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Introduction There are several prognostic scores for the assessment of risk of atrial fibrillation (AF) recurrence post ablation procedure. However, the use of these complex scores is difficult and the validation on different populations brought divergent results. Our goal was to compare the performance of these risk scores as the basis for the development of a new, simplified score based only on few universally predictive variables. Methods All cryoballoon‐based AF ablations performed in a single‐center over a 10‐year period were prospectively analyzed with regard to AF recurrence. This served to analyze the performance of APPLE, CAAP‐AF, SCALE‐CryoAF, MB‐LATER, CHADS2, and CHA2DS2‐VASc risk scores. Results A total of 597 patients, mostly (78.1%) with paroxysmal AF were studied. Analyzed risk scores performed poorer than in the original publications because some risk factors were not predictive of AF recurrence. A simplified score named 0‐1‐2 PL, composed of just two universally predictive variables, AF type (1 point for P ersistent AF) and LA dimension (1 point for L A size >45 mm) was developed. The 0‐1‐2 PL score stratified patients into low risk (0 points), intermediate risk (1 point), and high risk categories (2 points) which were related to a 2‐year risk of AF recurrence of 21%, 37%, and 55%, respectively. This score had C‐statistics (0.620) higher/comparable to other investigated much more complex scores. Conclusion The assessment of risk of AF recurrence at the pre‐ablation stage can be simplified without compromising accuracy. This could help to popularize risk assessment and standardization of AF management., This study suggests that despite the significant differences between risk scores in terms of the choice of risk factors and the relative weights assigned to them, their performance for pre‐ablation risk assessment is quite similar, and weaker than originally reported. It seems that the assessment of the risk of AF recurrence at the pre‐ablation stage can be simplified by using the novel 0‐1‐2 PL score instead of more complex scores.

IntroductionOne of the challenges of left bundle branch (LBB) pacing is to place the pacing lead deep enough in the septum to obtain capture of the LBB, yet not too deep to avoid perforation. We hypothesized that the occurrence of the ectopic beats of qR/rsR’ morphology in V1 lead (fixation beats) during the lead fixation would predict that the final desired intraseptal lead depth was just reached, while the lack of fixation beats would indicate too shallow position, and need for more lead rotations.MethodsConsecutive patients during LBB pacing device implantation were analyzed retrospectively and then prospectively with respect to the occurrence of the fixation beats during each episode of lead rotation. We compared the presence of fixation beats during the lead rotation event directly before the LBB capture area depth was reached versus during the events before intermediate/unsuccessful positions.ResultsA total of 339 patients and 1278 lead rotation events were analyzed. In the retrospective phase, the fixation beats were observed in 327/339 of final lead positions and in 9/939 of intermediate lead positions (pConclusionsMonitoring fixation beats during deep septal lead deployment can facilitate the procedure and possibly increase the safety of lead implantation.

Background: Several electrocardiographic (ECG) algorithms have been developed for predicting accessory pathway (AP) location in Wolff–Parkinson–White syndrome. However, their accuracy may be related to the manifested degree of preexcitation on ECG. Aims: Our goal was to assess the effect of the degree of preexcitation on the accuracy of 4 traditional AP localization algorithms and to compare them with the algorithm specifically designed for ECGs with maximal preexcitation (Pambrun) Methods: The study included 300 patients who underwent successful ablation of an overt atrioventricular AP. Resting and maximally preexcited ECGs obtained during incremental atrial pacing were assessed using 4 traditional AP localization algorithms: Xie, d’Avila, Iturralde, and Taguchi. Maximally preexcited ECGs were additionally assessed with the Pambrun algorithm. We compared the precision of the algorithms to predict accurate or anatomically adjacent AP location. Results: Theoverall accuracy of traditional AP localization algorithms using resting ECG ranged between 26% and 53.7% and improved to a range of 47.3% to 69.7% when adjacent locations were accepted. When used with maximal preexcitation, all algorithms had significantly higher accuracy, with a mean improvement of 14.3 and 15.6 percentage points for precise and adjacent sites, respectively. The Pambrun algorithm for maximally preexcited ECGs had the highest precision for both accurate and adjacent locations of the APs (89.7% and 97%, respectively). Conclusions: Greater preexcitation on ECG improved the accuracy of the traditional AP localization algorithms. The algorithm designed to use maximally preexcited ECGs has the best accuracy. Maximally preexcited ECG recordings should preferably be used in clinical practice to facilitate the ablation procedure.

