Publications by authors named "Skevos Sideris"

79 Publications

Permanent pacemaker implantation in unexplained syncope patients with electrophysiology study-proven atrioventricular node disease.

Hellenic J Cardiol 2022 Jan 8. Epub 2022 Jan 8.

First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece.

Background: Syncope, whose cause is unknown after an initial assessment, has an uncertain prognosis. It is critical to identify patients at highest risk who may require a pacemaker and to identify the cause of recurrent syncope to prescribe proper therapy. Aim of this study was to evaluate the effect of permanent pacing on the incidence of syncope in patients with unexplained syncope and electrophysiology study-proven atrioventricular node disease.

Material And Methods: This was an observational study based on a prospective registry of 236 consecutive patients (60.20 ± 18.66 years, 63.1% male, 60.04 ± 9.50 bpm) presenting with recurrent unexplained syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). The decision to implant a permanent pacemaker was made in all cases by the attending physicians according to the results of the EPS. 135 patients received the antibradycardia pacemaker (ABP), while 101 declined.

Results: The mean of reported syncope episodes was 1.97 ± 1.10 (or presyncope 2.17 ± 1.50) before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (49.19 ± 29.58 months), the primary outcome event (syncope) occurred in 31 of 236 patients (13.1%), 6 of 135 (4.4%) in the ABP group as compared to 25 of 101 (24.8%) in the no pacemaker group (p < 0.001).

Conclusion: Among patients with a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined atrioventricular node disease, identifies a subset of patients who will benefit from permanent pacing.
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http://dx.doi.org/10.1016/j.hjc.2022.01.001DOI Listing
January 2022

Noninvasive risk factors for the prediction of inducibility on programmed ventricular stimulation in post-myocardial infarction patients with an ejection fraction ≥40% at risk for sudden cardiac arrest: Insights from the PRESERVE-EF study.

Ann Noninvasive Electrocardiol 2021 Dec 6:e12908. Epub 2021 Dec 6.

First Department of Cardiology, Hippokrateion General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece.

Background: In the PRESERVE-EF study, a two-step sudden cardiac death (SCD) risk stratification approach to detect post-myocardial infarction (MI) patients with left ventricle ejection fraction (LVEF) ≥40% at risk for major arrhythmic events (MAEs) was used. Seven noninvasive risk factors (NIRFs) were extracted from a 24-h ambulatory electrocardiography (AECG) and a 45-min resting recording. Patients with at least one NIRF present were referred for invasive programmed ventricular stimulation (PVS) and inducible patients received an Implantable Cardioverter - Defibrillator (ICD).

Methods: In the present study, we evaluated the performance of the NIRFs, as they were described in the PRESERVE-EF study protocol, in predicting a positive PVS. In the PRESERVE-EF study, 152 out of 575 patients underwent PVS and 41 of them were inducible. For the present analysis, data from these 152 patients were analyzed.

Results: Among the NIRFs examined, the presence of signal averaged ECG-late potentials (SAECG-LPs) ≥ 2/3 and non-sustained ventricular tachycardia (NSVT) ≥1 eposode/24 h cutoff points were important predictors of a positive PVS study, demonstrating in the logistic regression analysis odds ratios 2.285 (p = .027) and 2.867 (p = .006), respectively. A simple risk score based on the above cutoff points in combination with LVEF < 50% presented high sensitivity but low specificity for a positive PVS.

Conclusion: Cutoff points of NSVT ≥ 1 episode/24 h and SAECG-LPs ≥ 2/3 in combination with a LVEF < 50% were important predictors of inducibility. However, the final decision for an ICD implantation should be based on a positive PVS, which is irreplaceable in risk stratification.
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http://dx.doi.org/10.1111/anec.12908DOI Listing
December 2021

His Bundle Pacing: A promising alternative strategy for Antibradycardic-pacing. Report of a single center-experience.

Hellenic J Cardiol 2021 Nov 26. Epub 2021 Nov 26.

