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The development of novel treatment methods is crucial for managing refractory ventricular tachycardia resistant to conventional therapies. Stereotactic arrhythmia radiotherapy holds promising potential for such patients, enabling precise non-invasive ablation of arrhythmogenic substrate with minimal damage to surrounding organs. This approach could be invaluable for patients in whom the target tissue is inaccessible through catheter ablation, frequent implantable cardioverter-defibrillator shocks significantly diminish their quality of life, or for those contraindicated for such treatment options due to poor health status. The target for irradiation is precisely defined through prior imaging diagnostics, ECGs of ventricular tachycardias and invasive or non-invasive electrophysiological mapping of the heart. After radiation treatment planning, irradiation of a single high dose of 25 Gy follows, which is generally well tolerated by the patients. Previous studies have reported good treatment efficacy, with a significant reduction in ventricular tachycardia episode frequency, while causing minimal side effects. We report on the first group of four patients with high-risk refractory ventricular tachycardia treated with stereotactic arrhythmia radiotherapy at the Institute of Oncology Ljubljana. This opens new possibilities for the treatment of this vulnerable patient group within the Slovenian healthcare system and contributes to the evolving field of radiotherapeutic treatment.

Purpose: Atrioesophageal fistula is one of the most feared complications of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) as it is associated with high mortality. Determining the esophagus location during RFCA might reduce the risk of esophageal injury. The present study aims to evaluate the feasibility of using intracardiac echocardiography integrated into a 3-dimensional electroanatomical mapping system (ICE/3D EAM) for the assessment of esophageal position and shifts in response to ablation. Methods: We prospectively enrolled 20 patients that underwent RFCA of AF under conscious analgosedation. The virtual anatomy of the left atrium, the pulmonary vein (PV) ostia, and the esophagus was created with ICE/3D EAM. The esophageal positions were obtained at the beginning of the procedure and then after left and right PV isolation (PVI). Esophageal shifts were measured offline after the procedure using the tools available in the 3D EAM system. Results: Most esophagi moved away from the ablated PV ostia. After the left PVI, the median of the shifts was 2.8 mm (IQR 1.0–6.3). In 25% of patients, the esophagus shifted by >5.0 mm (max. 13.4 mm). After right PVI, the median of shifts was 2.0 mm (IQR 0.7–4.9). In 10% of patients, the esophageal shift was >5.0 mm (max. 7.8 mm). Conclusions: ICE/3D EAM enables the intraprocedural visualization of baseline esophageal position and its shifts after PVI. The shifts are variable, but they tend to be small and directed away from the ablation site. Repeated intraprocedural visualization of the esophagus may be needed to reduce the risk of esophageal injury.

IntroductionCatheter ablation for atrial fibrillation (AF) is the most frequently performed cardiac ablation procedure worldwide. The majority of ablations can now be performed safely with minimal radiation exposure or even without the use of fluoroscopy, thanks to advances in 3-dimensional electroanatomical mapping systems and/or intracardiac echocardiography. The aim of this study was to conduct a meta-analysis to compare the effectiveness of zero fluoroscopy (ZF) versus non-zero fluoroscopy (NZF) strategies for AF ablation procedures.MethodsElectronic databases were searched and systematically reviewed for studies comparing procedural parameters and outcomes of ZF vs. NZF approaches in patients undergoing catheter ablation for AF. We used a random-effects model to derive the mean difference (MD) and risk ratios (RR) with a 95% confidence interval (CI).ResultsOur meta-analysis included seven studies comprising 1,593 patients. The ZF approach was found to be feasible in 95.1% of patients. Compared to the NZF approach, the ZF approach significantly reduced procedure time [mean difference (MD): −9.11 min (95% CI: −12.93 to −5.30 min; p

Abstract Purpose The aim of this study was to evaluate the safety and efficacy of zero-fluoroscopy (ZF) catheter ablation (CA) for supraventricular tachycardias (SVT). Methods 584 consecutive patients referred to our institution for CA of SVT were analysed. Patients were categorised into two groups; zero-fluoroscopy (ZF) group and conventional fluoroscopy (CF) group. The ZF group was further divided into two subgroups (adults and paediatric). Patient characteristics, procedural information, and follow-up data were compared. Results The ZF group had a higher proportion of paediatric patients (42.2% vs 0.0%; p