Background Strength-duration curves for permanent His bundle (HB) pacing are potentially important for pacemaker programming. Objectives We aimed to calculate strength-duration curves and chronaxies of the HB and of the adjacent right ventricular (RV) working myocardium and to analyze zones of selective HB capture and battery current drain when pacing at different pulse durations (PDs). Methods Consecutive patients with permanent HB pacing were studied. The RV and HB capture thresholds were assessed at several PDs. Battery current drain and zones of selective HB capture at PDs of 0.1, 0.2, 0.4, and 1.0 ms were determined. Results In the whole group (N = 127), the HB chronaxie was shorter than the RV chronaxie. This difference was driven by patients with selective HB pacing (HB chronaxie 0.47 ms vs RV chronaxie 0.79 ms). The strength-duration curve for the HB had a lower rheobase and its steep portion started at shorter PDs, thus creating wider distance—zone of programmable selective HB pacing—between the HB and RV strength-duration curves at shorter PDs. The battery current drain was lower with pacing at PDs of 0.1–0.4 ms vs 1.0 ms. Chronaxie-adjusted PDs offered the lowest current drain. Conclusion For the first time, the strength-duration curves for permanent selective and nonselective HB pacing were determined. Selective HB capture and battery longevity can be promoted by shorter PDs (0.2 ms). Longer PDs (1.0 ms) offer greater safety margin for RV capture and may be preferable if simultaneous RV capture during HB pacing is desired.

AimsDuring non-selective His bundle (HB) pacing, it is clinically important to confirm His bundle capture vs. right ventricular septal (RVS) capture. The present study aimed to validate the hypothesis that during HB capture left ventricular lateral wall activation time, approximated by the V6R-wave peak time (V6RWPT), will not be longer than the corresponding activation time during native conduction.MethodsConsecutive patients with permanent HB pacing were recruited; cases with abnormal His-ventricle interval or left bundle branch block were excluded. Two corresponding intervals were compared: stimulus-V6RWPT and native HBpotential-V6RWPT. Difference between these two intervals (delta V6RWPT), diagnostic of lack of HB capture, was identified using receiver operating characteristic (ROC) curve analysis.ResultsA total of 723 ECGs (219 with native rhythm, 172 with selective HB, 215 with non-selective HB, and 117 with RVS capture) were obtained from 219 patients. The native HB-V6RWPT, non-selective-, and selective-HB paced V6RWPT were nearly equal, while RVS V6RWPT was 32.0 (±9.5) ms longer. The ROC curve analysis indicated delta V6RWPT > 12 ms as diagnostic of lack of HB capture (specificity of 99.1% and sensitivity of 100%). A blinded observer correctly diagnosed 96.7% (321/332) of ECGs using this criterion.ConclusionWe validated a novel criterion for HB capture that is based on the physiological left ventricular activation time as an individualized reference. HB capture can be diagnosed when paced V6RWPT does not exceed the value obtained during native conduction by more than 12 ms, while longer paced V6RWPT indicates RVS capture.

Background: Cardiac resynchronization therapy (CRT) using biventricular pacing (BVP) has limited efficacy in patients with heart failure (HF) and right bundle branch block (RBBB). Left bundle branch area pacing (LBBAP) has been reported as an alternative option for BVP-CRT. The aim of the study was to assess the feasibility and outcomes of LBBAP in patients with RBBB and indication for CRT in an international, multicenter, collaborative study. Methods: LBBAP was attempted in patients with LVEF