Department of Cardiology, Hippokration General Hospital, 114 Vasilisis Sofias Str, Athens, Greece. Electronic address:

His Bundle Pacing (HBP) is proven to be a safe and effective alternative pacing modality that, in addition, avoids Pacemaker-induced Cardiomyopathy (PICM) by achieving a ''physiological'' ventricular stimulation, via the native conduction system. Indications include various causes of bradycardia requiring antibradycardic pacing, inadequately controlled Atrial Fibrillation requiring AV node ablation and established PICM. In addition, HBP may also be used as an alternative therapy for patients with Heart Failure (HF) and an indication for Cardiac Resynchronization Therapy. Available data show a benefit from HBP with regard to preservation or restoration of intra- and inter-ventricular synchronization, improvement in Left Ventricular Ejection Fraction, functional status and Quality of Life, decrease in atrial fibrillation incidence and improvement in HF hospitalization rates, compared to conventional pacing. Nevertheless, superiority in terms of mortality rates has not been consistently demonstrated and long-term efficacy and safety remains to be proven. In the present manuscript, we review the status of HBP and we present our current experience with this novel pacing modality.
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http://dx.doi.org/10.1016/j.hjc.2021.10.005DOI Listing
November 2021

Optimal technique for right ventricular lead implantation in isolated persistent left superior vena cava.

Europace 2022 Jan;24(1):11

Department of Cardiology, Hippokration General Hospital, 114 Vasilisis Sofias str, Athens, Greece.

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http://dx.doi.org/10.1093/europace/euab111DOI Listing
January 2022

Syncope associated with supraventricular tachycardia: Diagnostic role of implantable loop recorders.

Ann Noninvasive Electrocardiol 2021 Sep 6;26(5):e12850. Epub 2021 May 6.

First Department of Cardiology, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece.

Syncope represents a relatively uncommon symptom of supraventricular tachycardia (SVT). It is likely that an impaired autonomic vasomotor response to the hemodynamic stress of tachycardia is the determinant of hemodynamic changes leading to cerebral hypoperfusion and syncope. In this regard, tilt-table test may detect abnormalities in the autonomic nervous function and predict the occurrence of syncope during SVT. Electrophysiology studies may reproduce the SVT, distinguish it from other life-threatening ventricular tachyarrhythmias, and exclude other causes of syncope. Not infrequently mixed syncope mechanisms are revealed during the above diagnostic workup raising doubts about the operating mechanism in the clinical setting. In such cases of uncertainty, an implantable loop recorder, providing long-term cardiac monitoring, may play a pivotal role in the establishment of the diagnosis, confirming the association of an arrhythmic event with the symptom. Herein, we present four such cases with recurrent unexplained syncope finally attributed to paroxysmal SVT guiding them to a potentially radical treatment through radiofrequency catheter ablation.
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http://dx.doi.org/10.1111/anec.12850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411760PMC
September 2021

Permanent pacemaker implantation in unexplained syncope patients with borderline sinus bradycardia and electrophysiology study-proven sinus node disease.

J Arrhythm 2021 Feb 22;37(1):189-195. Epub 2020 Nov 22.

First Department of Cardiology National and Kapodistrian University "Hippokration" Hospital Athens Greece.

Background: Significant sinus bradycardia (SB) in the context of sinus node dysfunction (SND) has been associated with neurological symptoms. The objective was to evaluate the effect of permanent pacing on the incidence of syncope in patients with rather mild degrees of SB, unexplained syncope, and "positive" invasive electrophysiologic testing.

Methods: This was an observational study based on a prospective registry of 122 consecutive mild SB patients (61.90 ± 18.28 years, 61.5% male, 57.88 ± 7.73 bpm) presenting with recurrent unexplained pre and syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). Τhe implantation of a permanent antibradycardia pacemaker (ABP) was offered to all patients according to the results of the EPS. Eighty patients received the ABP, while 42 denied.

Results: The mean of reported syncope episodes was 2.23 ± 1.29 (or presyncope 2.36 ± 1.20) in the last 12 months before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (50.39 ± 32.40 months), the primary outcome event (syncope) occurred in 18 of 122 patients (14.8%), 6 of 80 (7.5%) in the ABP group as compared to 12 of 42 (28.6%) in the no pacemaker group ( = .002).

Conclusions: Among patients with mild degree of SB and a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined SND after differentiating reflex syncope, identifies a subset of patients who will benefit from permanent pacing.
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http://dx.doi.org/10.1002/joa3.12460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7896452PMC
February 2021

Arrhythmic risk stratification in hypertrophic cardiomyopathy: are we missing something?

Europace 2021 04;23(4):648-649

First University Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital, 181 Dorieon Avenue, Drafi, Athens 19009, Greece.

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http://dx.doi.org/10.1093/europace/euaa317DOI Listing
April 2021

Can we prevent sudden cardiac death in those with relatively preserved left ventricular systolic function?

