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Aims Intracardiac electrograms (IEGMs) recorded by implantable cardioverter-defibrillators (ICDs) are essential for arrhythmia diagnosis and ICD therapy assessment. Short IEGM snapshots showing 3–10 s before arrhythmia detection were added to the Biotronik Home Monitoring system in 2005 as the first-generation IEGM Online. The RIONI study tested the primary hypothesis that experts’ ratings regarding the appropriateness of ICD therapy based on IEGM Online and on standard 30 s IEGM differ in

Aims The diagnosis of Brugada syndrome (BS) is typically made in a young and otherwise healthy population. In patients with a high risk of sudden cardiac death (SCD), the only currently recommended therapy is an implantable cardioverter defibrillator (ICD), but these are not without complications. We investigated whether remote ICD monitoring could simplify follow-up and detect potential complications in these patients. Methods and results Thirty-five consecutive patients (26 males, 44 ± 11 years) implanted with an ICD for BS with a remote monitoring [‘Home Monitoring’ (HM), Biotronik, Germany] system were prospectively enrolled in this study. They were matched for age, sex, and follow-up duration with 35 BS patients implanted with an ICD without this capability. During a mean follow-up of 33 ± 17 months, the number of cardiology consultations was significantly lower in the HM group (3 ± 2 vs. 7 ± 3; P < 0.001). Inappropriate shock(s) [IS(s)] occurred in three patients (8.5%) in the HM group vs. six (17%) in the control group ( P = NS). Ten patients in the HM group had a median of four alerts (‘ventricular tachycardia/ventricular fibrillation detection’ in all patients, ‘shock’ in three, ‘ineffective shock’ in two patients with shock on noise, ‘extreme ventricular pacing impedance’ in one patient due to lead failure, and ‘deactivated therapy’ in two patients with lead failure before replacement). In 5 of these 10 patients, prompt reprogramming of the ICD may have prevented IS(s). Conclusion Remote ICD monitoring in patients with BS decreases outpatient consultations and may help prevent ISs.

Aims To evaluate the contribution of the posterior left atrium (LA) to chronic atrial fibrillation (AF). Methods and results Twenty-seven patients with chronic-AF were studied. After pulmonary vein (PV) isolation, the posterior-LA was isolated by ablation joining the right- and left-PVs using an irrigated-tip catheter. Isolation was demonstrated by absent/dissociated posterior-LA activity and the inability to pace the region. Ablation impact was determined by the effect on cycle length (CL) and AF termination. Posterior-LA isolation was achieved using 35 ± 12 min of radiofrequency with total fluoroscopic and procedural durations of 64 ± 16 and 199 ± 46 min, resulting in abolition of electrograms ( n = 21) or autonomous activity ( n = 6; CL 820 ± 343 ms). AFCL increased from 156 ± 28 ms to 162 ± 27 ms with PV-isolation and to 175 ± 32 ms by posterior-LA exclusion ( P < 0.0001). AF persisted in all after PV-isolation and terminated in 5 (19%) during posterior-LA-isolation. After 10 ± 6 months, 12 patients developed atrial tachycardia (four) or AF (eight); four underwent repeat posterior-LA-isolation, while the others required additional ablation/antiarrhythmics. After 21 ± 5 months, 17 (63%) were in sinus rhythm following posterior-LA-isolation. Conclusion This study demonstrates the feasibility of complete posterior-LA exclusion by catheter ablation. This strategy results in maintenance of sinus rhythm in 63% at ∼2 years follow-up.

