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Abstract Cardiovascular deaths account for about 40% of all deaths of patients with chronic kidney disease (CKD), particularly those on dialysis, while sudden cardiac death (SCD) might be responsible for as many as 60% of SCD in patients undergoing dialysis. Studies have demonstrated a number of factors occurring in hemodialysis (HD) that could lead to cardiac arrhythmias. Patients with CKD undergoing HD are at high risk of ventricular arrhythmia and SCD since changes associated with renal failure and hemodialysis-related disorders overlap. Antiarrhythmic therapy is much more difficult in patients with CKD, but the general principles are similar to those in patients with normal renal function - at first, the cause of arrhythmias should be found and eliminated. Also the choice of therapy is narrowed due to the altered pharmacokinetics of many drugs resulting from renal failure, neurotoxicity of certain drugs and their complex interactions. Cardiac pacing in elderly patients is a common method of treatment. Assessment of patients’ prognosis is important when deciding whether to implant complex devices. There are reports concerning greater risk of surgical complications, which depends also on the extent of the surgical site. The decision concerning implantation of a pacing system in patients with CKD should be made on the basis of individual assessment of the patient.

Background: Ventricular electrical storm (VES) is characterized by the occurrence of multiple episodes of sustained ventricular arrhythmias (VA) over a short period of time. Radiofrequency ablation (RFA) has been reported as an effective treatment in patients with ventricular tachycardia (VT)., Objective: The aim of the present study was to indicate the short-term and long-term predictors of recurrent VA after RFA was performed due to VES., Methods: A retrospective, single-centre study included patients, who had undergone RFA due to VT between 2012 and 2021. In terms of the short-term (at the end of RFA) effectiveness of RFA, the following scenarios were distinguished: complete success: inability to induce any VT; partial success: absence of clinical VT; failure: inducible clinical VT. In terms of the long-term (12 months) effectiveness of RFA, the following scenarios were distinguished: effective ablation: no recurrence of any VT; partially successful ablation: VT recurrence; ineffective ablation: VES recurrence., Results: The study included 62 patients. Complete short-term RFA success was obtained in 77.4% of patients. The estimated cumulative VT-free survival and VES-free survival were, respectively, 28% and 33% at the 12-month follow-up. Ischemic cardiomyopathy and complete short-term RFA success were predictors of long-term RFA efficacy. Neutrophil to lymphocyte ratio (NLR) and GFR <60 mL/min/1.73 m 2 were associated with VES recurrence. NLR ≥2.95 predicted VT and/or VES recurrence with a sensitivity of 66.7% and specificity of 72.2%., Conclusion: Ischemic cardiomyopathy and short-term complete success of RFA were predictors of no VES recurrence during the 12-month follow-up, while NLR and GFR <60 ml/min/1.73 m 2 were associated with VES relapse., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2024 Grzegorz Sławiński et al.)

Background: The right ventricular outflow tract (RVOT) is located above the supraventricular crest and reaches the level of the pulmonary valve. Detailed knowledge of the RVOT spatial structure and its morphology is extremely important for cardiac invasive therapeutic procedures., Objectives: To examine the spatial structure of the RVOT using virtual models of the right ventricle (RV) interior obtained post mortem., Material and Methods: The study was carried out using 40 adult hearts from both sexes fixed in formalin. Donors had a negative history of cardiovascular diseases. Silicone models of the interior of the RV were made and then subjected to a digital modelling procedure using the photogrammetry technique. For each 3D model of the RV, the RVOT was extracted and measurements were performed., Results: Statistical analysis demonstrated that the dimensions of the transverse (p < 0.001) and sagittal (p = 0.002) axis at the level of the upper and lower border of the RVOT differed significantly. There was also a significant difference between the right and left height of the RVOT (p = 0.009). A clear correlation was found between the volume of the RVOT and the volume of the entire RV (r = 0.718, p < 0.001)., Conclusions: The obtained 3D models of the RVOT can help standardize the data related to RVOT architecture. Furthermore, they can extend knowledge about the RVOT in the field of cardiology and improve the procedures in cardiac surgery.

Congenital disorders of glycosylation (CDG) are a growing, heterogeneous group of genetic disorders caused by a defect in the glycoprotein synthesis. The first and still widely used method for routine CDG screening was isoelectric focusing (IEF) of serum transferrin. Dried blood spot (DBS) testing is commonly used in newborn screening procedures to detect inborn errors of metabolism. The aim of this study was to demonstrate the reliability of the IEF method in DBS testing. Dried blood spot testing can help in the postmortem diagnosis of CDG disorders when other material is unavailable. The patterns and concentrations of transferrin isoforms in serum and DBS are comparable, and slight differences do not affect interpretation of results.

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia, the most common cause of supraventricular tachycardia in the global population and the most common arrhythmia requiring treatment in an emergency department., Objectives: To systematically review recent literature and quantify the correlation between the choice of pharmacological cardioversion (PCV) drug and the national or international guidelines., Material and Methods: A systematic review was performed in accordance with the PRISMA statement methodology. The PubMed search engine was used to search for articles regardless of type or language and published in the last 6 years (May 2014-May 2020). In addition, we searched for AF guidelines and recommendations published online by cardiology and emergency medicine societies., Results: The search strategy returned a total of 2615 abstracts. A total of 2598 full texts were screened; 2540 full texts were excluded with reasons and 58 articles from 32 countries were included in the analysis. In 17 of the 58 articles (29%), we noted discrepancies with the AF guidelines, specifically regarding the PCV drug used, the patients' comorbidities and the contraindications associated with the PCV drug. The most common clinical situation for the use of a contraindicated drug was when ibutilide was administered to patients with heart failure. The analysis did not reveal any statistically significant correlations, although the correlation between the sample size and guideline adherence was close to statistical significance (p < 0.06)., Conclusion: Our systematic analysis revealed substantial non-adherence to AF treatment guidelines.

