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Patients with vetricular tachycardia are usually treated with antiarrhythmic drugs and ablation if the arrhythmia substrate is available for invasive treatment. Despite high efficiency of this treatment there is a significant group of patients who do not benefit from available treatment methods, either because they cannot be applied or do not allow for durable control of the disease. For that reason a novel treatment method, STereotactic Arrhythmia Radioablation (STAR) has been proposed and its safety and efficiency is extensively studied throughout the world. The method is based on irradiation of the arrhythmia substrate identified with electrophysiological examination with high-precision image-guided radiosurgical methods usually used for ablation of malignant tumors. Here we present the protocol of the first Polish study on STAR in patients with intractable ventricular tachycardia (STARVT, NCT04642963), designed to test the safety of the method. Secondary endpoints include measures of the treatment efficiency.

The electrophysiology-guided noninvasive cardiac radioablation, also known as STAR (stereotactic arrhythmia radioablation) is an emerging treatment method for persistent ventricular tachycardia. Since its first application in 2012 in Stanford Cancer Institute, and a year later in University Hospital Ostrava, Czech Republic, the authors from all around the world have published case reports and case series, and several prospective trials were established. In this article, we would like to discuss the available clinical evidence, analyze the potentially clinically relevant differences in methodology, and address some of the unique challenges that come with this treatment method.

Structural, hemodynamic, and morphological cardiac changes following Fontan operation (FO) can contribute to the development of arrhythmias and conduction disorders. Sinus node dysfunction, junction rhythms, tachyarrhythmias, and ventricular arrhythmias (VAs) are some of the commonly reported arrhythmias. Only a few studies have analyzed this condition in adults after FO. This study aimed to determine the type and prevalence of arrhythmias and conduction disorders among patients who underwent FO and were under the medical surveillance of the John Paul II Hospital in Krakow. Data for the study were obtained from 50 FO patients (mean age 24 ± 5.7 years; 28 men (56%)). The median follow-up time was 4 (2–9) years. Each patient received a physical examination, an echocardiographic assessment, and a 24 h electrocardiogram assessment. Bradyarrhythmia was diagnosed in 22 patients (44%), supraventricular tachyarrhythmias in 14 patients (28%), and VAs in 6 patients (12%). Six patients required pacemaker implantation, and three required radiofrequency catheter ablation (6%). Arrythmias is a widespread clinical problem in adults after FO. It can lead to serious haemodynamic impairment, and therefore requires early diagnosis and effective treatment with the use of modern approaches, including electrotherapy methods.

Background: Implantable cardioverter-defibrillator (ICD) therapy has been proven effective in the prevention of sudden cardiac death, but data on outcomes of ICD therapy in the young and otherwise healthy patients with long QT syndrome (LQTS) are limited. Aim: We sought to collect data on appropriate and inappropriate ICD discharges, risk factors, and ICD-related complications. Methods: All LQTS patients implanted with an ICD in 14 centres were investigated. Demographic, clinical, and ICD therapy data were collected. Results: The study included 67 patients (88% female). Median age at ICD implantation was 31 years (12–77 years). ICD indication was based on resuscitated cardiac arrest in 46 patients, syncope in 18 patients, and malignant family history in three patients. During a median follow-up of 48 months, 39 (58%) patients received one or more ICD therapies. Time to first appropriate discharge was up to 55 months. Inappropriate therapies were triggered by fast sinus rhythm, atrial fibrillation, and T-wave oversensing. No predictors of inappropriate shocks were identified. Risk factors for appropriate ICD therapy were: (1) recurrent syncope despite b-blocker treatment before ICD implantation, (2) pacemaker therapy before ICD implantation, (3) single-chamber ICD, and (4) noncompliance to b-blockers. In 38 (57%) patients, at least one complication occurred. Conclusions: ICD therapy is effective in nearly half the patient population; however, the rates of early and late complica­tions are high. Although the number of unnecessary ICD shocks and reimplantation procedures may be lowered by modern programming and increased longevity of newer ICD generators, other adverse events are less likely to be reduced.