Background Radiofrequency (RF) ablation of cavotricuspid isthmus (CTI) dependent flutter can be performed using different types of ablation catheters. It has been proposed that irrigated and large-tip catheters are capable of creating larger lesions, resulting in greater efficacy. This prospective, randomised clinical study compared the efficacy of irrigated and large-tip catheters of different designs. Methods Eighty patients (69 men, 66±11 years) undergoing de novo RF ablation of CTI-dependent flutter were randomised to ablation using one of the following catheters: (i) externally-irrigated \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((n=20)\) \end{document}, (ii) internally-cooled \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((n=20)\) \end{document}, (iii) single sensor, 8-mm tip \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((n=20)\) \end{document}, or (iv) double sensor, 8-mm tip \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((n=20)\) \end{document}. The study endpoint was the demonstration of bidirectional CTI conduction block within 12 min of cumulative RF delivery. Crossover to the externally-irrigated catheter was permitted if this was not achieved. The ablation and procedural parameters, safety and efficacy were compared. Results The primary endpoint was achieved in 64 patients (80%), including all 20 patients randomised to the externally-irrigated catheter. Crossover was required in 16 patients: 9 initially using the internally-cooled catheter (45%), 3 using single-sensor, 8-mm-tip (15%), and 4 using double-sensor, 8-mm-tip (20%) catheters. The higher initial failure rate with the internally-cooled-tip catheter was significant compared to the externally-irrigated \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((p=0.001)\) \end{document} and single-sensor, 8-mm-tip \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((p=0.04)\) \end{document} catheters. The externally-irrigated catheter achieved the study endpoint more frequently with fewer RF applications of shorter duration compared to the internally-cooled-tip catheter and 8-mm-tip catheters, the difference being significant compared with internally cooled ablation. No major complications were observed. Conclusion Among commonly used ablation catheters, the externally-irrigated catheter has a higher efficacy for rapid achievement of CTI block.

Aims This single-centre prospective study was designed to determine the incidence, therapeutic implications and prognosis of atrial arrhythmias (AA) in patients with Brugada syndrome (BS). Methods and results Fifty nine consecutive patients with BS and 31 age and gender-matched controls underwent an electrophysiological exploration and were followed-up during 34±13 months. The final AA incidence was 20% in BS patients vs 0% in controls (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(p{

Complete cure of atrial fibrillation in highly symptomatic patients can now be achieved using a surgical or catheter based approach. Most electrophysiology laboratories working on catheter ablation for paroxysmal atrial fibrillation target pulmonary veins using a transseptal approach. The aim of the procedure is to achieve complete disconnection of the pulmonary veins, demonstrated by the disappearance or dissociation of their potentials. This is clearly facilitated by the use of a circular catheter dedicated to the mapping of the pulmonary vein ostia, which allows the identification of the connections from the atrium to the vein. Using this approach in targeting all four pulmonary veins, 70% of patients are cured without the need for antiarrhythmic drugs. However, some complications have been described, including tamponade, embolic events and pulmonary vein stenosis. The learning curve for this procedure is steep, but in experienced centres the safety profile is very acceptable.

Atrial fibrillation, the most common arrhythmia, is frequently disabling and drug resistant. Non-pharmacological approaches including surgery and catheter-based ablation have been developed for the most symptomatic patients. These new treatment strategies have dramatically increased our knowledge of the pathophysiology of this arrhythmia but most importantly demonstrated that atrial fibrillation is curable. These approaches are far from being perfect but good enough to be offered in routine practice to selected patients in experienced centers. The importance of pulmonary veins in the initiation of AF has clearly been demonstrated and their role in maintaining AF is likely. Most of the curative approaches are therefore based on their isolation. Future technical improvements based on presently applied concepts are likely to widen the indications for ablation therapy of AF.

Left ventricular hypertrophy (LVH) is associated with an increased risk of cardiovascular complications independently of other known risk factors, but so far the predictive value of its evolution under treatment has been studied relatively little. Since 1983 we have followed up a cohort of initially untreated hypertensive patients with echocardiographic measurements of left ventricular mass (LVM). We analyzed the data on 474 patients with more than 5 years of follow-up to assess the prognostic value of LVM and its evolution during treatment for high blood pressure. A total of 40 patients were lost to follow-up. The mean follow-up period was 89 +/- 31 months. A cardiovascular complication was recorded in 40 individuals. There was a strong link between increased LVM and the occurrence of complications (P.001). At least a second determination of LVM was performed in 311 patients, and the last value before the occurrence of any complication (60 +/- 38 months after the initial examination) was retained. In this subgroup, 28 patients presented with a cardiovascular event. There was a trend toward a reduction of the incidence of events in the group with a regression of LVH as compared to the group with persistent LVH, but there was no difference when patients were split into quartiles according to LVM evolution between baseline and follow-up. Thus, the reduction of LVM on treatment was not a good marker of future cardiovascular events and its seems at least premature to say that LVM fulfils all conditions for a surrogate end point in the evaluation of morbidity/ mortality in the hypertensive.