Background: Autonomic imbalance is associated with poor prognosis of patients with systolic dysfunction. Most of the previous data were written several years ago and constituted to cardiovascular or arrhythmic mortality. The current treatment of these patients has improved substantially over the last decades, and thus, the population at risk of death may have altered as well. Consequently, data on high-risk patients with systolic dysfunction in the modern era are sparse and those from previous trials may no longer be applicable. The aim herein, was to verify whether well-known autonomic indices - baroreflex sensitivity (BRS) and heart rate variability (HRV) - remain accurate predictors of mortality in patients with systolic dysfunction., Methods: Non-invasively obtained BRS and HRV were analyzed in 205 clinically stable patients with left ventricular ejection fraction (LVEF) ≤ 40%. 28 patients died within 28 ± 9 month follow-up., Results: Baroreflex sensitivity, low-frequency (LF) in normalized units, LF to high-frequency ratio and standard deviation of average R-R intervals were significantly associated with mortality; cut-off values of the highest discriminatory power for abovementioned parameters were ≤ 3.0 ms/mmHg, ≤ 41, ≤ 0.7 and ≤ 25 ms, respectively. In bivariate Cox analyses (adjusted for LVEF, New York Heart Association [NYHA] or absence of implantable cardioverter-defibrillator [ICD]) autonomic indices remain significant predictors of death., Conclusions: Baroreflex sensitivity and HRV - may still be helpful in identifying patients with left ventricular systolic dysfunction at the highest risk of all-cause mortality, independently of LVEF, NYHA class, and ICD implantation.

Background: Radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) can be curative. There are conflicting data on whether AF associated atrial and ventricular structural remodeling reverses after ablation. The aim of this study was to evaluate the hemodynamic effect of AF ablation in patients with preserved left ventricular ejection fraction (LVEF)., Methods: Forty three AF patients were studied (aged 56 ± 11 years; 29 male, 23% persistent AF, LVEF ≥ 50%) in whom RFCA was performed. Echocardiographic evaluation of atrial and ventricular diameters, volumes and strain imaging by two-dimensional speckle tracking were performed before and at least 6 months after RFCA. Nine patients had AF during baseline examination., Results: A significant decrease in the left (LA) and right (RA) atrial volume and an increase in the LA strain were observed 15 ± 7 months after RFCA. In the subgroup with baseline sinus rhythm, the increment in LA strain was only borderline significant. An increase in RA, right ventricular (RV) and Biatrial strain was noticed (p < 0.05). LVEF and global longitudinal strain of the left ventricle (LV), however, did not improve substantially., Conclusions: Radiofrequency catheter ablation of AF in patients with preserved LV systolic function results in significant improvement in RA and RV function with a substantial reduction in LA and RA size. No deleterious impact of AF ablation on LA function was revealed.

Objectives: Pulmonary arterial hypertension (PAH) is a rare disorder with unfavorable prognosis despite implementation of specific PAH-oriented therapy. The aim of the study was to define predictors of poor prognosis in patients from one center treated according to the Polish National Health Fund program., Patients and Methods: Forty-seven consecutive patients (30 women; aged 39±17 years) with PAH diagnosis were enrolled to the study. Clinical assessment, laboratory measurements, electrocardiogram, echocardiography, 6-minute walk test, 24-hour Holter monitoring, cardiopulmonary exercise test and microvolt T-wave alternans test were performed during routine visits. Eight patients died during 2.6±1.7 years follow-up., Results: Parametrs which differentiated patients who died were brain natriuretic peptide (BNP) concentration ≥330 pg/mL (sensitivity 88%, specificity 92%, area under the ROC curve [AUC] 0.92); bilirubin concentration ≥1.2 mg/dL (sensitivity 88%, specificity 81%, AUC 0.85); right atrial area ≥21 cm2 (sensitivity 86%, specificity 69%, AUC 0.84), right ventricular (RV) dimension in the apical 4-chamber view ≥47 mm (sensitivity 86%, specificity 86%, AUC 0.85) and RV to left ventricular diastolic diameter ratio ≥1.5 (sensitivity 83%, specificity 84%; AUC 0.85). In multivariate analysis, independent predictors of mortality were higher BNP (p = 0.04) and bilirubin level (p = 0.03), higher right atrial area (p = 0.02) and lower tricuspid annular plane systolic excursion (p = 0.03)., Conclusions: In PAH patients treated with specific PAH-oriented therapy right atrial enlargement, impaired right ventricular systolic function, as well as increased BNP and bilirubin concentration was associated with an increased mortality risk.

