Objective: Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) remains a major challenge in interventional cardiology. The exact toxic components of cigarette smoke and the mechanisms involved in smoking-related cardiovascular dysfunction are largely unknown, but it increases inflammation, thrombosis, and oxidation of low-density lipoprotein cholesterol. There is only insignificant knowledge reported in the literature about the influence of smoking habits on acute outcome in CTO PCI.
Methods: Between 2012 and 2017, a total of 559 patients were included in the study. The patients all underwent PCI for at least 1 CTO. Antegrade and retrograde CTO techniques were applied. The Shapiro-Wilk test was used to test for normality of distribution. Continuous variables were tested for differences with the Kruskal–Wallis test or the Mann–Whitney U test, as appropriate. Categorical variables were tested using Fisher’s exact test.
Results: Non-smokers were older than smoking patients (65.3±10.3 years vs. 58.3±9.2 years; p<0.001). The mean age of the cohort was 62.1 years (±10.5). Smokers were more often male (85.7% vs. 79.7%; p=0.074), suffered from longer lesion length (36.1±17.5 mm vs. 39.1±17.2 mm; p=0.023) and therefore needed longer stents (64.2±26.5 mm vs. 69.0±28.0 mm; p=0.084). The success rate was comparable for smokers and non-smokers. In-hospital procedural complications were rare and demonstrated no statistically significant difference.
Conclusion: The results of this retrospective study revealed no significant association between smoking and acute outcome in CTO PCI. Smokers did, however, have longer lesions and needed longer stents.

Objective: The aim of this study was to assess the myocardial energy expenditure (MEE) in patients with cardiac syndrome X (CSX) and to examine its association with exercise electrocardiogram (ECG) parameters.
Methods: A total of 99 patients who underwent coronary angiography and who were diagnosed as having normal coronary arteries were included. The patients were divided into 2 groups based on symptoms and exercise ECG parameters: 56 CSX patients and 43 control patients with a negative stress test. MEE was calculated using transthoracic echocardiography-derived parameters: circumferential end-systolic stress, left ventricular ejection time, and stroke volume.
Results: In patients with CSX, the MEE at rest was 28% higher in than the control group (89.2±36.3 vs. 69.8±17.2 cal/minute). Correlation analysis revealed a moderately negative correlation between MEE and the Duke treadmill score (DTS) (β: -0.456; p<0.001). Receiver operating characteristic analysis with a cut-off value of 74.6 cal/minute for MEE had a sensitivity of 78.1% and a specificity of 75.3% for the prediction of CSX (area under the curve: 0.872; p<0.001). An extra 1 calorie spent per minute at rest increased the likelihood of CSX by about 86% (odds ratio: 1.863).
Conclusion: This study demonstrated that MEE was greater in CSX patients compared with a control group. Increased MEE was determined to be an independent predictor of CSX. DTS was inversely correlated with MEE. Increased MEE may have a crucial role in CSX pathophysiology.

Objective: This study was performed to examine the association between the SYNTAX II score (SS-II) and no-reflow observed on electrocardiography and examine their use in the evaluation of risk of an in-hospital major adverse cardiovascular event (MACE) in patients with ST-segment elevation myocardial infarction (STEMI).
Methods: A total of 126 consecutive STEMI patients who underwent primary percutaneous coronary intervention (pPCI) were recruited. The SS-II was derived using angiographic and basic patient clinical features. The difference in the sum of ST-segment elevations measured between before the pPCI and the assessment determined approximately 60 minutes after the pPCI was interpreted as the sum of ST-segment resolution (ΣSTR). MACE is a composite endpoint frequently used in cardiovascular research and usually includes endpoints reflecting safety and effectiveness. ΣSTR <50% was defined as incomplete ΣSTR (no-reflow group; n=44), while ΣSTR ≥50% was defined as complete ΣSTR (normal-flow group, n=82).
Results: The SS-II was significantly higher in the no-reflow group (p<0.001). SS-II and no-reflow findings were associated with MACE. Logistic regression analysis demonstrated significant predictive values of SS-II (Odds ratio [OR]: 1.169; 95% confidence interval [CI]: 1.084–1.260; p<0.001) and ΣSTR (OR: 0.764; 95% CI: 0.632–0.924; p=0.006) for in-hospital MACE.
Conclusion: SS-II was significantly associated with no-reflow as assessed by electrocardiography. In patients with STEMI, SS-II and no-reflow (incomplete ΣSTR) may be important predictive factors for in-hospital MACE.