BackgroundDuring left bundle branch (LBB) area pacing, it is important to confirm that the capture of the LBB is achieved, not just the capture of only the adjacent left ventricular myocardium (LV septal capture). Our aim was to establish ECG criteria for LBB capture by analyzing ECGs with confirmed LBB capture and non-capture. We hypothesized that since LBB pacing results in physiologic depolarization of the left ventricle then the native QRS can serve as a reference for the diagnosis of LBB capture in the same patient.MethodsOnly patients with direct evidence of LBB capture (output-dependent or refractoriness-dependent QRS morphology transition) were included. Several QRS characteristics were compared between the native rhythm and different types of LBB area capture. Receiver-operator characteristics analysis was performed to determine the optimal V6 R-wave peak time (RWPT) cut-off for LBB diagnosis.ResultsA total of 357 ECG tracing (124 patients) were analyzed: 118 with native rhythm, 124 with non-selective LBB capture, 69 with selective LBB capture and 46 with LV septal capture. Our hypotheses that during LBB capture the paced V6 RWPT (measured from QRS onset) equals the native V6 RWPT and that the paced V6 RWPT (measured from the stimulus) equals the LBB potential to V6 R-wave peak interval were positively validated. Criteria based on these rules had sensitivity and specificity of 98.0–88.2% and 85.7–95.4%, respectively. The optimal and 100% specific V6 RWPT values for differentiation between LBB capture and LV septal capture in patients with narrow QRS / right bundle branch block were 83 ms and 74 ms, respectively; while in patients with left bundle branch block/asystole/ventricular escape the optimal and 100% specific V6 RWPT values were 101 ms and 80 ms, respectively.ConclusionsNovel criteria for LBB capture were developed and optimal V6 RWPT cut-offs were determined.What this study addsWe showed that LBB pacing truly reproduce the physiological depolarization of the left ventricle since the paced V6 RWPT equals the native conduction V6 RWPT.Individualized LBB capture criteria, that use the native QRS as a reference, were developed.The optimal V6 RWPT values for differentiation between LBB capture and LV septal capture were determined, separately for patients with healthy and diseased LBB.

Since the cryoballoon was introduced into clinical practice, approximately half a million patients have undergone a pulmonary vein isolation (PVI) using this tool throughout the world. This single-shot technique makes the pulmonary vein isolation procedure easier and has the potential to expand access to the interventional treatment of atrial fibrillation (AF), eventually leading to a reduction of the AF-related disease burden. Several studies and metanalyses have assessed the acute and long-term efficacy of cryoballoon-based PVI. The reported success rate of PV isolation during the procedure is about 98%. Despite this, the long-term effectiveness of the procedure (AF free survival) assessed at 1 year after the ablation is in the range of 70–82%. The AF-free survival rate significantly depends on the clinical characteristics of the studied group and the presence of risk factors, especially the type of AF (paroxysmal vs. persistent), LA size and the presence of heart failure. For a safe and effective procedure the electrophysiologist should be aware of all minute details of the procedure including several tricks developed by the most experienced operators and the pre-procedural and post-procedural management recommendations. Detailed knowledge of complications of cryoballoon (CB)-based ablation is mandatory. This review concentrates on the practical aspects and recommendations for a cryoballoon ablation procedure. The review is based on the authors’ experience, including 800 procedures performed over 11 years with a low complication rate, and is presented within the context of the literature.

Aims The recently introduced technique of direct transseptal pacing of the left bundle branch is poorly characterized with many questions with regard to the optimal implantation strategy and safety concerns largely left unanswered. We developed a cadaver model for deep septal lead deployment in order to investigate the depth of penetration in relation to lead behaviour, lead tip position, and the number of rotations. Methods and results Five fresh human hearts and five lumenless, 4.1-Fr pacing leads were used for deep septal deployment simulations. The leads were positioned with the use of a dedicated delivery sheath and screwed into the interventricular septum at several sites progressively more distal from the atrioventricular ring with a predetermined number of lead rotations. During each lead deployment, the depth of tip penetration was measured and the lead behaviour was noted. Four distinct lead behaviours were observed: (i) helix only penetration, no matter how many rotations were performed, due to the ‘endocardial entanglement effect’ (43.1% cases) or (ii) ‘endocardial barrier effect’ (19.6% cases), (iii) shallow/moderate penetration, with ensuing ‘drill effect’ when more rotations were added (9.8% cases), and (iv) deep progressive penetration with each additional rotation, occurring when the ‘screwdriver effect’ was present (27.4% cases, including three septal perforations). These different lead behaviours seemed to be determined by the lead position—mainly the strength of the initial endocardial layer—and the number of fully transmitted rotations. Conclusion New insights into deep septal lead deployment technique were gained with regard to safe and successful implantation.