INTRODUCTION    Inadvertently induced ventricular fibrillation (VF) by radiofrequency (RF) energy delivery for premature ventricular complexes (PVCs) is a rare phenomenon; nevertheless, it is crucial to assess long‑term risk of sudden cardiac death in these patients. OBJECTIVES    The aim of our study was to define the long‑term prognosis in patients with normal ejection fraction (EF), in whom VF was inadvertently induced by RF energy application during ablation of symptomatic idiopathic PVCs originating from the right ventricular outflow tract (RVOT). PATIENTS AND METHODS    Among over 20 000 RF catheter ablations performed at 5 tertiary centers (2008-2016), 6 patients (5 men) had VF induced by RF application to the RVOT. The mean (SD) age of patients was 35.2 (16.8) years. All patients had normal EF (≥60%). We analyzed the risk of malignant ventricular arrhythmias and assessed heart function during follow‑up. RESULTS    After ablation, baseline contrast‑enhanced magnetic resonance imaging was performed in 4 of the 6 patients; no area of late gadolinium enhancement was observed. One patient received an implantable cardioverter‑defibrillator (ICD). Exercise tests revealed only rare PVCs. All patients completedthe follow‑up (mean [SD] duration of follow‑up, 64.0 [34.9] months). All patients were alive, with no cases of syncope, documented ventricular tachycardia, or VF. The patient with an ICD received 2 inappropriate high‑voltage therapies. CONCLUSIONS    Patients with inadvertently induced VF via RF energy application during ablation of PVCs from the RVOT, who have normal left ventricular function and no electrocardiography abnormalities have good prognosis and low VF risk during long‑term follow‑up. Therefore, ICD placement seems to be not indicated for these patients.

Background: An implantable cardioverter-defibrillator (ICD) is routinely used to prevent sudden cardiac death. Since the introduction of that device into clinical practice, a defibrillation test (the so-called pre-discharge test [PDT]) has been an inseparable part of the ICD implantation procedure. Recently, the usefulness of PDT has been called into question., Methods: The aim of this research was to analyze ICD tests performed within two time periods: in years 1995-2001 (period I) and 2007-2010 (period II), in order to compare the results of tests and solutions to all the problems with ICD systems revealed by means of PDT., Results: During period I, 193 tests were performed, among which the ICD system malfunction was observed in 16 cases. Those included: sensing issues, specifically R-wave undersensing during ventricular fibrillation (VF) (7 patients) and T-wave oversensing (4 patients), as well as high defibrillation threshold (DFT) (2 patients) and ICD-pacemaker interaction (3 patients). During period II, among 561 tests, system malfunction was observed in 15 cases. In 1 patient it was VF undersensing, and in the remaining 14 it was high DFT. All the above problems were solved by means of appropriate ICD reprogramming, repositioning of the endocardial defibrillation lead or implantation of an additional subcutaneous defibrillation lead., Conclusions: Contemporary ICD technical solutions, compared to older systems, in most cases allow to avoid sensing problems. The key rationale behind ICD testing is the ability to confirm the efficacy of high-voltage therapy. Despite the increasing maximal defibrillation out-put of devices, and all possible adjustments to the characteristics of the impulse, there is still a group of patients that require additional procedures to ensure the appropriate defibrillation efficacy.

Atrial fibrillation increases the risk of thrombus formation. It is commonly responsible for cerebral stroke whereas less frequently for pulmonary embolism. The aim of the study was to describe the morphology of the left atrial appendage in the human heart with respect to sex, age and weight. Macroscopic examination was carried out on 100 left appendages taken from the hearts of the patients aged 18-77, both sexes. All hearts preserved in 4% water solution of formaldehyde carried neither marks of coronary artery disease nor congenital abnormalities. Three axes of appendage orientation were performed. After the appendage had been cut off, morphological examination was performed in long and perpendicular axes. Measurements of the appendages were taken from anatomical specimens and their silicone casts. We classified the left atrial appendage into 4 morphological groups according to the number of lobes. Most left atrial appendages in female population were composed of 2 lobes. In the male group typically 2 or 3-lobed appendages were observed. The mean left atrial appendage orifice ranged from 12.0 to 16.0 mm and the most significant difference in the orifices between males and females was observed in LAA type 2 (about 3.3 mm). A smaller orifice and narrower, tubular shape of the LAA lobes could explain a higher risk of thrombus formation during nonvalvular atrial fibrillation in women. Knowledge of anatomical variability of the LAA helps diagnose some undefined echoes in the appendage during transesophageal echocardiographic examination.

Introduction: Patients with left ventricular ejection fraction (LVEF) ≤ 35% are eligible for implantable cardioverter-defibrillator (ICD) placement in the primary prevention of sudden cardiac death. Nevertheless, other risk factors facilitating the selection of individuals with highest mortality are still sought. The aim of the study was to verify the usefulness of microvolt T-wave alternans (MTWA) testing in the assessment of all-cause mortality and life-threatening ventricular arrhythmias (EVENTs) in these patients. Previous data from the literature are inconclusive., Material and Methods: Patients with LVEF ≤ 35% were eligible if they did not have a history of sustained ventricular arrhythmias, and were treated with β-blockers. Participants underwent MTWA testing and were subsequently followed., Results: The group consisted of 139 patients. MTWA results were classified as non-negative (MTWA&#95;non-neg) in 93 and negative (MTWA&#95;neg) in 46 patients. During the 14.3 ±8.6 months of follow-up, EVENTs were observed in 21 patients. The 1-year EVENT rate was 16.4% among MTWA&#95;non-neg patients, and 2.6% among MTWA&#95;neg patients (p = 0.006). The sensitivity of the MTWA test was 95.24%, the specificity - 38.14%, the positive predictive value - 21.51% and the negative predictive value - 97.83%., Conclusions: In the group of patients with left ventricular systolic dysfunction, with the exclusion of patients with the history of life-threatening ventricular arrhythmia and individuals not being on chronic β-adrenolytic therapy, the abnormal result of MTWA testing is associated with significantly increased risk of all-cause mortality and life-threatening ventricular arrhythmia during 1 year of follow-up, thus identifying the individuals at the highest risk.