Izhodišče: Katetrska ablacija je danes uveljavljena metoda zdravljenja preddvorne fibrilacije (AF). O zgodnjih in srednjeročnih izidih smo že poročali. Tokrat želimo predstaviti še dolgoročne klinične izide. Metode: Spremljali smo vse bolnike, pri katerih smo v obdobju 2003‒2009 prvič opravili katetrsko ablacijo paroksizmalne ali vztrajajoče AF zaradi neučinkovitosti antiaritmičnega zdravljenja. Upoštevali smo tudi ablacijske posege zaradi tipične atrijske undulacije (AU) po letu 1999. Glavni cilj ablacijskega posega je bil popolna električna osamitev pljučnih ven (PV). Uporabili smo metodo segmentne radiofrekvenčne ablacije s fluoroskopskim nadzorom in beleženjem elektrogramov na krožnem katetru »laso«. Pri bolnikih s tipično AU smo opravili linijsko ablacijo kavotrikuspidalne ožine. Bolnike smo spremljali vsaj 5 let po doseženi popolni osamitvi PV oz. do telefonskega razgovora v aprilu 2020 oz. do morebitne smrti. Razvrstili smo jih v tri skupine: a) uspešne, tj. v stabilnem sinusnem ritmu z nemotečimi palpitacijami do 5 min, brez rednega antiaritmičnega zdravljenja, b) delno uspešne, ko so bili pretežno v sinusnem ritmu, z epizodami dokumentirane AF/AU do enkrat letno in tudi občasno uporabo antiaritmičnih zdravil v ustreznih odmerkih in c) neuspešne, tj. s pogostimi epizodami AF/AU, neučinkovitim antiaritmičnim zdravljenjem v ustreznih odmerkih ali z dolgotrajno vztrajajočo AF/AU. Ablacijski poseg smo ponovili zaradi recidiva AF/AU, vendar ne prej kot po 3 mesecih. Ob sumu na ponovitev aritmije smo naročili serijske posnetke EKG in Holterjevega monitoriranja. Podatke smo vrednotili s Kaplan-Meierjevo analizo, testom-t in Fisherjevim testom. Vrednost p < 0,05 je bila značilna. Rezultati: V raziskavo smo uvrstili 128 bolnikov (95 moških, 33 žensk; mediana starost pri prvem posegu zaradi AF je bila 54,5 let, rang 19–75), pri katerih smo opravili povprečno 1,7 ablacijskega posega zaradi AF oziroma 2 posega, če smo upoštevali še ablacije AU. Spremljanje je zaključilo 117 bolnikov (85 moških in 32 ženskah) po povprečno 11,7 letih (mediana 140 mesecev, rang 21–230 mesecev). Umrlo je 10 bolnikov (6 moških, 4 ženske), nihče pa zaradi ablacijskega posega. Od soobolevnosti sta bili v ospredju maligna bolezen in ščitnična disfunkcija. Verjetnost za ohranitev stabilnega sinusnega ritma je bila po 10 letih približno 50-odstotna. Po 15-odstotnem padcu verjetnosti za sinusni ritem v prvem letu je bil padec nato linearen, in sicer 4 % letno. Ablacijsko zdravljenje je bilo uspešno pri 54 bolnikih (46 %), delno uspešno pri 25 (21 %) in neuspešno pri 38 bolnikih (33 %, manj uspešno pri ženskah, p < 0,05). V zadnjih 10 letih spremljanja smo opravili manjši del ablacijskih posegov ‒ 46 (16 %). Antiaritmična zdravila je prejemalo 38 bolnikov (32 %), pretežno amiodaron in propafenon. Med ablacijskim posegom smo povzročili tamponado pri 5 bolnikih (4 %). Nihče od njih ni potreboval kirurškega posega. Drugih večjih zapletov ni bilo. Zaključek: Ablacijsko zdravljenje AF je dolgoročno dovolj uspešno, varno in po podatkih drugih avtorjev tudi cenovno učinkovito. Zato ga lahko priporočimo večini bolnikov z AF. Za celostno obravnavo bolnikov z AF pa so pomembni tudi: ureditev odpravljivih dejavnikov tveganja, antiaritmično zdravljenje in kakovostno antikoagulacijsko zdravljenje.