Objective: Radiofrequency (RF) ablation is a highly successful procedure for the management of typical atrial flutter (AFL), an abnormal heart rhythm originating within the atria. There is no strong evidence that the use of contact force (CF) has any impact on procedural duration or acute success in the management of cavotricuspid isthmus (CTI)-dependent AFL. The aim of this study was to compare acute procedural parameters using a non-CF, 4-mm, gold-tip, irrigated catheter and a CF-sensing catheter in patients with AFL.
Methods: This was a retrospective cohort study. Consecutive patients who underwent typical AFL catheter ablation with either a gold-tip or CF-sensing catheter were enrolled. The procedural parameters obtained were: time to achieve bidirectional block, time to terminate AFL, total duration of RF application, procedure duration, fluoroscopy time, acute reconnection within 20 minutes following the last RF application, and procedural complications.
Results: Of the 40 patients screened, 37 were included in the study. The procedural endpoint of bidirectional isthmus block was achieved in all patients. The use of gold-tip catheters was associated with a shorter length of time to achieve bidirectional block (median time: 20.0 minutes [interquartile range {IQR}: 12.0–28.0 minutes]) compared with a median time of 36.0 minutes (IQR: 12.0–53.0 minutes; p=0.048) in the CF group. Furthermore, there was a trend toward reduced procedural duration in favor of the gold-tip catheter (median gold-tip: 74.0 minutes [IQR: 57.0–84.0 minutes]; median CF: 85.0 minutes [IQR: 57.0–107.0 minutes]; p=0.171). A greater requirement for the use of long sheaths was observed in cases where the CF catheter was employed for the procedure (CF: 11, 57.9 %; non-CF: 1, 5.6%; p=0.005).
Conclusion: The time required to achieve bidirectional block, which is also reflected in the procedural time, was less when using a gold-tip catheter, and there was less need for the use of a long sheath. Further studies may be useful to evaluate this finding.

Objective: Epicardial adipose tissue (EAT) secretes various pro-inflammatory and atherogenic substances that have several effects on the heart. The goal of this study was to evaluate the association between EAT thickness and both P-wave dispersion (Pd) and corrected QT interval (QTc), as simple, non-invasive indicators of arrhythmia on a surface electrocardiogram.
Methods: This retrospective observational study included 216 patients who had normal coronary arteries observed on coronary angiography. Each patient underwent 12-derivation electrocardiography to measure Pd and QTc, and transthoracic echocardiography to measure EAT thickness. The patients were divided into 2 groups according to the median EAT value (EAT low group: <5.35 mm; EAT high group: ≥5.35 mm).
Results: P-wave dispersion (p=0.001) was significantly greater in the EAT high group compared with the EAT low group. However, the QTc (p=0.004) was significantly greater in the latter group. The median left ventricular end-diastolic diameter (p=0.033), mean left ventricular end-systolic diameter (p=0.039), and mean left atrial diameter (p=0.012) were significantly greater in the EAT high group. Multiple logistic regression analysis using the backward elimination method revealed that the leukocyte count (Odds ratio [OR]: 1.000; 95% confidence interval [CI]: 1.000–1.000; p=0.001), Pd (OR: 1.1026; 95% CI: 1.010–1.043; p=0.002), QTc interval (OR: 0.988; 95% CI: 0.979–0.997; p=0.009), and left ventricular ejection fraction (OR: 0.922; 95% CI: 0.859–0.989; p=0.023) were independently associated with greater EAT thickness.
Conclusion: Echocardiographic end-diastolic EAT thickness on the free wall of the right ventricle was associated with Pd and QTc in patients with normal coronary arteries.