Introduction: Our aim was to evaluate the differences in the early hemodynamic response to the tilt test (HUTT) in patients with and without syncope using impedance cardiography (ICG)., Material and Methods: One hundred twenty-six patients (72 female/48 male; 37 ±17 years) were divided into a group with syncope (HUTT(+), n = 45 patients) and a group without syncope (HUTT(-), n = 81 patients). ECG and ICG signals were continuously recorded during the whole examination, allowing the calculation of heart rate (HR), stroke volume (SV), and cardiac output (CO) for every beat. The hemodynamic parameters (averaged over 1 min) were analyzed at the following points of the HUTT: the last minute of resting, the period immediately after the tilt (0 min), 1 min and 5 min after the maneuver. The absolute changes of HR, SV and CO were calculated for 0, 1, and 5 min after the maneuver in relation to the values at rest (ΔHR, ΔSV, ΔCO). Also, the percentage changes were calculated (HRi, SVi, COi)., Results: There were no differences between the groups in absolute and percentage changes of hemodynamic parameters immediately after and 1 min after tilting. Significant differences between the HUTT(+) and HUTT(-) groups were observed in the 5(th) min of tilting: for ΔSV (-27.2 ±21.2 ml vs. -9.7 ±27.2 ml; p = 0.03), ΔCO (-1.78 ±1.62 l/min vs. -0.34 ±2.48 l/min; p = 0.032), COi (-30 ±28% vs. -0.2 ±58%; p = 0.034)., Conclusions: In the 5(th) min the decrease of hemodynamic parameters (ΔSV, ΔCO, COi) was significantly more pronounced in HUTT(+) patients in comparison to the HUTT(-) group.

Introduction: Double antiplatelet therapy with clopidogrel and acetylsalicylic acid is a standard procedure after acute coronary syndrome. This treatment carries a higher risk of complications. The main goal of this research was to assess the patients' quality of life after undergoing antiplatelet therapy with clopidogrel after acute coronary syndrome (ACS)., Material and Methods: In the questionnaire research 3220 patients after ACS and treated with clopidogrel were included. The evaluation was carried out with the quality of life questionnaire SF-12., Results: 37.9% of the interviewees experienced ACS-ST-elevation myocardial infarction (STEMI), 62.1% non-ST-elevation myocardial Infarction (NSTEMI), on average within 23 ±42 weeks (p < 0.05). 7.2% of the interviewees were receiving non-invasive treatment and in 2.4% cases it was fibrinolysis. 90.4% were treated with primary angioplasty and stenting. In 53.8% of cases a covered stent (DES) was implanted. 95.6% of the patients received, besides clopidogrel, acetylsalicylic acid. The lowest quality of life was observed after non-invasive treatment or fibrinolytic only (p < 0.05). The quality of life in those patients who underwent angioplasty and stent implantation was similar (p < 0.05). With time, a progressive improvement of all assessed quality of life aspects was observed (p < 0.05). The improvement was noted regardless of the ACS treatment method (p < 0.001). The differences between the patients were smaller at each successive evaluation (p < 0.05). In the case of vitality, emotional and psychic condition, they disappeared completely (p < 0.05)., Conclusions: The quality of life rises along with time passed after acute coronary syndrome. Invasive methods provide better quality of life than fibrinolysis and non-invasive treatment in the acute coronary syndrome patients.

Introduction: The aim of the study was to describe the experience in performing ablation without fluoroscopy., Material and Methods: From 575 ablation procedures with CARTO performed in the period 2003-2008, 108 (42 M; age 40 ±16 years) were done without fluoroscopy. One patient had ablation using the Localisa system. There was one man with thrombocytopenia and two pregnant women., Results: Right ventricular (RV) outflow tract arrhythmias and other RV arrhythmias were noted in 38 patients (35%) and 17 patients (15%), respectively. There were 5 (4.6%) left ventricular (LV) outflow tract arrhythmias and 19 (17.5%) other LV tachycardias; right accessory pathways in 17 patients (20%), in the middle cardiac vein in 1, Mahaim fibres in 1, and 3 cases of permanent junctional reciprocating tachycardias. One patient with CRT had AV node ablation (Localisa). In 3 patients there were also other arrhythmias treated: slow AV nodal pathway, typical flutter isthmus and right atrial tachycardia. In 2004, 1/96 CARTO procedures was done without fluoroscopy, in 2006 2/97, in 2007 19 (2 in LV) of 93, in 2008 87 (22 in LV) of 204. The percentage of ablations without fluoroscopy in every hundred CARTO procedures was: 1%, 1%, 8%, 23%, 46%, 28% (mean 18%). There were no procedure-related complications., Conclusions: It is feasible to perform ablations within both right and left sides of the heart without fluoroscopy. The number and type of non-fluoroscopic procedures depends on the operator's experience. Pregnant patients, with malignant history or with hematologic diseases should be ablated without fluoroscopy in centres that specialise in these kinds of procedures.