Mezczyzne w wieku 23 lat przyjeto do szpitala po reanimacji z powodu migotania komor. Mimo wykonania tomografii komputerowej glowy, echokardiografii i koronarografii z wentrykulografią nie wykryto organicznej przyczyny zatrzymania krązenia. W warunkach podstawowych w badaniu EKG nie uwidoczniono zaburzen przewodzenia i fazy repolaryzacji w odprowadzeniach V1-V3. Wobec braku ajmaliny podjeto probe doustnej prowokacji zespolu Brugadow za pomocą prajmaliny w dawce 40 mg. Godzine po jej podaniu zaobserwowano elektrokardiograficzne cechy zespolu Brugadow typu 1, ktore osiągnely swą definitywną, klasyczną forme po 90 minutach. Pacjentowi wszczepiono kardiowerter-defibrylator. Diagnostyke w kierunku zespolu Brugadow nalezy rozwazyc po zatrzymaniu krązenia rowniez u osob bez choroby organicznej serca z prawidlowym spoczynkowym zapisem EKG.

We discuss a 56‑year‑old man with Fabry disease (FD), a genetic X‑linked glycolipid storage disorder. The patient presented at the Emergency Room in a local hospital due to tachycardia‑associated chest pain, which had occurred occasionally in the past, but on that occasion was long‑lasting (>12h) and distressing. The patient had been diagnosed with FD at the age of 42. He presented a range of symptoms characteristic for the condition, including hypertrophic cardiac myopathy with impaired left ventricular relaxation, angiokeratomas, cornea verticillata, hypohydrosis and acroparesthesia. Residual alpha‑galactosidase A activity at diagnosis was ≈3%. The Enzyme Replacement Therapy (ERT) with the agalsidase alpha was induced. A year later pacemaker implantation was performed due to sick sinus syndrome with symptomatic, severe episodes of bradycardia. The initial diagnosis was tachycardia‑associated chest pain with troponin release in the context of FD left ventricular hypertrophy. However, a decision was made to perform an urgent angiographic evaluation to exclude coronary pathology as a potential factor in the clinical picture. Coronary angiography showed a critical, flow-limiting, stenosis of the left anterior descending artery (LAD) which changed the initial type 2 myocardial infarction (MI) diagnosis to the type 1 MI. Percutaneous stent‑assisted treatment was performed with an optimal angiographic and clinical outcome. However, 5 days later the patient developed a minor left hemispheric ischaemic stroke. In conclusion, the clinical course of a rare pathology such as FD may be importantly complicated by other (more common) pathologies. Physicians, in their diagnostic and therapeutic decision‑making, need to be open to thinking beyond the patient label. JRCD 2018; 3 (7): 246–252

Background: Patients with aortic stenosis (AS) may develop heart failure even in the absence of severe valve stenosis. Our aim was to assess the contribution of systemic arterial properties and the global left ventricular afterload to graded heart failure symptoms in AS. Methods: We retrospectively reviewed medical records of 157 consecutive subjects (mean age, 71±10 years; 79 women and 78 men) hospitalized owing to moderate-to-severe degenerative AS. Exclusion criteria included more than mild aortic insufficiency or disease of another valve, atrial fibrillation, coronary artery disease, severe respiratory disease or anemia. Heart failure symptoms were graded by NYHA class at admission. Systemic arterial compliance (SAC) and valvulo-arterial impedance (Zva) were derived from routine echocardiography and blood pressure. Results: Sixty-one patients were asymptomatic, 49 presented mild (NYHA II) and 47 moderate-to-severe (NYHA III-IV) heart failure symptoms. Mild symptoms were associated with lower SAC and transvalvular gradients, while more severe exercise intolerance coincided with older age, lower systolic blood pressure, smaller aortic valve area and depressed ejection fraction. By multiple ordinal logistic regression, the severity of heart failure symptoms was related to older age, depressed ejection fraction and lower SAC. Each decrease in SAC by 0.1 ml/m² per mmHg was associated with an increased adjusted odds ratio (OR) of a patient being in one higher category of heart failure symptoms graded as no symptoms, mild exercise intolerance and advanced exercise intolerance (OR: 1.16 [95% CI, 1.01-1.35], P=0.045). Conclusions: Depressed SAC may enhance exercise intolerance irrespective of stenosis severity or left ventricular systolic function in moderate-to-severe AS. This finding supports the importance of non-valvular factors for symptomatic status in AS.