Europace 2021 04;23(4):648

First University Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion General Hospital, 181 Dorieon Avenue, Drafi, Athens 19009, Greece.

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http://dx.doi.org/10.1093/europace/euaa316DOI Listing
April 2021

Transvenous extraction of permanent pacemaker and defibrillator leads: Reduced procedural complexity and higher procedural success rates in patients with infective versus noninfective indications.

J Cardiovasc Electrophysiol 2021 02 25;32(2):491-499. Epub 2020 Dec 25.

Department of Cardiology, Hippokration General Hospital, Athens, Greece.

Introduction: Transvenous lead extraction (TLE) is critical in the long-term management of patients with cardiac implanted electronic devices (CIEDs). The aim of the study is to evaluate the outcomes of TLE and to investigate the impact of infection.

Methods And Results: Data of patients undergoing extraction of permanent pacemaker and defibrillator leads during October 2014-September 2019 were prospectively analyzed. Overall, 242 consecutive patients (aged 71.0 ± 14.0 years, 31.4% female), underwent an equal number of TLE operations for the removal of 516 leads. Infection was the commonest indication (n = 201, 83.1%). Mean implant-to-extraction duration was 7.6 ± 5.4 years. Complete procedural success was recorded in 96.1%, and clinical procedural success was achieved in 97.1% of attempted lead extractions. Major complications occurred in two (0.8%) and minor complications in seven (2.9%) patients. Leads were removed exclusively by using locking stylets in 65.7% of the cases. In the subgroup of noninfective patients, advanced extraction tools were more frequently required compared to patients with CIED infections, to extract leads (success only with locking stylet: 55.8% vs. 67.8%, p = .032). In addition, patients without infection demonstrated lower complete procedural success rates (90.7% vs. 97.2%, p = .004), higher major complication rates (2.4% vs. 0.5%, p = .31) and longer procedural times (136 ± 13 vs. 111 ± 15 min, p = .001).

Conclusions: Our data demonstrate high procedural efficacy and safety and indicate that in patients with noninfective indications, the procedure is more demanding, thus supporting the hypothesis that leads infection dissolves and/or prohibits the formation of fibrotic adherences.
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http://dx.doi.org/10.1111/jce.14841DOI Listing
February 2021

Comparing efficacy and safety in catheter ablation strategies for atrial fibrillation: protocol of a network meta-analysis of randomised controlled trials.

BMJ Open 2020 11 23;10(11):e041819. Epub 2020 Nov 23.

Research Center of Epidemiology and Statistics (CRESS-U1153), Univeristé de Paris, Paris, Île-de-France, France.

Introduction: Atrial fibrillation (AF) is the most common sustained arrhythmia. Catheter ablation (CA) of AF is an increasingly offered therapeutic approach, primary to relieve AF-related symptoms. Despite the development of new ablation approaches, there is no consensus regarding the most efficient ablation strategy. The objective of this network meta-analysis (NMA) is to compare the efficacy and safety of all different CA approaches for the treatment of patients with paroxysmal (PAF) and non-PAF (non-PAF).

Methods And Analysis: We will perform a systematic search to identify randomised controlled trials of different CA approaches for the treatment of PAF and non-PAF, through the final search date of 1 March 2020. Information sources will include major bibliographic databases (MEDLINE, Web of Science and CENTRAL) and clinical trial registries. Our primary outcomes will be the efficacy (recurrence-free survival) and safety of different CA approaches for the treatment of AF. Secondary outcomes will be all-cause mortality and procedural time. An NMA will be performed to determine the relative effects of different catheter ablation approaches (such as pulmonary vein isolation alone or in combination with ablation lines, ablation of complex fractionated atrial electrograms, etc). In PAF, a separate analysis will be performed including different energy sources (such as radiofrequency, cryogenic and laser energy). Risk of bias assessment and sensitivity analyses will be conducted to assess the robustness of the findings to potential bias.

Ethics And Dissemination: No ethical approval will be needed because data are collected from previous studies. The results will be presented through peer-review journals and conference presentation.

Prospero Registration Number: CRD42020169494.
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http://dx.doi.org/10.1136/bmjopen-2020-041819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684831PMC
November 2020

Signal-averaged electrocardiogram findings among right ventricular arrhythmogenic cardiomyopathy (ARVC) patients: Do they have a place in ARVC management?

Int J Cardiol 2021 01 8;322:175. Epub 2020 Oct 8.

