients, 51 of whom were symptomatic, were included in the study. MPV was determined to be higher in symptomatic group compared with asymptomatic group (median 10.0 fl [25th-75th percentile: 9.0–11.0] vs median 8.56 fl [25th-75th percentile: 8.0–9.0], respectively; p<0.001,. Cut-off point of 9.0 fl for MPV had 70% sensitivity and 86% specificity in predicting symptomatic PFO patients.

Conclusion: MPV is higher in symptomatic than in asymptomatic PFO patients. This finding may be a subsidiary risk factor to identify patients with PFO and high risk of cardioembolic stroke.

Objective: Gender is an important feature in the management of atrial fibrillation (AF). This study investigated gender-related differences in patients with AF in Turkey.
Methods: As a part of RAMSES (ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in Turkey, NCT02344901) study, information of the patients with AF who successively applied to the hospital was analyzed. This cross-sectional, multicenter, nationwide observational study enrolled 6264 non-valvular AF (NVAF) outpatients (55.9% women) from Turkey.
Results: Compared with men, women with NVAF were older (71 years [range: 65–78 years] vs. 70 years [range: 62–77 years]; p<0.001), had lower frequency of coronary artery disease (22.0% vs. 38.3%; p<0.001) and congestive heart failure (18.2% vs. 27.2%; p<0.001). Women had higher median CHA2DS2-VASc score (4 [range: 3–5] vs. 3 [range: 2–4]; p<0.001), but similar HAS-BLED score (2 [range: 1–2] vs. 2 [range: 1–2]; p=0.141) when compared with men. Anticoagulant therapy use was higher in women (74.5% vs. 69.9%; p<0.001). Analysis of anticoagulation therapy use revealed that 68.5% of men and 61.6% of women (p=0.204) who had low risk for stroke (CHA2DS2-VASc score: 0 [male], 1 [female]) received anticoagulation therapy, and 30.5% of the men. Meanwhile, 25.3% of the women (p<0.001) with high risk for stroke (CHA2DS2-VASc score: ≥1 [male], ≥2 [female]) had not received any anticogulant therapy.
Conclusion: Although women with NVAF receive better treatment than men, anticoagulation therapy is suboptimal in large proportion of men and women, with underuse in high-risk patients and overuse in low-risk patients. There is an urgent need to improve optimization of anticoagulation in patients with NVAF.

Objective: Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with increased morbidity and mortality. Atrial fibrosis augments recurrence rate following AF catheter ablation. Osteopontin is a multifunctional molecule involved in several pathophysiological pathways, including fibrosis. Presently described is investigation of relationship between serum osteopontin level and AF recurrence after AF cryoablation.
Methods: The study was designed to be prospective and observational; 60 patients with paroxysmal (n=47) and persistent (n=13) AF were included. Osteopontin level was measured both before and 6 months after AF ablation with cryoballoon.
Results: Preprocedure and postprocedure osteopontin level did not differ between the 2 groups of AF patients (p=0.286, p=0.493, respectively). Postprocedure osteopontin level was significantly higher compared with preprocedure value (32.18 ng/mL vs 15.58 ng/mL; p=<0.001). Left atrial diameter, AF type, and preprocedure osteopontin level were related to AF recurrence (p≤0.05). An age-adjusted multivariate logistic regression analysis was conducted to determine independent predictors of AF recurrence. Among these, AF type (β=2.211; p=0.004; odds ratio [OR]: 9.124; 95% confidence interval [CI]: 2.026–41.094) was found to be the most important factor related to AF recurrence. Preprocedure osteopontin level also predicted AF recurrence independently (β=0.059; p=0.048; OR: 1.061; 95% CI 1.001–1.125).
Conclusion: Study results revealed persistency of AF and high preprocedure osteopontin level independently predicted AF recurrence in patients undergoing cryoballoon AF ablation. Association of a biochemical marker with AF recurrence might be beneficial to selection of appropriate patients for cryoballoon procedure and assessment of long-term procedural success.

Objective: An imbalance between parasympathetic and sympathetic tone is a main cause of neurally mediated reflex syncope (NMRS). These patients may be very symptomatic and the condition may require cardiac pacemaker implantation. Cardioneuroablation (CNA) is a relatively novel technique based on radiofrequency ablation of vagal ganglia that can be used in treatment of NMRS. The aim of this analysis was to compare potential role of CNA in patients with NMRS.

Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, literature search was conducted using the keywords “cardioneuroablation,” “vagal denervation,” “reflex syncope,” “vagal ablation,” and “ganglionic plexi ablation.” Retrieved citations were first screened independently by 2 reviewers for inclusion and exclusion criteria.
Results: Freedom from syncope and freedom from prodrome were 100% and between 50% and 100%, respectively, in the studies. Ablation was performed via both atria in 3 studies; only left atrial approach was used in the remaining studies. There was no major complication related to the procedure reported.

Conclusion: Focused or extensive vagal ganglia ablation may be a potential alternative to pacemaker implantation in a carefully selected patient population. In contrast to pharmacological therapy and pacemaker implantation, ganglia ablation is designed to get to the root of the problem: disturbances in the intrinsic cardiac autonomic nervous system. This novel technique should be evaluated in large-scale, randomized, controlled trials.

Objective: Pulmonary vein (PV) anatomy has drawn attention since assumption that atrial fibrillation (AF) may originate from PVs and that electrical isolation of PVs may be beneficial in eliminating these triggers. The present study aims to investigate PV anatomy and its variations in a sample of Turkish patients undergoing PV isolation (PVI) for AF.
Methods: 250 patients underwent multidetector computed tomography before cryoballoon-based PVI for AF. PV and left atrial (LA) anatomy were evaluated in 3-dimensional epicardial reconstructions.
Results: 980 PVs were observed. All PVs drained into the LA. Mean superoinferior (SI) dimension for each vein was significantly larger than mean anteroposterior (AP) dimension. Accessory PVs were only seen on right side. Accessory veins were significantly smaller in both AP and SI diameter than other veins. Right-sided PV ostia were more round. Expected anatomy of 2 atrial ostia for right upper and lower lobe veins on each side was seen in 94.8% of patients. Remainder had other variant anatomy in right PVs. Conjoined ostium in the LA was seen in 35.6% of patients.
Conclusion: PV variations were common in Turkish AF cohort undergoing PVI, which may be important to know about prior to ablation therapy for procedural success.

Objective: Hypertension is the most prevalent modifiable risk factor for cardiovascular (CV) and cerebrovascular morbidity and mortality. This study aimed to assess the effects of renin-angiotensin-aldosterone system (RAAS) blockade on CV outcomes.
Methods: This study was designed according to the Preferred Reporting Items for Systemic reviews and Meta-Analyses statement. Databases were searched for articles published as of December 2014. Two sets of studies were selected. One set included randomized clinical trials comparing RAAS blocker (angiotensin II receptor blocker [ARB] or angiotensin-converting enzyme inhibitor [ACEI]) with placebo or active treatment. Second set included head-to-head randomized clinical trials comparing an ARB with an ACEI. Studies in both sets had reported any CV outcome parameter or death, i.e., all-cause mortality, CV mortality, emergence of CV events, myocardial infarction, cerebrovascular event, stroke, heart failure, and hospitalization for heart failure.
Results: Fifty-four pairwise comparisons of 51 trials with 277,609 patients were included. Statistically significant differences in favor of RAAS blockers vs non-RAAS blockers (risk ratio [RR] ranging from 0.805 to 0.967) were observed in terms of most CV outcomes, including all-cause mortality, CV mortality, CV events, myocardial infarction, heart failure and stroke. ARBs and ACEIs were found to be completely comparable (RR ranging from 0.923 to 1.090, all non-significant).
Conclusion: RAAS blockers are superior to medications other than RAAS blockers with respect to impact on CV outcomes in patients with hypertension. ARBs and ACEIs are comparable in terms of these outcomes.

Summary– Septal reduction therapy (SRT) is the accepted therapeutic option for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). At this time, surgical septal myectomy is the gold standard method, but alcohol septal ablation is an acceptable alternative treatment for patients with suitable anatomy. Endocardial septal ablation (ESA) therapy is a little-known method of SRT. Presently described is case of successful ESA procedure performed for HOCM.