Introduction: Among the recipients of implantable cardioverter-defibrillators (ICDs), there is a group of patients in whom the defibrillation threshold (DFT) is too high to enable a sufficient safety margin between the DFT and the maximal available output of the device. The aim of the study was to investigate the ability of an additionally implanted single-coil subcutaneous array electrode to reduce the DFT in such patients., Material and Methods: Medtronic 6996SQ electrode was implanted in 15 patients selected from our follow-up group of 741 ICD patients: 10 of them had insufficient post-implant DFT safety margin, and 5 had ineffective first maximal energy shock as recorded by the device. In 6 cases the patients had CRT-D devices, in 5 cases - dual-chamber ICDs, and in 4 cases - single-chamber ICDs. In all patients but one the defibrillating electrode was single-coil. In one patient it was dual-coil. The underlying disease was coronary artery disease in 10 patients, dilated cardiomyopathy in 4 patients and hypertrophic cardiomyopathy in 1 patient., Results: The subcutaneous electrode was successfully implanted in all the patients qualified for the procedure. No technical issues or perioperative complications were observed. Mean DFT was reduced from 33.3 ±4.1 J before the procedure to 25.3 ±4.4 J after the implantation procedure (p < 0.01)., Conclusions: Our results show that the use of a single-coil subcutaneous electrode to reduce the DFT is a safe and effective procedure. Further studies are necessary to confirm these results.

Introduction: The Public Access to Defibrillation (PAD) program was designed to raise the awareness of sudden cardiac death (SCA) pre-hospital management among the community. The goal of the following research was to confirm the final impact of the Polish PAD program on various resident groups that differ by age, training and education level., Material and Methods: The trial total number of participants reached 404 people from three cities divided into two groups. In group one (n = 295) were randomly selected people inside the trial area and in group two (n = 109) we had individuals who were theoretically trained in basic life support (BLS) algorithms, including the use of an automatic external defibrillator (AED). The research method was based on two different questionnaires completed by participants from each group., Results: The greatest knowledge of SCA, as well as the use of AED, and the best practical skills, were possessed by the residents of cities with a population over 100 000, aged between 18 and 30 years, who completed secondary or higher education (31.7%). The group with the smallest knowledge about SCA lived in the country (10.7%). The second group with little knowledge of the subject consisted mostly of individuals with primary education (4.19%) or professional abilities and over 50 years old (2.16%)., Conclusions: There must be some actions taken in order to increase the community awareness concerning automatic defibrillation. Training on AED and the possibility of practical exercise needs to be organized and should be conducted especially among residents of the countryside and people under 30 or over 50 years old.

Background: The aim of the study was to assess whether medical students' fainting outside the university or while witnessing surgical procedures and/or autopsies influenced their choice of a specialization., Materials and Methods: The study group consisted of 605 medical students (from fourth to sixth year of study) from five medical universities in Poland (325 women, 212 men and 8 responders of an unspecified gender). The median age of subjects studied was 23 years, and the interquartile range was 23-24 years. The students at each university were chosen randomly by the author who worked there and had contact with them. An anonymous questionnaire was developed to gather information regarding demographics, the specialization which each student wanted to choose, the syncope occurrence in the medical history, the syncope and presyncope occurrence during surgery and autopsy as well as the syncopal events' characteristics., Results: The group of 15% of women and 30% of men declared to have pursued the surgical specialization (P<0.001), 29% of women and 56% of men declared the intention to pursue an invasive specialization (P<0.001). As many as 36.0% of women studied and 13.1% of men studied reported syncopal spells outside university (P<0.001). Only 41 students (6.8%) reported that syncope or presyncope in any studied circumstances had an impact on their specialization choice. The multivariate analysis showed that the choice of surgical specialization is related to the male gender and the absence of syncopal spells outside the university., Conclusions: Syncopal and presyncopal spells may affect the professional choices of the medical students. The male gender and a lack of syncope occurrence outside operating room are related to the choice of surgical specialization.

Introduction: False chordae tendineae are fibrous-muscular bundles which do not interconnect with right atrioventricular valves. The structures have occasionally been described in the right ventricle. There are reports suggesting their influence on electromechanical processes taking place in the heart, in thromboembolic events as well as in the course of cardiac invasive procedures. The objective of the study was to perform a macroscopic evaluation of false chordae tendineae in the right ventricle., Material and Methods: The research specimens consisted of 100 hearts of adult humans, aged from 18 to 59 years, fixed in a solution of 10% formaldehyde and 98% ethanol. The ratio of false chordae tendineae to individual elements of the right ventricle, such as its walls, papillary muscles, septomarginal trabecula and the apex of the ventricle, was examined., Results: During examination, six types of chordae tendineae were described based on the criterion of the type of structures they connected. The most common were false chordae connecting ventricle walls within its apex, while the least common were individual segments of papillary muscles. The research proved that the examined structures are morphologically extremely diverse. Substantial clinical implications of their presence seem very probable., Conclusions: The present work is the first of a scheduled series devoted to the problem of false chordae tendineae. Further analyses will cover the subject of morphological aspects in a microscopic perspective.