First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Attica, Athens 11527, Greece.

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http://dx.doi.org/10.1016/j.ijcard.2020.10.007DOI Listing
January 2021

Arrhythmic risk stratification in heart failure mid-range ejection fraction patients with a non-invasive guiding to programmed ventricular stimulation two-step approach.

J Arrhythm 2020 Oct 2;36(5):890-898. Epub 2020 Aug 2.

First Department of Cardiology and Electrophysiology Laboratory Hippokration General Hospital National and Kapodistrian University of Athens School of Medicine Athens Greece.

Background: Although some post myocardial infarction (post-MI) and dilated cardiomyopathy (DCM) patients with mid-range ejection fraction heart failure (HFmrEF/40%-49%) face an increased risk for arrhythmic sudden cardiac death (SCD), current guidelines do not recommend an implantable cardiac defibrilator (ICD). We risk stratified hospitalized HFmrEF patients for SCD with a combined non-invasive risk factors (NIRFs) guiding to programmed ventricular stimulation (PVS) two-step approach.

Methods: Forty-eight patients (male = 83%, age = 64 ± 14 years, LVEF = 45 ± 5%, CAD = 69%, DCM = 31%) underwent a NIRFs screening first-step with electrocardiogram (ECG), SAECG, Echocardiography and 24-hour ambulatory ECG (AECG). Thirty-two patients with presence of one of three NIRFs (SAECG ≥ 2 positive criteria for late potentials, ventricular premature beats ≥ 240/24 hours, and non-sustained ventricular tachycardia [VT] episode ≥ 1/24 hours) were further investigated with PVS. Patients were classified as either low risk (Group 1, n = 16, NIRFs-), moderate risk (Group 2, n = 18, NIRFs+/PVS-), and high risk (Group 3, n = 14, NIRFs+/PVS+). All in Group 3 received an ICD.

Results: After 41 ± 18 months, 9 of 48 patients, experienced the major arrhythmic event (MAE) endpoint (clinical VT/fibrillation = 3, appropriate ICD activation = 6). The endpoint occurred more frequently in Group 3 (7/14, 50%) than in Groups 1 and 2 (2/34, 5.8%). Logistic regression model adjusted for PVS, age, and LVEF revealed that PVS was an independent MAE predictor (OR: 21.152, 95% CI: 2.618-170.887,  = .004). Kaplan-Meier curves diverged significantly (log rank,  < .001) while PVS negative predictive value was 94%.

Conclusions: In hospitalized HFmrEF post-MI and DCM patients, a NIRFs guiding to PVS two-step approach efficiently detected the subgroup at increased risk for MAE.
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http://dx.doi.org/10.1002/joa3.12416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532265PMC
October 2020

Trends in ablation procedures in Greece over the 2008-2018 period: Results from the Hellenic Cardiology Society Ablation Registry.

Hellenic J Cardiol 2021 Jan-Feb;62(1):48-54. Epub 2020 Sep 19.

Metropolitan General, Athens, Greece.

Objective: In 2008, the radiofrequency ablation (RFA) procedures registry of the Hellenic Society of Cardiology was created. This online database allowed electrophysiologists around the country to input data for all performed ablation procedures. The aim of this study is to provide a thorough report and interpretation of the data submitted to the registry between 2008 and 2018.

Methods: In 2008, a total of 27 centers/medical teams in 24 hospitals were licensed to perform RFA in Greece. By 2018, the number had risen to 31. Each center was tasked with inserting their own data into the registry, which included patient demographics (anonymized), type of procedure and technique, complications, and outcomes.

Results: A total of 18587 procedures in 17900 patients were recorded in the period of 2008-2018. By 2018, slightly more than 70% of procedures were performed in 7 high-volume centers (>100 cases/year). The most common procedure since 2014 was atrial fibrillation ablation, followed by atrioventricular nodal reentry tachycardia ablation. Complication rates were low, and success rates remained high, whereas the 6-month relapse rates declined steadily.

Conclusion: This online RFA registry has proved that ablation procedures in Greece have reached a very high standard, with results and complication rates comparable to European and American standards. Ablation procedures for atrial fibrillation are increasing constantly, with it being the most common intervention over the last 6-year period, although the absolute number of procedures still remains low, compared to other European countries.
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http://dx.doi.org/10.1016/j.hjc.2020.09.005DOI Listing
August 2021

X-linked dilated cardiomyopathy: the important role of genetic tests and imaging in the early diagnosis and treatment.