Background A percutaneous intravascular cardioverter-defibrillator (PICD) has been developed with a right ventricular (RV) single-coil lead and titanium electrodes in the superior vena cava (SVC)–brachiocephalic vein (BCV) region and the inferior vena cava (IVC). Objective To compare defibrillation thresholds (DFTs) of the PICD with those of a conventional ICD in humans. Methods Ten patients with ischemic cardiomyopathy and ejection fraction ≤35% were randomized to initial testing with either PICD or conventional ICD. A standard dual-coil lead was positioned in the RV apex. If randomized to PICD, the device was placed into the vasculature such that 1 titanium electrode was positioned in the SVC-BCV region and the second in the IVC. For PICD DFTs, the RV coil of the conventional ICD lead was connected to the PICD mandrel [shock vector: RV (+) to SVC-BCV (−) + IVC (−)]. When testing the conventional ICD, a subcutaneous pocket was formed in the left pectoralis region and the ICD was connected to the lead system and positioned in the pocket [shock vector: RV (+) to SVC (−) + active can (−)]. Each device was removed before testing with the other. A step-down binary search protocol determined the DFT, with the initial shock being 9 J. Results The mean PICD DFT was 7.6 ± 3.3 J, and the conventional ICD system demonstrated a mean DFT of 9.5 ± 4.7 J (N = 10; paired t test, P = .28). Conclusion The intravascular defibrillator has DFTs similar to those of commercially available ICDs.

Objectives The purpose of the study was to determine the efficacy and safety of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach. Background Embolic stroke is the most devastating consequence of atrial fibrillation. Exclusion of the LAA is believed to decrease the risk of embolic stroke. Methods Eighty-nine patients with atrial fibrillation were enrolled to undergo percutaneous ligation of the LAA with the LARIAT device. The catheter-based LARIAT device consists of a snare with a pre-tied suture that is guided epicardially over the LAA. LAA closure was confirmed with transesophageal echocardiography (TEE) and contrast fluoroscopy immediately, then with TEE at 1 day, 30 days, 90 days, and 1 year post-LAA ligation. Results Eighty-five (96%) of 89 patients underwent successful LAA ligation. Eighty-one of 85 patients had complete closure immediately. Three of 85 patients had a ≤2-mm residual LAA leak by TEE color Doppler evaluation. One of 85 patients had a ≤3-mm jet by TEE. There were no complications due to the device. There were 3 access-related complications (during pericardial access, n = 2; and transseptal catheterization, n = 1). Adverse events included severe pericarditis post-operatively (n = 2), late pericardial effusion (n = 1), unexplained sudden death (n = 2), and late strokes thought to be non-embolic (n = 2). At 1 month (81 of 85) and 3 months (77 of 81) post-ligation, 95% of the patients had complete LAA closure by TEE. Of the patients undergoing 1-year TEE (n = 65), there was 98% complete LAA closure, including the patients with previous leaks. Conclusions LAA closure with the LARIAT device can be performed effectively with acceptably low access complications and periprocedural adverse events in this observational study.

Atrial fibrillation (AF) is leading cardiac arrhythmia with important clinical implications. Its diagnosis is usually made on the basis on 12-lead ECG or 24-hour Holter monitoring. More and more clinical evidence supports diagnostic use of cardiac event recorders and cardiovascular implantable electronic devices (CIED). Treatment options in patients with atrial fibrillation are extensive and are based on chosen rhythm and/or rate control strategy. The use and selected contraindications to AF related pharmacotherapy, including anticoagulants are shown. Nonpharmacological treatments, comorbidities and risk factors control remain mainstay in the treatment of patients with AF. Electrical cardioversion consists important choice in rhythm control strategy. Much progress has been made in the field of catheter ablation and cardiac surgery methods. Left atrial appendage occlusion/closure may be beneficial in patients with AF. CIED are used with clinical benefits in both, rhythm and rate control. Pacemakers, implantable cardioverter-defibrillators and cardiac resynchronization therapy devices with different pacing modes have guaranteed place in the treatment of patients with AF. On the other hand, the concepts of permanent leadless cardiac pacing, atrial dyssynchrony syndrome treatment and His-bundle or para-Hisian pacing have been proposed. This review summarizes and discusses current and novel treatment options in patients with atrial fibrillation.

Brugada syndrome is an autosomal dominant genetic disease with variable expression characterized by abnormal electrocardiographic findings – right bundle branch block and ST-segment elevation in the anterior precordial leads, without evidence of structural heart disease. Individuals affected by the disease have an increased risk of ventricular tachyarrhythmias and sudden cardiac death (SCD). We present a case of a 33-year old man who was admitted to cardiology department after sudden cardiac arrest due to ventricular fibrillation. Evaluation for a structural heart disease was negative and routine tests did not reveal the cause of cardiac arrest. Retrospective evaluation of the patient electrocardiograms showed changes consistent with Brugada type 2 pattern that were variable over time. Performed pharmacological challenge with sodium channel blocker – ajmaline – provided an ambiguous result. Nevertheless, the patient was qualified for an implantable cardioverter defibrillator implantation as a secondary SCD prophylaxis. He underwent the procedure without complications and was discharged home in good general condition without symptoms.