The peak incidence of cardiovascular complications in the morning points to a possible role of the abrupt increase in blood pressure on arising. However, there is as yet no firm evidence linking the extent of the elevation in blood pressure on arising and the risk of cardiovascular complications. We sought a correlation between blood pressure on arising and left ventricular mass in a population of 181 previously untreated hypertensive patients. Ambulatory blood pressure was measured over a 24-h period, and each patient was requested to trigger a blood pressure determination immediately after standing on arising in the morning. Left ventricular mass was measured with M-mode echocardiography and indexed for height, height(2.7), and body surface area. The systolic blood pressure on arising was significantly (P

We describe three cases of patients with Alzheimer's disease who presented with cardiac syncope soon after initiation of a cholinesterase inhibitor therapy (donepezil). Bradyarrhythmia was documented in two patients, considered probable in one, and was presumed related to the cholinergic therapy. Pacemaker implantation seemed justified rather than donepezil cessation. More over, it permitted an increase in donepezil dosage.

We report the case of a 60-year-old patient with preserved ventricular function and no organic mitral leaflet disease implanted with a dual-chamber pacemaker. Right ventricular pacing induced a major ventricular dyssynchrony, a severe mitral regurgitation, and symptoms of congestive heart failure. Upgrading to a biventricular device was associated with a decrease in the symptoms, the ventricular dyssynchrony, and the mitral regurgitation.

A 48-year-old woman with congenital heart disease was referred to our centre for refractory right and left heart failure. She was born with a pulmonary stenosis associated with an atrial and ventricular septal defect and underwent a surgical repair at the age of 16. From the age of 44, she gave a history of decline …

The present study was done to compare the values of mean daytime and nighttime blood pressure (BP) calculated over arbitrary periods to those calculated over the true retiring and rising times of the individual patients. A total of 88 individuals, including 55 untreated hypertensives (office BP > 140/90 mm Hg) and 33 normotensives, were recruited. Ambulatory BP was monitored over 24 h during the normal routine of the patient. The patient was requested to trigger a recording on going to bed and on rising in the morning to clearly identify these periods. The mean daytime and nighttime values were calculated over arbitrarily defined periods (6 AM to 10PM daytime and 10 PM to 6 AM nighttime) and as a function of the true retiring and rising times of the individual patients. The true daytime BP was significantly higher than the value calculated over the arbitrary period and the true nighttime BP was significantly lower than the value calculated between 10 PM and 6 AM (paired t test, P < .05). Employing a cutoff value of 135/85 mm Hg for daytime BP, a significant proportion of patients classified as normotensive when daytime BP was calculated over arbitrary periods were in fact classified as hypertensive from the values calculated over true retiring and rising times.

To assess the prevalence of asymmetric septal hypertrophy (ASH) in hypertensive patients, 613 echocardiographic examinations performed over a period of one year were reviewed. Asymmetric septal hypertrophy (defined by an echocardiographic interventricular septum to left ventricular free wall thickness ratio of greater than or equal to 1.3 and by the presence of suggestive two-dimensional echocardiographic abnormalities) was found in 28 patients (5%). Clinical characteristics of asymmetric septal hypertrophy were assessed in 101 patients who underwent a complete evaluation. Patients with asymmetric septal hypertrophy (n = 9) were compared with patients with echocardiographic symmetrical left ventricle hypertrophy (n = 38) and without left ventricular hypertrophy (n = 54). Our results indicate that neither the severity of hypertension, nor the renin-angiotensin system nor sympathetic nerve activity appear to be the primary determinants in the development of asymmetric septal hypertrophy.