Future Cardiol 2020 11 8;16(6):629-634. Epub 2020 Jun 8.

Unit for Athletes & Hereditary Cardiovascular Diseases (EKKAN), 1st Cardiology Department, National & Kapodistrian University of Athens University Medical School, Hippokration Hospital, Athens, Greece.

Familial dilated cardiomyopathy predominantly affects younger adults and may cause advanced heart failure and sudden cardiac death. Therefore, detailed family history, family members screening, appropriate genetic testing and counselling may allow correct identification of cardiac remodeling etiology, as well as earlier disease detection. Accordingly, we present a case with an early diagnosis of an X-linked dilated cardiomyopathy guided by clinical features, cardiac MRI and genetic testing. The diagnostic workup was guided by the positive family history of cardiomyopathy and sudden cardiac deaths. Clinical implications including early management, better arrythmia risk stratification and the revealing of a potential endemic entity clustering in several male subjects of a community on Crete island are further discussed.
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http://dx.doi.org/10.2217/fca-2020-0030DOI Listing
November 2020

A perforated mitral valve anterior leaflet aneurysm in a patient presenting with acute pulmonary oedema.

Hellenic J Cardiol 2020 May - Jun;61(3):226-228. Epub 2019 Nov 20.

Department of Cardiology, Hippokration General Hospital, Athens, Greece. Electronic address:

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http://dx.doi.org/10.1016/j.hjc.2019.10.009DOI Listing
August 2021

Arrhythmic risk stratification in post-myocardial infarction patients with preserved ejection fraction: the PRESERVE EF study.

Eur Heart J 2019 09;40(35):2940-2949

First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, 114 Vasilissis Sofias avenue, Athens, Attica, Greece.

Aims: Sudden cardiac death (SCD) annual incidence is 0.6-1% in post-myocardial infarction (MI) patients with left ventricular ejection fraction (LVEF)≥40%. No recommendations for implantable cardioverter-defibrillator (ICD) use exist in this population.

Methods And Results: We introduced a combined non-invasive/invasive risk stratification approach in post-MI ischaemia-free patients, with LVEF ≥ 40%, in a multicentre, prospective, observational cohort study. Patients with at least one positive electrocardiographic non-invasive risk factor (NIRF): premature ventricular complexes, non-sustained ventricular tachycardia, late potentials, prolonged QTc, increased T-wave alternans, reduced heart rate variability, abnormal deceleration capacity with abnormal turbulence, were referred for programmed ventricular stimulation (PVS), with ICDs offered to those inducible. The primary endpoint was the occurrence of a major arrhythmic event (MAE), namely sustained ventricular tachycardia/fibrillation, appropriate ICD activation or SCD. We screened and included 575 consecutive patients (mean age 57 years, LVEF 50.8%). Of them, 204 (35.5%) had at least one positive NIRF. Forty-one of 152 patients undergoing PVS (27-7.1% of total sample) were inducible. Thirty-seven (90.2%) of them received an ICD. Mean follow-up was 32 months and no SCDs were observed, while 9 ICDs (1.57% of total screened population) were appropriately activated. None patient without NIRFs or with NIRFs but negative PVS met the primary endpoint. The algorithm yielded the following: sensitivity 100%, specificity 93.8%, positive predictive value 22%, and negative predictive value 100%.

Conclusion: The two-step approach of the PRESERVE EF study detects a subpopulation of post-MI patients with preserved LVEF at risk for MAEs that can be effectively addressed with an ICD.

Clinicaltrials.gov Identifier: NCT02124018.
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http://dx.doi.org/10.1093/eurheartj/ehz260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748724PMC
September 2019

Impact of Valve Over-Sizing After Transcatheter Aortic Valve Implantation With a Self-Expanding Valve: A Multislice Computed Tomography Study.

J Invasive Cardiol 2019 May;31(5):E76-E82

Hippokration Hospital, 26 Karaoli and Dimitriou Streets, 15562 Holargos, Athens, Greece.

Background: In transcatheter aortic valve implantation (TAVI), prosthesis over-sizing prevents paravalvular leak (PVL). Strategies of over-sizing for self-expanding bioprostheses are not well established at present.

Methods: Patients with aortic valve stenosis scheduled for TAVI underwent preprocedural multislice computed tomography. Based on the degree of over-sizing, a ROC curve was drawn to define the optimal value of valve sizing for reducing PVL after TAVI.