A recent experimental study suggested that proton pump inhibitors (PPI), widely used to prevent gastroduodenal complications of dual antiplatelet therapy, may increase the accumulation of the endogenous nitric oxide synthesis antagonist asymmetric dimethylarginine (ADMA), an adverse outcome predictor. Our aim was to assess the effect of PPI usage on circulating ADMA in coronary artery disease (CAD). Plasma ADMA levels were compared according to PPI use for ≥1 month prior to admission in 128 previously described non-diabetic men with stable CAD who were free of heart failure or other coexistent diseases. Patients on PPI tended to be older and with insignificantly lower estimated glomerular filtration rate (GFR). PPI use was not associated with any effect on plasma ADMA (0.51 ± 0.11 (SD) vs. 0.50 ± 0.10 µmol/L for those with PPI (n = 53) and without PPI (n = 75), respectively; p = 0.7). Additionally, plasma ADMA did not differ between PPI users and non-users stratified by a history of current smoking, CAD severity or extent. The adjustment for patients’ age and GFR did not substantially change the results. Thus, PPI usage does not appear to affect circulating ADMA in non-diabetic men with stable CAD. Whether novel mechanisms of adverse PPI effects on the vasculature can be translated into clinical conditions, requires further studies.

We present a complication of the infected pacing system extraction by lobular pneumonia in a 73-year-old female patient. The pacing system involved DDD pacemaker, atrial and ventricular endocardial leads implanted 12 year beforehand. The defect of the atrial lead emerged during the pacemaker replacement 4 years ago. The diagnosis of the injury cause and its reparation were not undertaken at that time. An interruption of the atrial lead which resulted in the formation of a loop inside the cardiac chamber was found when purulant pacemaker pocket infection had been diagnosed. The patient was referred for the pacing system extraction after preoperative specific antibiotic treatment. After a long-lasting, difficult, two-step leads extraction procedure, pneumonia developed. An echocardiogram revealed enlargement of the right atrium and ventricle, with elevated pulmonary artery pressure up to 40 mmHg. An atypical chest X-ray with the presence of a large pleural liquid volume led to the work-up of hemorrhagic complications and postponed the antithrombotic therapy. With the delay of 1.5 month the pulmonary scintigraphy showed features of pulmonary embolism. The embolism was most likely caused by a vegetation mobilized from the endocardial lead and/or endocardium during the extraction maneuvers. Before the surgery, the vegetations attached to the leads or to the endocardium had not been visualized. Anticoagulant therapy with antivitamins K was successful, which resulted in the pulmonary pressure normalization. The patient has remained in a good condition for the next 3 months of follow-up.

Przedstawiono trudności w interpretacji rytmu z szerokimi zespolami QRS u 25-letniej pacjentki z preekscytacją komor oraz okresowo wystepującym przyspieszonym rytmem z szerokimi zespolami QRS (94/min), spelniającym w elektrokardiogramie (EKG) morfologiczne kryteria rytmu komorowego, bez poprzedzających zalamkow P. Wstepne trudności w interpretacji EKG wyjaśnilo wykonane badanie elektrofizjologiczne, w ktorym wykazano nadkomorowe pochodzenie rytmu przewodzonego do komor przez droge dodatkową. Wykonanie ablacji prądem o czestotliwości radiowej drogi dodatkowej odslonilo okresowo wystepujący rytm dolno-przedsionkowy pochodzący z okolic mieśniowki zatoki wiencowej. Bliskie sąsiedztwo rytmu przedsionkowego i drogi dodatkowej skutkowalo natychmiastowym przewodzeniem do komor, doskonale imitując rytm komorowy. Opisany przypadek zwraca uwage na potrzebe uwzglednienia rytmu pozazatokowego z preekcytacją komor w toku diagnostyki rytmu z szerokimi zespolami QRS.

A 56-year-old woman, previously healthy, was hospitalized after an episode of ventricular tachycardia in the course of infection. In view of the fulminant course of heart failure the patient was connected to an extracorporeal membrane oxygenation (ECMO) system. After 3 weeks of treatment with ECMO the patient received a heart transplant. A histopathological examination of the tissues of the explanted heart revealed giant cell myocarditis. The patient was treated with immunosuppression based on induction therapy followed by a standard regimen with steroids. Currently, the patient remains in good general condition with an left ventricular ejection fraction of 60%.