Introduction: Syncope is a common presentation of sinus node dysfunction (SND). Some patients who receive a permanent pacemaker due to SND do not benefit from it and further diagnostic workup leads to the diagnosis of vasovagal syncope (VVS). The aim of the study was to identify electrophysiological criteria that can be used for identification of patients with SND and concurrent VVS., Material and Methods: Transoesophageal atrial pacing (TAP) was performed in 100 patients divided into four groups depending on symptoms and TAP results. Standard electrophysiological parameters of sinus node function and their variability were obtained in the basal state and after pharmacological autonomic blockade (AB)., Results: Patients with concurrent SND and VVS had a greater variability of sinoatrial conduction time assessed by Strauss' method than patients without incidents of syncope (83.2 ±53.9 vs. 34.1 ±19.6, 47.8 ±33.6 and 32.1 ±22.99). Apart from abnormal sinus node recovery time and second pause, patients with SND had bigger basal state variability of these parameters. In patients with SND and concurrent vasovagal syncope the variability of sinus node recovery time (SNRT), corrected SNRT (cSNRT) and second pause (IIP) decreased after autonomic blockade., Conclusions: Patients with concurrent SND and VVS have distinct electrophysiological features - greater sinoatrial conduction time (SACT) variability and the decrease of SNRT, cSNRT and IIP variability after AB. However, further studies in larger study groups are needed to validate our findings. Transoesophageal atrial pacing is a useful procedure in patients with syncope, especially when the coexistence of more than one cardiac cause is suspected.

Introduction: The septomarginal trabecula is a constant element of the anatomy of the human heart, which connects the interventricular septum and the anterior wall of the right ventricle. Considering the diversity of opinions about the structure and numerous studies suggesting its important role in haemodynamics and conduction of electrical impulses in the heart, we decided to study this element in detail., Material and Methods: The research was conducted on 220 human hearts. Attention was mainly paid to the structure and topography of the trabecula. Its relation to the anterior papillary muscle was also a part of the study., Results: The presence of this morphologically diverse element was confirmed in each of the studied hearts. In most cases the trabecula originated from the upper part of the interventricular septum, separating at an angle increasing proportionally to the number of branches of the crista supraventricularis as well as the number of secondary trabeculae. The criteria established for the study, which included the course of the trabecula in the lumen of the right ventricle and its relation to the anterior papillary muscle, let us distinguish 4 types of septomarginal trabecula (I, II, III, IV). The most common was type III, the undivided trabecula, tightly connecting with the anterior papillary muscle., Conclusions: Based on the results of the following study we propose a hypothesis on the genesis of respective parts of the septomarginal trabecula and a plausible sequence of changes they undergo during human ontogenesis and phylogenesis of the primates.

Introduction: High-resolution electrocardiography (ECG-CREM) is a method based on digital electrocardiography. In order to facilitate the interpretation of the Crem records the technique of vectorcardiography was used. In comparison the origin of the ventricular premature complexes (VPCs) could be estimated based on a standard 12-lead electrocardiogram. The aim of the study was to assess the point of origin of the VPCs in ECG-CREM and correlate it with standard electrocardiography (ECG-Stand)., Material and Methods: Our study included 26 patients (16 females, 10 males), aged 51-83 years (avg. 58.1 ±12.3), who presented with recurrent, during at least 6 months' observation, VPCs. The point of origin of VPCs was compared in both methods., Results: The performed analysis of collected ECG-Stand records revealed the presence of arrhythmogenic focal points in six different locations (1, 3, 5, 7, 8, 9). However, we did not affirm their presence in points 2,4,6. They were most commonly located in RVOT zones 8 (30.7%), 9 (23.0%), 5 (23.0%), and most seldom in zones 1, 3, 7 (7.6% each). In the simultaneous record of ECG-CREM with a single VPC it was confirmed that the FPb zone was activated the most frequently (40.0%); the next in relation to frequency were SD and ST (20.0%). Less frequent VPCs have their origin in Crem zones SP, FPa and SB (6.6%)., Conclusions: Electrocardiogram of high signal resolution (ECG-CREM) might be useful in recognition of the origin of ventricular premature complexes from RVOT.

Background: It has been proposed that multisite atrial pacing (MSAp) restores atrial electrical activation and prevents atrial fibrillation recurrence; however, single-site Bachmann's bundle pacing (BBp) has also been reported as providing effective atrial resynchronization. Coronary sinus pacing (CSp) leads to reversed impulse propagation within the atria., Methods and Results: Acute echocardiographic examination was performed in 15 healthy subjects, and in 25 patients with sinus node dysfunction and recurrent atrial fibrillation during MSAp (atrial leads in the BB area and CS ostium), and single-site BBp and CSp. Regional atrial synchrony was assessed by tissue Doppler echocardiography. Pacing mode had no effect on stroke volume. CSp resulted in right atrial filling diminution, shortened mechanical atrioventricular delay in the right heart and diminished right ventricular inflow. The magnitude of reversion of the physiological right-to-left atrial contraction sequence was most prominent during CSp (15+/-11, 12+/-23, 3+/-21, 42+/-23 ms; control, MSAp, BBp, CSp respectively, P<0.0001). BBp provided the best atrial contraction synchrony, and had a comparable effect on global cardiac function to MSAp., Conclusions: Single-site BBp provides comparable hemodynamics to MSAp and is sufficient to restore atrial contraction synchrony. Single-site CSp induced echocardiographic pacemaker syndrome in the right heart.

Background: Optimal right ventricular (RV) pacing site in patients referred for permanent cardiac pacing remains controversial. A prospective randomized trial was done to compare long-term effect of permanent RV apex (RVA) vs RV outflow tract (RVOT) pacing on the all-cause and cardiovascular mortality., Methods and Results: A total of 122 consecutive patients (70 men, 69 +/-11 years), with standard pacing indications were randomized to RVA (66 patients) or RVOT (56 patients) ventricular lead placement. After the 10-year follow-up period the mortality data were summarized on the basis of an intention-to-treat analysis. During the long-term follow-up, 31 patients from the RVA group died vs 24 patients in the RVOT group (hazard ratio (HR), 0.96; 95% confidence interval (CI), 0.57-1.65; P=0.89). There were 10 cardiovascular deaths in the RVA and 12 in the RVOT group (HR, 1.04; 95%CI, 0.45-2.41; P=0.93). There were no differences in the all-cause or cardiovascular mortality between the pacing sites after adjustment for age, gender, arterial hypertension, atrial fibrillation, New York Heart Association class and left ventricular end-diastolic diameter., Conclusions: The RVOT provides no additional benefit in terms of long-term survival over RVA pacing.