Results: A total of 152 consecutive patients were included in the study (mean age, 79.95 ± 7.71 years; log EuroScore: 23.87 ± 8.93%). Based on the ROC curve, sizing of 14% was the optimal that would lead to less moderate/severe PVL (P<.01). Group 1 was defined as sizing <14% (n = 49 patients) and group 2 was defined as sizing ≥14% (n = 103 patients). During a follow-up period of 36 ± 14 months, a total of 9 patients died from group 1 vs 4 patients from group 2 (P<.01). Two of the patients who died had moderate/severe PVL and 11 had no/mild PVL (P=.27). From the population, a total of 49 patients (32%) were found to be in the "borderline" zone. Patients who received the smaller valve had lower mean left ventricular outflow tract diameter (P=.048), higher rate of calcium load (mild: 10 [32%] vs 13 [72%]; moderate: 16 [52%] vs 3 [17%]; severe: 5 [16%] vs 2 [11%]; P=.02) and lower mean of sinus of Valsalva diameter (P=.046) compared with patients who received the bigger valve.

Conclusions: In patients undergoing TAVI, over-sizing the prosthesis at least 14% reduces PVL. In borderline cases, taking into consideration additional anatomical parameters may result in low rates of PVL.
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May 2019

The effect of diet, lifestyle and psychological factors in the prognosis of ischemic heart failure.

Metabol Open 2019 Mar 13;1:11-18. Epub 2019 Mar 13.

First Cardiology Division, University of Athens, Hippokration General Hospital, 114 Vasilisis Sofias Str, Athens, Greece.

Background/objective: Dietary patterns may play an important role in the prognosis of heart failure.

Methods: Dietary habits, sleeping habits, physical activity and anxiety and depression status were recorded in 326 patients (90 females, mean age 73.45 ± 10.9 years) with ischemic heart failure prospectively followed for 30 months.

Results: Lower ΗADS-depression scores (p = 0.03), a low-fat meat diet (p = 0.035) and moderate coffee consumption (p = 0.005) were associated with better prognosis. Non-significant differences were recorded in outcomes with regard to consumption of other dietary categories.

Conclusions: A balanced diet as well as emphasis on the treatment of depression may improve outcomes in ischemic heart failure.
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http://dx.doi.org/10.1016/j.metop.2019.03.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424785PMC
March 2019

Echocardiography for prediction of 6-month and late response to cardiac resynchronization therapy: implementation of stress echocardiography and comparative assessment along with widely used dyssynchrony indices.

Int J Cardiovasc Imaging 2019 Feb 8;35(2):285-294. Epub 2019 Jan 8.

First Cardiology Clinic, Hippokration Hospital, University of Athens, 114 Vas. Sofias Ave, 11528, Athens, Greece.

Non-response cardiac resynchronization therapy (CRT) remains an issue, despite the refinement of selection criteria. The purpose of this study was to investigate the role of stress echocardiography along with dyssynchrony parameters for identification of CRT responders or late responders. 106 symptomatic heart failure patients were examined before, 6 months and 2-4 years after CRT implementation. Inotropic contractile reserve (ICR) and inferolateral (IL) wall viability were studied by stress echocardiography. Dyssynchrony was assessed by: (1) Septal to posterior wall motion delay (SPWMD) by m-mode. (2) Septal to lateral wall delay (SLD) by TDI. (3) Interventricular mechanical delay (IVMD) by pulsed wave Doppler for (4) difference in time to peak circumferential strain (TmaxCS) by speckle tracking. (5) Apical rocking (ApR) and septal flash (SF) by visual assessment. At 6 months there were 54 responders, with 12 additional late responders. TmaxCS had the greatest predictive value with an area under curve (AUC) of 0.835, followed by the presence of both ICR and viability of IL wall (AUC 0.799), m-mode (AUC = 0.775) and presence of either ApR or SF (AUC = 0.772). Predictive ability of ApR and of ICR is augmented if late responders are also included. Performance of dyssynchrony parameters is enhanced, in patients with both ICR and IL wall viability. Stress echocardiography and dyssynchrony parameters are simple and reliable predictors of 6-month and late CRT response. A stepwise approach with an initial assessment of ICR and viability and, if positive, further dyssynchrony analysis, could assist decision making.
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http://dx.doi.org/10.1007/s10554-018-01520-6DOI Listing
February 2019

Novel therapeutic options in the prevention of atrial fibrillation.