Background The arrhythmic role of the left atrial appendage (LAA) has been implicated in the maintenance of persistent atrial fibrillation. LAA isolation with catheter ablation has been successful but is limited by the risk of tamponade and electromechanical dissociation with the potential for LAA thrombus formation. Objective To assess whether LAA ligation results in LAA electrical isolation. Methods A total of 68 patients with contraindication or intolerance to oral anticoagulation therapy underwent LAA ligation with the LARIAT suture delivery device. Patients had unipolar [n = 30(44%)] or bipolar [n = 38(56%)] voltage measurements pre- and post-LAA ligation. Results All 68 patients underwent successful LAA ligation. There was a statistically significant reduction in the mean LAA voltage from pre-ligation (unipolar pre-ligation voltage 1.1 ± 0.53 mV; bipolar pre-ligation voltage 4.7 ± 2.83 mV) to post-ligation (unipolar post-ligation voltage 0.3 ± 0.38 mV; bipolar post-ligation voltage 0.6 ± 0.27 mV). Ninety-four percent of the patients had a reduction in the LAA voltage after the closure of the snare, with 10 of 30 (33%) of the patients having complete elimination of LAA voltage with the initial tightening of the suture. Pacing from the LAA after the closure of the snare resulted in lack of capture of the left atrium in 28 of 31 patients. Conclusions The snare closure of the LAA using the LARIAT device produces an acute reduction in the LAA voltage and inhibits the capture of the left atrium during LAA pacing. Future studies are needed to determine whether LAA ligation affects atrial fibrillation burden.

The purpose of the study was to determine the efficacy and safety of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach.Embolic stroke is the most devastating consequence of atrial fibrillation. Exclusion of the LAA is believed to decrease the risk of embolic stroke.Eighty-nine patients with atrial fibrillation were enrolled to undergo percutaneous ligation of the LAA with the LARIAT device. The catheter-based LARIAT device consists of a snare with a pre-tied suture that is guided epicardially over the LAA. LAA closure was confirmed with transesophageal echocardiography (TEE) and contrast fluoroscopy immediately, then with TEE at 1 day, 30 days, 90 days, and 1 year post-LAA ligation.Eighty-five (96%) of 89 patients underwent successful LAA ligation. Eighty-one of 85 patients had complete closure immediately. Three of 85 patients had a ≤ 2-mm residual LAA leak by TEE color Doppler evaluation. One of 85 patients had a ≤ 3-mm jet by TEE. There were no complications due to the device. There were 3 access-related complications (during pericardial access, n = 2; and transseptal catheterization, n = 1). Adverse events included severe pericarditis post-operatively (n = 2), late pericardial effusion (n = 1), unexplained sudden death (n = 2), and late strokes thought to be non-embolic (n = 2). At 1 month (81 of 85) and 3 months (77 of 81) post-ligation, 95% of the patients had complete LAA closure by TEE. Of the patients undergoing 1-year TEE (n = 65), there was 98% complete LAA closure, including the patients with previous leaks.LAA closure with the LARIAT device can be performed effectively with acceptably low access complications and periprocedural adverse events in this observational study.

The Ex-Maze III procedure is a recently developed surgical method for ablation of atrial fibrillation (AF). The procedure uses epicardial approach and can be performed on the beating heart.To evaluate the efficacy and safety of Ex-Maze III ablation in patients undergoing mitral valve (MV) surgery.The study group consisted of 20 consecutive patients (8 males, mean age 67 years) who underwent MV surgery and had concomitant AF. Eighteen patients were diagnosed with long-standing permanent AF and 2 patients with paroxysmal AF. The mean duration of AF was 9.5 years prior to surgery. All the patients underwent the Ex-Maze III procedure on the beating heart immediately before the MV surgery (MV replacement in 17 patients and MV repair in 3 patients). The patients were followed 1, 3, 6 and 12 months after procedure with ECG and 24-h ambulatory ECG monitoring (at 12 months).There were no serious complications in the study group. All the patients were in AF immediately after the procedure and underwent electrical or pharmacological cardioversion (4 and 16 patients, respectively). The proportion of patients remaining in sinus rhythm was 15 (75%) patients at 1 month, 16 (80%) patients at 3 months, 17 (85%) patients at 6 months and 12 months after procedure.The Ex-Maze III procedure for ablation of AF on the beating heart is safe and effective in patients with AF undergoing concomitant MV surgery. In order to better evaluate the outcomes of the procedure a prospective randomised multicentre study is needed.