Izvleček Refleksna nevrokardiogena sinkopa je ena izmed najbolj pogostih oblik izgube zavesti, pri kateri prekomeren odziv parasimpatičnega živčnega sistema vodi do padca krvnega pritiska preko vazodilatacije in/ali znižanja srčnega utripa. Gre za sinkopo, ki praviloma ni povezana z organsko boleznijo, zato je njena prognoza dobra in umrljivost ni povečana, lahko pa vpliva na kvaliteto življenja. Z novo metodo zdravljenja - kardionevroablacijo - želimo doseči izboljšanje kvalitete življenja pri pacientih s pogostimi epizodami refleksne nevrokardiogene sinkope s prevladujočo kardioinhibitorno komponento, pri katerih nefarmakološki in farmakološki načini zdravljenja niso učinkoviti, vstavitev srčnega spodbujevalnika pa zaradi mladosti odsvetovana. Gre za perkutani elektrofiziološki poseg, kjer z radiofrekvenčno ablacijo z endokardialne strani uničimo specifične parasimpatične ganglije epikardialno na srcu. Na ta način dosežemo delno parasimpatično denervacijo srca in s tem zmanjšamo ali odpravimo prekomeren vpliv parasimpatičnega živčevja na srce in posledično tudi kardioinhibitorno komponentno refleksne nevrokardiogene sinkope.

Ventricular tachycardia (VT) poses a significant risk for sudden death and heart failure exacerbation in patients with ischemic heart disease. Catheter-based radiofrequency ablation is the last treatment option for patients with frequent VT recurrences despite antiarrhythmic drugs. The aim was to present our retrospective catheter ablation data in this group of patients.The majority of 34 patients, who underwent percutaneous endocardial radiofrequency catheter ablation, were male, median age 67.5 years, who presented with electrical storm, had underlying cardiomyopathy after remote inferior wall myocardial infarction and preceding myocardial revascularization procedure, and had been implanted with cardioverter-defibrillator (ICD). Two ablation methods were used: linear ablation and/or scar homogenization. Acute ablation success (non-inducibility of any VT) was achieved in 59 % of procedures. VT could not be interrupted in 2 (6 %) patients. Pericardial tamponade that needed surgical intervention occurred in one procedure (2 %), and was related to inadvertent perforation of the right ventricular apex with a diagnostic catheter. Seven (20 %) patients died and additional 3 were lost from the median of 31 (6–151, rank) months of follow-up. No late VT recurrences were demonstrated in 20 (59 %) patients, and rare in 4 (12 %). Overall, the ablation procedure was successful in 71 % of patients.Catheter ablation gave very good long-term clinical result in about two-thirds of our patients with ischaemic cardiomyopathy and frequent VT recurrences. Catheter ablation, preferably with scar homogenization approach, should be considered early to reduce the number of VT episodes and ICD discharges.