Hellenic J Cardiol 2018 Sep - Oct;59(5):279-280. Epub 2018 Dec 20.

Department of Cardiology, Hippokration General Hospital, 114 Vasilisis Sofias str, Athens, Greece. Electronic address:

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http://dx.doi.org/10.1016/j.hjc.2018.12.001DOI Listing
June 2019

Percutaneous lead extraction and repositioning: An effective and safe therapeutic strategy for early ventricular lead perforation with dislocation both inside and outside the pericardial sac following a cardiac device implantation.

J Cardiovasc Electrophysiol 2019 03 26;30(3):299-307. Epub 2018 Dec 26.

Department of Cardiology, Hippokration General Hospital, Athens, Greece.

Introduction: Cardiac perforation of the right ventricle associated with pacemaker or implantable cardioverter defibrillator (ICD) leads' implantation is uncommon, albeit potentially life-threatening, complication. The aim of this study is to further identify the optimal therapeutic strategy, especially when lead dislocation has occurred outside the pericardial sac.

Methods And Results: The study population included 10 consecutive patients (six female, mean age: 66.5 years old) diagnosed with early ventricular lead perforation following a pacemaker or ICD implantation, with significant protrusion inside the pericardial sac (n = 2) or migration of the lead at the pleural space ( n = 3), the diaphragm ( n = 1), or the abdominal cavity ( n = 4), during the period 2013-2017. All patients were symptomatic; however, individuals presenting with hemodynamic instability were excluded. The outcome of the percutaneous therapeutic approach was retrospectively assessed. All patients underwent a successful removal of the perforating lead percutaneously at the electrophysiology lab, by direct traction, and repositioning in another location of the right ventricle. The operation was performed by a multidisciplinary team, under continuous hemodynamic and transesophageal echocardiographic monitoring and cardiac surgical backup. The periprocedural period was uneventful. Subjects were followed up for at least 1 year. Interestingly, all patients developed a type of postcardiac injury syndrome, successfully treated with a 3-month regimen of ibuprofen and colchicine.

Conclusion: Percutaneous traction and repositioning of the perforating ventricular lead are effective, safe, and less invasive compared with the thoracotomy method in hemodynamically stable patients when dislocation has occurred outside the pericardial sac provided that there is no visceral organs injury.
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http://dx.doi.org/10.1111/jce.13804DOI Listing
March 2019

T wave alternans extracted from 30-minute short resting Holter ECG recordings predicts mortality in heart failure.

J Electrocardiol 2018 Jul - Aug;51(4):588-591. Epub 2018 Mar 26.

First Department of Cardiology and Electrophysiology Laboratory, Hippokration General Hospital, National and Kapodistrian, University of Athens School of Medicine, Athens, Greece.

Background: We extracted T Wave Alternans (TWA) from a 30 minute Short Resting Holter ECG (SRH ECG) in the supine position, as a Total Mortality (TM) predictor in Heart Failure (HF).

Methods: Signals from 146 HF patients (LVEF = 33 ± 10%), were analyzed with Modified Moving Average method. After 42.1 months, 26 patients died.

Results: (Deceased vs Living group): TWA:31 ± 18 μV vs 25 ± 13 μV(p = 0.05), LVEF:32 ± 10% vs 34 ± 9% (p = 0.5), Heart Rate:73 ± 11 bpm vs 69 ± 12 bpm (p = 0.2), SDNN/HRV:45 ± 42 ms vs 41 ± 29 ms (p = 0.4), QRS:123 ± 26 ms vs 119 ± 29 ms (p = 0.5).Cox regression model adjusted for TWA, LVEF and QRS, revealed that the TWA was an independent TM predictor (H.R.: 1.022, 95% C.I.: 0.999-1.046, p = 0.05).The TWA ≥ 42 μV demonstrated HR: 2.521, (95% C.I.: 0.982-6.472, p = 0.05).

Conclusions: In severely affected HF patients, TWA from a SRH ECG may be present even during slow resting heart rates and proved to be an important and independent TM predictor. The SRH ECG recording is an efficient and fast method for mortality risk evaluation in HF patients.
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http://dx.doi.org/10.1016/j.jelectrocard.2018.03.012DOI Listing
May 2019

Signal-averaged electrocardiography: Past, present, and future.

J Arrhythm 2018 Jun 28;34(3):222-229. Epub 2018 May 28.

Electrophysiology Laboratory and First University Department of Cardiology Hippokration General Hospital National and Kapodestrian University of Athens Athens Greece.