INTRODUCTION Atrial fibrillation (AF) is a common arrhythmia affecting approximately 1% to 2% of the general population. OBJECTIVES The aim of the study was to evaluate the efficacy and safety of thoracoscopic ablation in patients with AF. PATIENTS AND METHODS A total of 25 patients aged from 42 to 77 years (mean 56.4 years) with persistent or long-standing persistent AF were scheduled for the procedure. Thoracoscopic epicardial ablation of the right atrium, pulmonary veins, and left atrium was performed on the beating heart using the Cox MAZE III-based diagram, via 3 ports and 2 cm incision below the xiphoid. Exit block was always assessed. Patients were prospectively followed for 12 months after the procedure. 24-hour electrocardiography (Holter monitoring) was used to confirm the results. RESULTS Conduction block across ablation lines was achieved in 21 patients (84%). At 1 month of follow-up, the sinus rhythm (SR) was observed in 18 of 20 patients. At 3 months, the SR was observed in 19 patients (76%). Two patients had atrial flutter, while 3 still experienced AF. At 6 months, the SR was observed in 21 patients (84%); 2 patients still had AF, 1 patient atrial flutter, and 1 patient had a pacemaker implanted. Results of follow-up at 1 year did not differ from those at 6 months. No changes in the size of the left atrium and left ventricular ejection fraction, no deaths, stroke, transient ischemic attack, or infectious complications were observed. CONCLUSIONS The efficacy of epicardial thoracoscopic ablation of the left and right atrium was high, reaching 84% during 1-year follow-up. No serious complications were observed in the postoperative period (except for the need for pacemaker implantation in 1 patient).

Cardiac resynchronization therapy (CRT) is an acknowledged treatment for advanced heart failure in acquired dilated cardiomyopathy, resistant to pharmacotherapy. Although there are no therapeutic standards regarding heart failure originating from congenital heart defects with systemic right ventricle, a number of CRT implantations by transvenous approach in congenitally corrected transposition of the great arteries (CCTGA) have been reported since 2001, even though none of them expressly referred to a case concomitant with dextrocardia and situs inversus anomaly. We present a 57 year-old patient with dextrocardia and CCTGA, who underwent surgical closure of interatrial and interventricular septal defects at the age of 19, and in whom a VVI pacemaker was subsequently implanted at age 36. A three-lead CRT system was implanted by transvenous approach. Imaging techniques, including multi-slice computed tomography, targeted to pacing system and unusual anatomical relationships were applied. Within a 20-month follow-up, a significant improvement of functional NYHA class, systemic right ventricle ejection fraction and exercise capability were observed. Entirely transvenous CRT system implantation is feasible in patients with dextrocardia and CCTGA, and has substantial potential for long-term benefits.

Although the short-term results after radiofrequency (RF) catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT), accessorry pathway (AP), atrioventricular junction (AVJ) and common atrial flutter (Aflu) have been widely reported, there is insufficient data on long-term outcome.To evaluate the long-term efficacy of RF ablation of cardiac arrhythmias in a single center.The study population consisted of 349 consecutive patients (mean age 49.5 years) who underwent RF ablation of AP (136 patients), AVNRT (105 patients), AVJ (86 patients) or Aflu (15 patients). In 4 patients two AP and in 3 patients AP and AVNRT were ablated during the same session. The patients were subsequently followed-up for an average of 44.3 months (12-76 months).Ablation was successful in 341 patients (97.7%). Major complications occurred in 8 patients (2.3%) and included av block (6 patients), ventricular fibrillation (1 patient) and cardiac tamponade (1 patient). Tachycardia recurrences were observed in 21 patients (6.2%) after successful ablation. All the recurrences occurred within 10 months (mean 2.3 months) after ablation. The recurrence rate was 5.8% (6 patients) in the AVNRT group, 9.2% (12 patients) in the AP group, 1.2% in the AVJ group (1 patient) and 13% (2 patients) in the Aflu group. The differences between groups were insignifficant.(1) The immediate success rate of RF ablation of AVNRT, AP, AVJ or Aflu was high and there was a low incidence of complications. (2) The recurrence rate during long-term observation is low. (3). All the recurrences occurred within 10 months after successful ablation.