Introduction Permanent deep septal stimulation with capture of the left bundle branch (LBB) enables maintenance/restoration of the physiological activation of the left ventricle. However, it is almost always accompanied by the simultaneous engagement of the local septal myocardium, resulting in a fused (nonselective) QRS complex, therefore, confirmation of LBB capture remains difficult. Methods We hypothesized that programmed extrastimulus technique can differentiate nonselective LBB capture from myocardial-only capture as the effective refractory period (ERP) of the myocardium is different from the ERP of the LBB. Consecutive patients undergoing pacemaker implantation underwent programmed stimulation delivered from the lead implanted in a deep septal position. Responses to programmed stimulation were categorized on the basis of sudden change in the QRS morphology of the extrastimuli, observed when ERP of LBB or myocardium was encroached upon, as: "myocardial," "selective LBB," or nondiagnostic (unequivocal change of QRS morphology). Results Programmed deep septal stimulation was performed 269 times in 143 patients; in every patient with the use of a basic drive train of 600 milliseconds and in 126 patients also during intrinsic rhythm. The average septal-myocardial refractory period was shorter than the LBB refractory period: 263.0 ± 34.4 vs 318.0 ± 37.4 milliseconds. Responses diagnostic for LBB capture ("myocardial" or "selective LBB") were observed in 114 (79.7%) of patients. Conclusions A novel maneuver for the confirmation of LBB capture during deep septal stimulation was developed and found to enable definitive diagnosis by visualization of both components of the paced QRS complex: selective paced LBB QRS and myocardial-only paced QRS.

Introduction His-Purkinje system pacing preserves or restores physiologic depolarization of the left ventricle during permanent pacing. It consists of two complementary techniques: His bundle pacing (HB-P) and the recently introduced left bundle branch pacing (LBB-P). There is limited data on HB-P outcomes and only a few reports of LBB-P results. Purpose Our aim was to investigate success rate, complications, acute and early pacing parameters in patients undergoing HB-P and LBB-P in the setting of a cardiology tertiary centre that routinely implants HB-P and LBB-P pacemakers. Methods On the basis of a prospective database we performed a longitudinal cohort study of all consecutive patients with His-Purkinje system devices implanted in the years 2014–2019. In all cases, model 3830 lumen-less 4.1 Fr pacing lead was used. HB-P was achieved via HB mapping or pace mapping, LBB-P was achieved via deep septal lead deployment under electrophysiological and 12-lead ECG guidance. Results Since 2014 there were 324 implantations of His-Purkinje system pacemakers. Baseline patients' characteristics are presented in Table. The overall success rate was 81.5%. Selective HB-P, non-selective HB-P and LBB-P were achieved in 53%, 19% and 28% of successful cases. The mean fluoroscopy time was 11±9 min. The lead delivery was performed using single sheath (C315His) in 83% cases, while in 17% extra steerable sheath was necessary (C304XL). The acute mean LBB-P capture threshold @0.5 ms was significantly lower than in HB-P (0.65±0.43V vs. 1.47±0.8V). The mean chronic LBB-P capture threshold @1.0 ms was also lower than in HB-P (0.45±0.3V vs. 0.95±0.7V, p Baseline characteristics Age; sex 73±12 years (19–95 years); 64% males Mean EF; mean QRS duration; Presence of heart failuire or ischemic heart disease 47±15%; 128±32 ms; 48%; 37.5% Pacing indication AV block 31%; sinus node disease 12%; atrial fibrillation with bradycardia 37%; CRT 20% QRS morphology narrow QRS 61%; LBBB 20%; other 14%; IVCD 6% CRT, Cardiac Resynchronization Therapy; IVCD, Interventricular Conduction Delay. Conclusion His-Purkinje system pacing in routine practice has an acceptable success rate, pacing parameters and complication rate; the LBB-P provides better pacing parameters than HB-P. We believe that such single-centre experience paves the way for a large randomized trial of physiologic pacing.