Summary– Infective endocarditis (IE) is a serious infectious condition with high morbidity and mortality in patients with end-stage renal disease (ESRD). It has been particularly associated with recurrent bacteremia due to vascular access via lumen catheters. The most common pathogen is Staphylococcus (S.) aureus, and most affected valve is mitral valve, which frequently calcified. Two patients with ESRD who received hemodialysis treatment via tunneled catheters, aged 56 and 88 years, were admitted with fever and high troponin level. Blood cultures revealed growth of S. aureus. Good quality transthoracic echocardiography (TTE) displayed calcified mitral and aortic valves with no vegetation or abscess formation. Myocardial necrosis as result of catheter infection was considered. Both patients had persistent positive blood cultures 3 and 5 days after initiation of antibiotic treatment. Therefore, transesophageal echocardiogram (TEE) was scheduled. Results revealed perivalvular abscess in the older patient, and highly mobile vegetation in the younger patient. The older patient refused surgery and died soon after due to refractory shock. Mitral valve surgery was planned for the other patient; however, she developed left ventricular failure and bleeding, and also subsequently died as result of refractory shock. Patient evaluations were particularly unfavorable: they had catheter infection as primary focus, and TTE did not detect vegetation or annular abscess. Diagnosis of IE in patients with ESRD using Duke criteria is problematic; we have to keep use of TEE in mind to detect vegetation or abscess formation when there is clinical suspicion regarding ESRD patients even after good quality TTE.

Summary– Kabuki syndrome is a rare congenital malformation syndrome characterized by mental retardation, skeletal deformities, auditory dysfunction, cardiac defects, and distinctive facial appearance. Although complex cardiovascular malformations present in early childhood, rarely, atrioventricular septal defects may also present in young adults. Presently described is case of a 22-year-old female with KS who presented with ostium secundum atrial septal defect with deficient rim and idiopathic thrombocytopenic purpura. In this case, minimally invasive robotic surgery was preferred for closure of atrial septal defect.

Summary– Atrioventricular (AV) block in the neonatal period is a rare disorder. It is frequently associated with underlying structural congenital heart disease and maternal lupus. Presently described is premature baby who developed 2: 1 AV block and congestive heart failure due to hypocalcemia. Dramatic clinical improvement was observed following treatment of intravenous 10% calcium gluconate. Therefore, it is suggested that serum calcium level of newborns with AV block and congestive heart failure be measured.

Summary– Muscular septal aneurysms are extremely rare without a ventricular septal defect and are diagnosed accidentally in most cases. Reported cases generally have rhythm disturbance or electrocardiographic findings of Wolf-Parkinson-White (WPW) syndrome. Presently described are 2 cases of ventricular septal aneurysm associated with WPW syndrome, which presented as dilated cardiomyopathy. Pre-excitation disappeared gradually in first patient. There was also concurrent decrease in degree of bulging of the interventricular septum and improvement of left ventricular systolic function. Second patient had complaints of palpitation and was referred for ablation of accessory pathway. Our findings suggest that presence of pre-excitation may lead to ventricular dyssynchrony and abnormal ventricular septal movement, resulting in appearance of aneurysm.

Summary– Transcatheter aortic valve replacement (TAVR) was designed to treat elderly patients with severe aortic stenosis at high risk for surgery, and is most commonly performed with retrograde approach through femoral arteries. However, in up to 30% of cases, it is either not possible to use this access route or it is considered to have high risk of vascular injury. Alternative approaches have been described for patients with no suitable femoral access: trans-subclavian, transaortic, or direct aortic access; however, since the introduction of new valves deployed with low-profile delivery systems, another alternative transcatheter approach has been discovered. Presently described is experience in 2 cases in which patients were treated with transfemoral TAVR using Edwards SAPIEN 3 transcatheter heart valves immediately following ipsilateral common iliac artery stenting.

Summary– Diuretics have been used for years to treat hypertension as both a monotherapy and in combination. Hydrochlorothiazide, indapamide, and chlorthalidone have frequently been considered in the same category as thiazide diuretics, but there is no evidence that their activities are similar. Studies have shown that chlorthalidone and indapamide reduce cardiovascular morbidity and mortality; however, there is no study indicating that hydrochlorothiazide has beneficial effects on cardiovascular outcomes such as myocardial infarction, renal failure, stroke, or death. Hydrochlorothiazide has less effect on blood pressure, a high risk of metabolic side effects, and may not have pleiotropic effects. As a result, it is not accurate to evaluate chlorthalidone and indapamide as similar to thiazide diuretics. Indapamide or chlorthalidone is a better choice of diuretic for use in the treatment of hypertension.