The aim of the study was to clinical analyse patients with cardioverter-defibrillator (ICD) treated in Cracow Department of Electrocardiology IK CMUJ between 1997-2004.Data from 199 patients, aged 10 to 82, mean 56.9 year, in whom 198 implantations (31 of dual-chamber) and replacements were analyzed.(1) Number of ICD implantation as primary prevention is insufficient in this Dept. (2) Simultaneous presence of pacemaker and ICD is acceptable. (3) Careful sudden cardiac death risk stratification, even in non-classic indicative diseases should be undertaken. (4) Subcutaneous ICD implantation, even in slim people can be done without danger of skin erosion and parameters deterioration. 5. Devices implanted in the past presented longevity shorter than expected. (6) Cooperation with house-officers and pathologists is insufficient.

Active-fixation pacemaker leads seem to have advantages over passive-fixation ones, such as the possibility of pacing at various sites, low dislodgement rate, and they are easier to extract. Unexpectedly their popularity in European countries is not high.The comparative estimation of acute electrical parameters between high-impedance fractal passive-fixation and traditional active-fixation leads. Second aim of the study was the evaluation of commonly used active- and passive-fixation leads in order to find the best solution for ambulatory implantation.35 patients received passive-fixation Biotronik Synox SX60BP pacemaker leads and 35 patients received active-fixation Biotronik YP60BP pacemaker leads. Intraoperative measurement of pacing threshold, impedance, R amplitude, and slew-rate were performed.The pacing threshold was statistically significant lower (p = 0.1) in passive-fixation "tined-tip" SX60BP group (0.45 vs. 0.63). In 3 active-fixation cases "exit block" with ineffective pacing occured in early post-operative period.Active-fixation YP60BP electrodes should not be used for ambulatory implantation course.

We present a 59 year old patient with advanced heart failure who underwent lead extraction. The lead was implanted 11 years ago, and 2 years later looped spontaneously following its fracture. The transvenous extraction process through inferior vena cava was complicated by knotting of the inactive lead over the active ventricular lead. The patient was pacemaker-dependent. Finally, the old lead was successfuly explanted. The active intact lead was used to create resynchronisation system.

A 61-year-old patient with a 20-year history of permanent pacemaker implantation and half--a-year cardiac resynchronization therapy using a left ventricular lead placed via surgical approach was admitted for extraction of an old coiled right ventricular lead, which triggered ventricular arrhythmia and created a risk of pulmonary embolism. The lead was extracted via the left femoral vein in two stages: untying a loop on the lead using a pig-tail catheter and Dotter basket followed by traction and dissection of adhesions using a Byrd dilator sheath. Dissection of the old lead from the active right ventricular one posed special technical problems.

During implantation of a DDD pacemaker the following difficulties may be encountered: venous anomalies (the absence of vessels of adequate calibre or difficulty in subclavian vein puncture), arrhythmias during implantation (episodes of atrial flutter/fibrillation while the atrial leads are being positioned), lack of mechanical stability of the electrode in the heart chamber and inability to achieve an acceptable pacing and sensing threshold during implantation. The purpose of the study was to analyse retrospectively the reasons for DDD pacemaker failure in patients operated on between 1993 and 2005.We reviewed retrospectively all implantation data from 1988 to 2005 to identify patients with primary failure of DDD pacemaker implantation. Further analysis included patients who had received a DDD pacemaker between 1993 and 2005, when this type of pacemaker made up between 9 and 40% of all pacemaker implantations. We implanted 7469 pacemakers, including 1958 (26.2%) dual-chamber pacemakers, in 783 patients with atrioventricular block (AVB), 392 with sick sinus syndrome (SSS), 450 with AVB +/- SSS and 333 with tachy-brady syndrome (TBS). The mean age of the patients was 65.5 +/- 17.3 years. DDD pacing was unsuccessful in 108 (1.4%) patients, including 32 with AVB, 22 with SSS, 16 with SSS +/- AVB and 38 with TBS. The mean age of these patients was 78.5 +/- 19.4 years.The reasons for failed implantation were venous anomalies in 12%, an arrhythmia episode in 27.8%, a high pacing threshold in the atrium in 17.6%, low atrial potential amplitude in 25.9% and lack of mechanical stability of the electrode in 16.7% of patients. The difficulties were encountered in elderly patients (p0.01), most frequently in patients with SSS and TBS (71). Between 2004 and 2005 venous anomalies and a high pacing threshold were the main causes of failure.Currently the main difficulties encountered during pacemaker implantation are venous anomalies and a high pacing threshold. Arrhythmia episodes, low atrial potential amplitude and lack of mechanical stability are of minor importance. Elderly patients with sick sinus syndrome and tachy-brady syndrome have the highest failure rate. (Cardiol J 2007; 14: 155-159).