Background: Short-term oucomes of radiofrequency (RF) catheter isolation of the pulmonary veins (PVs) in patients with paroxysmal or persistent atrial fibrillation (PAF/PEAF) are encouraging. However, long-term outcomes are not well defined. Therefore, we evaluated 3–5-year outcomes in our series of patients. Freedom from symptomatic AF/flutter/tachycardia recurrences with patients off antiarrhythmic drugs (AAD) was considered a treatment success.Methods: Consecutive patients with symptomatic PAF/PEAF and AAD failure, without significant structural heart disease, were prospectively recruited between September 2003 and November 2009. Irrigated-tip RF ablation catheter and Lasso catheter were used after standard trans-septal approach with X-ray fluoroscopic guidance. Ablation endpoints were: complete segmental/circumferential ostial and antral electrical PV isolation, non-PV foci ablation, and bi-directional flutter isthmus (FI) block when indicated. The procedure was repeated if AF/flutter/tachycardia recurred after 3-month blanking period. The suspected arrhythmia recurrences were evaluated by series of ECG/Holter recordings. Data were analyzed by t-, chi-square, and Fisher’s exact tests. P < 0.05 was considered statistically significant.Results: In 126 patients, median age 55 years (range 19–75), 94 men (75 %), 86 with PAF and 40 with PEAF (31 %), 207 procedures were performed: single in 63 (50 %), double in 48 (38 %), and multiple in 15. FI was ablated in 53 patients (42 %). Tamponade occurred in 4 (3 %). No PV stenosis, esophageal injury, or stroke were detected clinically in 115 patients (91 %) during 36-month (13–89) follow-up. We achieved treatment success in 69 patients (61 %), partial success with a significant reduction of AF/flutter/tachycardia recurrences on AAD in 13 patients (12 %), and in 33 patients (27 %) the procedure was not successful. Overall, 73 % of our patients had long-term benefit. Outcomes were better in patients with PAF vs. PEAF (84 % vs. 48 %, p < 0,001), in younger age, in those without concomitant diseases, and in those with normal PV anatomy. These results were maintained in the subgroup of 58 patients over 56 months of follow-up: 35 (60 %), 6 (11 %), and 17 (29 %), respectively.Conclusions: Lasso-guided RF irrigated-tip segmental/circumferential PV isolation is a safe and long-term successful treatment of PAF in the majority of our patients. The method needs improvements in patients with PEAF, possibly with the introduction of new technologies.

Intracardiac ultrasound was developed because of the need for accuracy during invasive heart procedures. This technology enables the operator to visualize heart structures and to precisely guide catheters and various devices in the heart. Mechanical (rotational) type of ultrasound probe was developed first, but has now been surpassed by newer sector type probe that is commonly used nowadays. Use of intracardiac ultrasound is most widespread in electrophysiology procedures and ablations due to heart rhythm disorders. It is also used in other invasive heart procedures, such as atrial septal defect closure, patent foramen ovale closure, ventricular septal defect closure, percutaneous procedures on the aortic valve and others. The use of intracardiac ultrasound ensures a higher level of safety during invasive heart procedures.

Andersen-Tawil syndrome (ATS) is a rare inherited or sporadic disorder characterized by ventricular arrhythmias, characteristic QT-U wave patterns in electrocardiogram, periodic paralysis, and dysmorphic features. We describe a patient of Slovenian origin who exhibited mild dysmorphic features, repetitive bidirectional and monomorphic ventricular tachycardias, and characteristic QT-U wave patterns. Ventricular arrhythmias persisted despite several catheter ablation procedures a different anti-arrhythmic drug treatments, resulting only in pacemaker implantation and amiodarone toxicity. Cardioverter-defibrillator was implanted after a major syncopal attack. Finally, molecular genetic screening revealed a novel heterozygous mutation (c.424A>C/p. Thr142Pro) in KCNJ2 gene consistent with the ATS.

Atrial fibrillation is the most common sustained cardiac dysrhythmia leading to an increased risk of heart failure and thromboembolic stroke. It is a multifactorial disease, the incidence of which increases with age and presence of other comorbidities. Especially in the young it can develop in the absence of known risk factors, and is called idiopathic or „lone“ atrial fibrillation, which in a smaller proportion can occur as a familial form. The familial idiopathic atrial fibrillation is a monogenetic disease; mutations found this far mainly cause an altered function of potassium channels. In contrast, the nonfamilial or sporadic form of idiopathic atrial fibrillation is a polygenetic disease where certain polymorphisms increase the risk of developing atrial fibrillation. These polymorphisms encode the subunits of cationic channels and proteins, which participate in inflammation and propagation of depolarisation. With the advances in genetics and discovery of mutations and polymorphisms which increase the risk of developing atrial fibrillation we will discover pathophysiological mechanisms of initiation and chronification of this dysrhythmia. The discoveries could be a basis for the development of new prevention and treatment strategies for atrial fibrillation.