The constant evolution of medical knowledge and accompanying development of diagnostic and treatment possibilities for arrhythmias and conduction disturbances has reawakened interest in the structure and function of the conduction system of the human heart, especially in the region of the atrioventricular (AV) junction and within the junction itself. Of the large number of studies dealing with the AV junction few focus on the initial zones of the AV node. These were described for the first time by Tawara in 1906. Similarly, Anderson et al. distinguished two origins of the AV node, the left one running towards the basis of the mitral valve and the right one leading towards the tricuspid valve. The differences in length and scale could be the result of the adoption of different reference points. The study was carried out on the material of 50 human hearts, of both sexes and ranging in age from 22 to 93, which were fixed in 10% formalin and 98% ethanol solution. The tissue obtained was fixed in the 10% formalin solution and, after being sunk in the paraffin, was cut into layers of about 10 mum thick. According to the age of the hearts, every 10(th) or 6(th) section was stained by the Masson-Goldner method. The preparations were examined under a LEICA 2000 and BIOLAR 2 microscope at magnifications of 2x to 400x. Each of the 50 examined hearts contained the atrioventricular node and its initial parts. We observed that the initial zone of the AV node is created by an assembly of cells typical for a conduction system that can create three groups that are initially independent of each other and are always arranged around the AV nodal artery. In all the hearts examined we found at least two initial parts of the node: the superior and inferior. These two groups were present in 45 hearts (90%). In the last 5 cases (10%) there was also a middle group. No cases were found either with a single initial group or without any initial groups. In the sections examined the superior group appeared to be first in 27 hearts (54%), while in 23 cases (46%) the inferior group was first. The length of each group was measured from its first appearance to its first direct contact with the second part. The length of the superior part varied from 0.15 to 2.91 mm (mean 0.90 +/- 0.6 mm), the inferior from 0.11 to 2.41 mm (mean 0.88 +/- 0.6 mm) and the middle from 0.67 to 2.21 mm (mean 1.04 +/- 0.7 mm). As mentioned above, in all 50 hearts there was a direct connection between the atrial muscle and the upper origin of AV node. Furthermore, in all sections (100%) the same part of the interatrial septal muscle was connected to the compact part of the node. Additionally, in 3 cases (6%) we were able to observe direct connections between the muscle fibres running from the fasciculus limbicus inferior to the initial zone of the AV node: in 2 cases (4%) with the superior group and in 1 case (2%) with the inferior group. In 8% of the material the atrial muscle of the supra-orificial zone made direct contact with the superior initial group and the compact zone of the node and in 10% there was contact between the suborificial muscle and the inferior group and the compact part of the node. This configuration was not observed in relation to the middle and inferior groups.

The aim of this study was ultrasound evaluation of atherosclerotic plaque morphology in relation to the degree of coronary artery lumen narrowing in patients with ischaemic heart disease. Intravascular ultrasound was performed on 38 patients (30 men and 8 women) aged 35 to 77 (average age 60 +/- 11 years old) with symptoms of ischaemic heart disease. The structure of atherosclerotic plaques with a degree of lumen narrowing of < 50% (1st group) was distinctly different from the structure of plaques with a degree of lumen narrowing of 50-75% (2nd group, p = 0.0045) and the structure of plaques with a degree of lumen narrowing of >/= 75% (3rd group, p < 0.001). The incidence of soft plaques decreased, whereas the percentage of mixed and hard plaques increased gradually with the increase in the degree of artery lumen narrowing. Significant differences in the incidence of plaque calcification were observed between the groups evaluated with crosssections of different degrees of lumen narrowing (p = 0.0032). The smallest number of calcifications was discovered in the 1st group as compared to the 2nd (p = 0.0027) and the 3rd group (p = 0.0026). With a higher degree of lumen narrowing, a lower percentage of eccentric plaques and a higher percentage of concentric plaques were observed. There were more eccentric plaques and fewer concentric plaques in cross-sections of the 1 st group as compared to the 2nd group (p = 0.0056) and the 3rd group (p = 0.0018). A comparison between the 2nd and 3rd groups showed no significant difference in the incidence of eccentric or concentric plaques (p = 0.5). In conclusion, intravascular ultrasound evaluation revealed significant relationships between the structure, presence of calcifications and location of atherosclerotic plaques and the degree of artery lumen narrowing. The incidence of mixed, hard, calcified and concentric plaques increased, whereas the percentage of soft, non-calcified and eccentric plaques decreased gradually with the increase in the degree of artery lumen narrowing.