Background. Slow breathing training (SBT) has been proposed as a new non-pharmacological treatment able to induce favorable effects in patients with chronic heart failure (CHF). However, no information is available regarding its effects on orthostatic blood pressure (BP) changes in these patients, an issue of practical relevance given the reported BP-lowering effect of SBT. The aim of this study is to evaluate the influence of SBT on BP and whether SBT induces orthostatic hypotension (OH) or changes in quality of life (QoL) in CHF patients. Methods. The analysis was performed as part of an ongoing crossover open trial aimed at assessing the clinical effectiveness of SBT in treated patients with CHF. The patients underwent 10-12 weeks of SBT with the RESPeRATE device and 10-12 week follow-up under usual care. Patients were randomly divided into two groups: group I began with SBT, followed by usual care; group II began with usual care, followed by SBT. Patients undergoing SBT were asked to perform each day two separate 15 min sessions of device-guided SBT at a breathing frequency of 6 breaths/min. In all patients, before the enrollment and after each study phase, clinical data collection and BP measurements in sitting, supine and standing position were performed. OH was defined as a decrease of ≥ 20 mmHg in systolic blood pressure (SBP) or ≥ 10 mmHg in diastolic blood pressure (DBP) within 3 min of standing. QoL was assessed three times at the beginning, and after each phase of the study by the Minnesota Living with Heart Failure (MLHF) questionnaire. Results. Forty patients (two equal groups) completed the study, with the following baseline characteristics: 32 males/eight females, age 63.3 ± 13.4 years, 25 with ischemic CHF, 37 in New York Heart Association class II and three in class III, left ventricular ejection fraction 30.8 ± 6.7%, mean BP 138.7 ± 16.5/83.1 ± 11.5 mmHg, 23 with arterial hypertension and four with a history of stroke. There were no significant differences between the groups in clinical characteristics, SBP and DBP at rest, while seated and before and after standing up. OH prevalence was low and did not change during the study (10% vs 10%). No significant difference in average SBP and DBP changes secondary to body position were found when comparing the two study phases. Decrease in MLHF score was observed in group I during SBT (p = 0.002), but not in group II. Conclusions. Our data indicate that SBT is safe, does not affect the prevalence of OH in CHF patients and shows a non-significant tendency to improve QoL. These results should be confirmed in a larger sample of patients to support the safety of SBT and its possible benefits as a novel component of cardiorespiratory rehabilitation programs in CHF.

Background: Coronary artery disease (CAD) remains the leading cause of death in developed countries, and there is an increasing number of both young and elderly patients requiring surgical treatment. Despite improvement of conventional risk stratification scores (EuroSCORE II, STS risk score), all of the calculations are estimated based on the typical population and the studies emphasise that the scales may need further investigation and modernisation because demographic changes of the population suffering from CAD are unavoidable. Aim: To characterise two increasing and challenging cohorts of patients undergoing coronary artery bypass grafting (CABG) and to identify preoperative risk factors for postoperative complications. Methods: In the retrospective cross-sectional study, we analysed 388 patients ≥ 80 years old and 190 patients ≤ 50 years old, who underwent CABG consecutively at our Institution. Data were obtained from medical records. Results: The vast majority of studied patients had commonly described risk factors for cardiovascular diseases, regardless of the age group. Diabetes was present in almost twice as many individuals in the older cohort, when compared to the EuroSCORE population. A similar observation was made for hypertension, which was more frequent in both age groups. Summarising all of the postoperative complications, at least one occurred significantly more frequently among the older group (10% vs. 20.9%, p = 0.001). The vast majority of major adverse cardiac and cerebrovascular events (MACCE) in the older group led to death (79.4%). Among patients ≥ 80 years old, higher New York Heart Association (NYHA) class (p = 0.001, OR 2.05 [1.34–3.12] for every next class) and renal failure (p = 0.02, OR 2.47 [1.16–5.25]) increased the MACCE rate, whereas higher left ven­tricular ejection fraction (LVEF) (p = 0.002, OR 0.81 [0.7–0.93] for every 5%) decreased the risk. Emergent admission was the only factor increasing the occurrence of any postoperative complications among patients ≤ 50 years old (p = 0.007, OR 3.63, 95% CI 1.37–9.62). On the other hand, among patients ≥ 80 years old, emergent admission was not associated with any postoperative complications. Conclusions: Young and old patients requiring CABG differ from the standard EuroSCORE population. Postoperative complications are more common among older patients, and MACCE is usually fatal in this age group. Individuals with risk factors for MACCE (higher NYHA class, renal failure, lower LVEF) should be carefully evaluated and qualified, and closely monitored post-surgery.