Objective: The purpose of this study was to assess the association between depression and all-cause mortality in patients with congestive heart failure (CHF) and an implanted cardiac device.
Methods: The study enrolled 260 patients (mean age 56.8±10.0 years; 83.1% male) with CHF and an implanted cardiac device (156 patients with a resynchronization therapy cardiac device, 104 patients with an implantable cardioverter defibrillator). The mean duration of follow-up was 48.6±32.2 months. The Beck Depression Inventory was used to measure depressive symptoms. Depression was considered absent for a score between 0 and 9, mild to moderate for a score between 10 and 18, and severe if the score was 19 or greater. The Cox proportional hazards regression model was used to estimate hazard ratios (HR) with a 95% confidence interval (CI) for the impact of depression on all-cause mortality. The HR was calculated after adjustment for the following confounders: age, gender, smoking status, hypertension, diabetes mellitus, body mass index, hypercholesterolemia, left ventricular ejection fraction, number of hemodynamically significant lesions of the coronary arteries, and the type of implanted cardiac device.
Results: During the follow-up period, 37 patients died (14.2%). The adjusted HR of depression for all-cause mortality was 1.05, with a 95% CI of 1.01–1.09. Patients without depression were accepted as a reference group with HR=1.0 for analysis of the categorical indicator. The HR was 1.32, with a 95% CI of 0.57–3.03, in patients with mild depressive symptoms, and the HR was 3.18 with a 95% CI of 1.31–7.73 in patients with severe depressive symptoms.
Conclusion: Increased depressive symptoms were independently associated with all-cause mortality in patients with CHF and an implanted cardiac device.

A 31-year-old male patient presented with complaints of palpitations, dizziness, and recurrent episodes of syncope. A 12-lead electrocardiogram (ECG) revealed manifest ventricular preexcitation, which suggested Wolff Parkinson White syndrome. In addition, an incomplete right bundle branch block and a 3-mm ST segment elevation ending with inverted T-waves in V2 were consistent with coved-type (type 1) Brugada pattern. An electrophysiological study was performed, and during the mapping, the earliest ventricular activation with the shortest A-V interval was found on the mitral annulus posterolateral site. After successful radiofrequency catheter ablation of the accessory pathway, the Brugada pattern on the ECG changed, which prompted an ajmaline provocation test. A type 1 Brugada ECG pattern occurred following the administration of ajmaline. Considering the probable symptom combinations of these 2 coexisting syndromes and the presence of recurrent episodes of syncope, programmed ventricular stimulation was performed and subsequently, ventricular fibrillation was induced. An implantable cardioverter-defibrillator was implanted soon after.

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

Percutaneous closure of atrial septal defects is accepted as a safe and effective treatment method. Device embolization is a rare, but potentially fatal complication. While embolized devices are typically removed surgically, in eligible cases, they can also be removed percutaneously at an experienced center. Presently described is the retrieval of an embolized device with a novel percutaneous technique.

A bifid cardiac apex is a rare congenital cardiac anomaly in humans and is usually associated with other congenital heart diseases. Presently described is a case of an incidentally detected bifid cardiac apex in a patient presenting with inferior ST-segment elevation myocardial infarction, which was subsequently confirmed with selective ventriculography. This anomaly, because it is rare, can be a source of confusion to clinicians, especially when acute coronary syndrome is present. The possible presence of this anomaly should, therefore, be kept in mind in daily practice.

Coronary fistulas are defined as the presence of an abnormal connection between the coronary arteries and the low-pressure vascular area or the cardiac cavity. The clinical significance depends on the amount of blood flow through the fistula segment, the volumetric load on the right and left heart chambers, and whether it leads to a coronary steal phenomenon. Although fistula flow can be better visualized by angiographic methods, it can also be seen by echocardiography. In this case, the fistula flow draining to the left ventricle was demonstratively visualized.