Signal-averaged electrocardiography records delayed depolarization of myocardial areas with slow conduction that can form the substrate for monomorphic ventricular tachycardia. This technique has been examined mostly in patients with coronary artery disease, but its use has been declined over the years. However, several lines of evidence, derived from hitherto clinical data in patients with healed myocardial infarction, indicate that signal-averaged electrocardiography remains a valuable tool in risk stratification, especially when incorporated into algorithms encompassing invasive and noninvasive indices. Such an approach can aid the more precise identification of candidates for device therapy, in the context of primary prevention of sudden cardiac death. This article reappraises the value of signal-averaged electrocardiography as a predictor of arrhythmic outcome in patients with ischemic heart disease and discusses potential future indications.
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http://dx.doi.org/10.1002/joa3.12062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6010001PMC
June 2018

Epicardial right ventricular lipoma presenting with sustained ventricular tachycardia.

J Card Surg 2018 08 19;33(8):438-439. Epub 2018 Jun 19.

Department of Cardiology, Hippokration General Hospital, Athens, Greece.

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http://dx.doi.org/10.1111/jocs.13738DOI Listing
August 2018

Echocardiography for the management of patients with biventricular pacing: Possible roles in cardiac resynchronization therapy implementation.

Hellenic J Cardiol 2018 Nov - Dec;59(6):306-312. Epub 2018 Feb 13.

First Cardiology Clinic, Hippokration Hospital, University of Athens, 114 Vas. Sofias Ave., 11528, Athens, Greece.

Cardiac resynchronization therapy (CRT) is an established therapeutic option for the subset of patients with heart failure (HF), reduced ejection fraction (EF), and dyssynchrony evidenced by electrocardiography. Benefit from CRT has been proven in many clinical trials, yet a sizeable proportion of these patients with wide QRS do not respond to this intervention, despite the updated practice guidelines. Several echocardiographic indices, targeting mechanical rather than electrical dyssynchrony, have been suggested to address this issue, but research so far has not succeeded in providing a single and simple measurement with adequate sensitivity and specificity for identification of responders. While there is still ongoing research in this field, echocardiography proves helpful in other aspects of CRT implementation, such as site selection for left ventricular (LV) lead pacing and optimization of pacing parameters during follow-up visits.
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http://dx.doi.org/10.1016/j.hjc.2018.02.006DOI Listing
July 2019

Programmed ventricular stimulation predicts arrhythmic events and survival in hypertrophic cardiomyopathy.

Int J Cardiol 2018 03 28;254:175-181. Epub 2018 Jan 28.

First Department of Cardiology and Electrophysiology Laboratory, Hippokration General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece.

Background: Sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) in the context of primary prevention remains suboptimal. The purpose of this study was to examine the additional contribution of programmed ventricular stimulation (PVS) on established risk assessment.

Methods: Two-hundred-and-three consecutive patients with diagnosed HCM and ≥1 noninvasive risk factors were prospectively enrolled over 19years. Patients were risk stratified, submitted to PVS and received an implantable cardioverter-defibrillator (ICD) according to then-current American Heart Association (AHA) guidelines and inducibility. Participants were prospectively followed-up for primary endpoint occurrence (appropriate ICD therapy or SCD). Contemporary (2015) AHA and European Society of Cardiology (ESC) guidelines were retrospectively assessed.

Results: During a median follow-up period of 60months the primary endpoint occurred in 20 patients, 19 of whom were inducible and received an ICD. Overall, 79 patients (38.9%) were inducible and 92 patients (45.3%) received an ICD (PVS sensitivity=95%, specificity=67.2%, positive predictive value=24%, negative predictive value=99.2%). AHA and ESC guidelines application misclassified 3 and 9 primary endpoint-meeting patients, respectively. Inducibility was the most important determinant of event-free survival in multivariate Cox regression (hazard ratio=33.3). A combined approach of ESC score≥6% or AHA indication for ICD with PVS inducibility yielded absolute sensitivity and negative predictive value, the former at a more cost-effective and specific way.

Conclusions: Inducibility at PVS predicts SCD or appropriate device therapy in HCM. Non-inducibility is associated with prolonged event-free survival, while the procedure was proven safe. Reintegration of PVS into established risk stratification models in HCM may improve patient assessment.
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http://dx.doi.org/10.1016/j.ijcard.2017.10.033DOI Listing
March 2018
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