Cardiac arrhythmias have troubled patients and fascinated physicians for centuries. The twentieth century was an era of progress, when the mechanism of cardiac disorders became more commonly recognised. Arrhythmias may be due to abnormalities of automaticity, to abnormalities of conduction, or to a combination of both. In order for re-entry to occur, an area of slowing conduction combined with unidirectional block must be present. Much investigation has centred on the underlying re-entry mechanisms of atrial flutter. In the light of these facts, it would seem that a close acquaintance with the detailed topography of the vena cava orifice (cavo), coronary sinus orifice (sinus) and the attachment of the septal leaflet of the tricuspid valve (tricupid) area could be of great interest, especially for invasive cardiologists. The research was conducted carried out on material consisting of 41 hearts of humans of both sexes from the age of 12 to 80 (6 female, 35 male). Classical macroscopic methods of anatomical evaluation were used. The following measurements were made: the shortest distance between the Eustachian valve and the attachment of the tricuspid valve on the left margin of the coronary sinus orifice (diameter 1), the distance between the attachment of the tricuspid valve and the inferior margin of the sinus orifice (diameter 2), the distance between the Eustachian valve and the attachment of the tricuspid valve on the right margin of the coronary sinus orifice (diameter 3), the distance between the inferior margin of the vena cava inferior and the attachment of the tricuspid valve (diameter 4) and, finally, the diameter between the attachment of the septal cusp of the tricuspid valve and the extemal border of the vena cava inferior (diameter 5). No correlation was found between the age and sex of the three groups of the material. The dimensions of the structure examined were similar in the three groups of hearts. In young adult hearts all the diameters measured ranged from 4 to 47 mm. The average diameters were, respectively: 15.02 mm (diameter 1), 8.97 mm (diameter 2), 17.27 mm (diameter 3), 26.87 mm (diameter 4), 36.42 mm (diameter 5). In the mature adult hearts all the diameters measured ranged from 8 to 45 mm; 18.19 mm (diameter 1), 10.54 mm (diameter 2), 19.95 mm (diameter 3), 28.90 mm (diameter 4), 39.63 mm (diameter 5). In the older adults hearts all the diameters measured ranged from 4 to 47 mm. The average diameters were, respectively: 15.65 mm (diameter 1), 8.70 mm (diameter 2), 7.25 mm (diameter 3), 26.80 mm (diameter 4), 35.85 mm (diameter 5). On the basis of our study we were able to conclude that the diameters of the cavo-sinus-tricuspid area were constant and did not differ significantly within the three (young, mature, old) adult groups examined.

The majority of anatomical structures within the heart during typical atrial flutters' ablation, right sided accessory pathway ablation or slow pathway ablation are invisible or blurred. Therefore it is very important to know in details interior right atrial structures during such procedures. In the neighborhood of coronary sinus orifice small concavity is visible. This area, called subthebesian fossa, is placed between the os of coronary sinus, the orifice of vena cava inferior and tricuspid annulus. The fossa is on the way of typical atrial flutters' reentrant circuit and is placed next to the isthmus area, which has become a target site for ablative therapy. Regarding the facts mentioned above we decided to examine the topography of this concavity in relation to neighboring structures. Research was conducted on material consisting of 45 human hearts of both sexes, from 19 to 71 years of age. The hearts came from patients whose death was not cardiologic in origin. The topography of the fossa was examined in relation to coronary sinus orifice (diameter A), vena cava inferior orifice (diameter B) and the attachment of the posterior leaflet of the tricuspid valve (diameter C). Besides we measured two perpendicular sizes in the inlet plane of the fossa. There were the longest size (diameter D) and the shortest size of the fossa (diameter E). We also defined deepness of the fossa (diameter F). Diameter A was from to 2 to 7mm (avg. 4.9 +/- 1.4 mm), diameter +/- from 2 to 8mm (avg. 4.0 +/- 1.6 mm) and diameter C from 5 to 9 mm (avg. 7.0 +/- 1.5 mm). The longest size in inlet plane of the concavity (diameter D) was from 12 to 18 mm (avg. 14.1 +/- 1.7 mm) and shortest size (diameter E) was from 7 to 14 mm (avg. 9.0 +/- 1.7 mm). The deepness of the fossa (diameter F) was from 2 to 7 mm (avg. 4.8 +/- 1.2 mm). The subthebesian concavity is inconstant anatomical structure, occurring in all forty five examined hearts (100%). The shape and sizes of the subthebesian fossa were variable in examined group of hearts. Our data suggest that differences in diameters between subthebesian fossa and neighboring structures may have clinical importance during ablation procedure.

One of the hypotheses put forward concerning the mechanism of vasovagal syncope is that the vagal afferent fibres are activated during vigorous contractions against a partly empty left ventricle. The aim of the study was to confirm this hypothesis by using 2D echocardiography during a head-up tilt test. The study was carried out on 39 patients (17 male, 22 female, age range 21-64 years), all with a history of recurrent syncope. The patients were examined using a 2D echo to measure the end-diastolic and end-systolic volume before the head-up tilt test after the Westminster protocol (45 min/60 grade) and every five minutes after tilting. T patients during head-up tilt test had a positive response and 32 proved negative. A reduction of both the end-diastolic and end-systolic volumes of the left ventricle was noticed. There was no significant difference in the degree of ejection fraction reduction. The difference in ejection fraction reduction between the two groups was similarly non-significant. It was also noticed that the patients with a positive response had more vigorous contractions than those with a negative test. The decision was therefore taken to use a different parameter for the left ventricle contraction, namely the LV posterior wall slope. As this parameter is partly dependent on time, its use in confirming the extremely vigorous nature of the contractions was considered appropriate. Only 6 patients were tested using this parameter. A tendency towards greater left ventricle posterior wall slope values, both before and during tilting was noticed in the group of patients with vasovagal reaction. Our data shows that vigorous contraction is probably less responsible for vasovagal syncope release than left ventricle volume reduction.