Pacemaker dependency (PD) can be defined as the risk of serious injury or death from sudden pacemaker failure, an event more dangerous than progressive rate decrease. The aim of this study was to evaluate the incidence of PD during long-term follow-up after pacing system implantation.The study included 3638 patients (mean age 65.3 +/- 10.2 years). Indications for pacing were sick sinus syndrome (SSS) in 1315 patients, atrioventricular block (AVB) in 1482, AVB and SSS in 478 and atrial fibrillation (AF) with bradycardia in 363 patients. The mean follow-up was 4.8 +/- 1.8 years. Pacemaker dependency was defined as the absence of an intrinsic rhythm of 30 beats/min during back-up pacing and after switching off the pacemaker. If any significant symptoms of bradycardia developed or if the underlying rhythm did not appear (asystole5 s) the pacing was restarted. Pacemaker dependency was observed in 76 (2.1%) of the 3638 patients . In this subgroup pacing indications were SSS in 8 (0.6%) of 1315 patients, AVB in 52 (3.5%) of 1482, SSS and AVB in 15 (3.1%) of 478 and AF with bradycardia in 1 (0.3%) of 363. Patients with AVB had a significantly higher incidence of PD than patients with SSS or AF (p0.001, p0.005, respectively). A total of 139 patients suffered from myocardial infarction and 106 patients had a temporary pacing prior to pacemaker implantation. The majority of these patients were pacemaker dependent (p0.001).In our study PD occurred very rarely, being found in 2.1% of all patients. Patients with AVB have a significantly higher incidence of PD than patients with SSS or AF. Temporary pacing prior to pacemaker implantation and previous myocardial infarction indicate patients at risk of PD development. (Cardiol J 2007; 14: 83-86).

Complete atrioventricular block, second-degree Mobitz type II and first-degree atrioventricular block with right bundle branch block were observed consecutively following successful radiofrequency ablation in close proximity to the sinus node. This resulted in the modification and disappearance of the inappropriate sinus tachycardia that had previously been present. Neither tachycardia nor conduction disturbances have been recorded in the 9-year follow-up, implying that ventricular pacing standby should also be considered in high atrial ablation cases. (Cardiol J 2007; 14: 504-507).

We describe a case of a 59-year-old female with paroxysmal atrial fibrillation and arterial hypertension who had syncopal attacks due to polymorphic ventricular tachycardia (PMVT) with a short coupling interval of an initiating beat (280 msec). We excluded structural heart disease. In the resting ECG the QTc interval was 420 msec. During Holter monitoring a slight changes of the ST-T segment in V1 were observed (from positive T wave with ST elevation of 1 mm to flat or negative T wave without ST elevation). Additionally, after PMVT a large U-wave (4 mm of amplitude) with the QTU interval of 600 msec and QTUc interval of 662 msec were observed. The U wave disappeared 9 minutes afterwards. The ajmaline test was positive for the Brugada syndrome. The patient received ICD and sotalol, and during 6-month follow-up she remains asymptomatic.

Radiofrequency catheter ablation (RFCA) may cause myocardial injury.To assess changes in myocardial enzymes levels following RFCA.Creatine kinase (CK), CK-MB, aspartate aminotransferase (GOT), alanine aminotransferase (GPT), troponin I and myoglobin levels were assessed in 53 patients (33 females, 20 males, mean age 53 years, range 23-78 years) before and 20 hours after successful RFCA (WPW type A = 13, WPW type B = 10, atrio-ventricular nodal tachycardia n = 17, atrial fibrillation or flutter n = 5, atrial tachycardia n = 2 and complex arrhythmias n = 6).The mean number of RF applications was 10.4, cumulative energy - 22 671 J, duration of application - 468 sec, and temperature - 58 degrees C. A significant post-RFCA increase in the troponin I and myoglobin levels was found whereas the changes in CK and GOT levels were less pronounced. A significant correlation between troponin I elevation and RFCA energy, particularly in males, was documented. There was a trend towards a decrease in the GPT and CK-MB levels. Troponin I and myoglobin levels increased regardless of the site of RF energy application.Troponin I and myoglobin are useful for the assessment of RFCA-induced myocardial injury, regardless of the site of RFCA application.

The left atrial appendage (LAA) has been implicated as a potential trigger for atrial fibrillation (AF). Catheter ablation to isolate the LAA with catheter ablation has been successful, but is limited by the risk of tamponade and the potential for mechanical standstill & thrombus formation. We