Background: Coronary artery disease (CAD) is a major cause of death and disability in developed countries. Despite the fact that prevalence accrues with age, an increasing number of young patients suffering from CAD is being observed worldwide. The aim of this study is to describe the population of young adults suffering from CAD and requiring coronary artery bypass grafting (CABG), and to assess early outcomes after the procedure. Methods: A retrospective cohort study analyzed 190 consecutive patients aged ≤50 years old that underwent CABG between 2010 and 2014. Baseline characteristics and operative data were presented in the study. Postoperative complications, such as major adverse cardiac and cardiovascular events (MACCE), prolonged mechanical ventilation (>72 hours), bleeding requiring reexploration, sternal dehiscence, and others were assessed. Results: A population comprising mostly overweight or obese males with a mean age of 46 ± 4.1 years was analyzed. Patients suffered mostly from three-vessel disease (81%), hypertension (74.7%), and had previous history of myocardial infarction (MI) (60%). The majority of patients had normal left ventricle ejection fraction (LVEF) (83.1%). 22.6% of cases were emergent procedures. Perioperative mortality was low (1%) and overall MACCE rate stood at 2.6%. Emergent surgery was associated with a higher incidence of postoperative complications (P = .007). The number of diseased vessels, LVEF, and CCS/NYHA class-on-admission was not associated with a higher incidence of postoperative complications (P > .05 for all). Conclusion: CAD in young patients remains an issue described insufficiently in the literature. Among our study cohort of younger patients undergoing CABG, the majority of the patients had multivessel disease and were slightly symptomatic with normal LVEF. Although the postoperative complication rate was low, the percentage of emergent surgeries was alarmingly high in this population. Consistent with the literature, we highlight the importance of CAD screening in the young population to detect subclinical disease, which might be treated therapeutically or operated electively.

Turner syndrome (TS) is a congenital disease caused by absence or structural abnormalities of sex chromosomes resulting in gonadal dysgenesis. Spontaneous pregnancies occur in 2-8% of patients, especially with mosaic kariotypes, however they are associated with increased risk of poor outcome both for mother and fetus. We report a 4-day-old male infant delivered by women with mosaic TS who was admitted to the pediatric intensive care unit and presented with severe panhypopituitarism as the early manifestation of pituitary stalk interruption syndrome (PSIS). To the best of our knowledge this is the first report of severe panhypopituitarism in a newborn borne by women with TS.

The authors made an attempt to verify if a coconut can be used as a model of human skull to determine the homicide weapon. During our experiment 27 strike attempts were performed with the use of 9 different tools. Among them there were authentic murder weapons and instruments which had been used in similar experiments conducted on human skulls in 1955. Depending on the size of an area in contact with a coconut, weapons caused dents corresponding to the shape of a weapon, irregular fractures or long linear cracks. Our results have shown that coconut can be used as an inexpensive screening model of human skull, but only to determine fractures made by tools with small striking surface.

adolescents Also, the logistic regression analysis was used to estimate the most important risk factors for WCH. The WCH prevalence was 5.2% (n1⁄426) in all adolescents, 8.0% in males and 2.7% in females (p