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Introduction: Quality of life must be perceived in two levels - objective and subjective. Heart arrhythmia is a disease of the cardiovascular system that, by its subjective and objective symptoms, can affect the individual's life physically, mentally, and also socially. It can limit a person in his or her everyday activities or in activities that make them happy or satisfied.Objectives: The aim of the research was to map the quality of life of patients with arrhythmia and to verify whether the duration of arrhythmia has an effect on the quality of life of patients with arrhythmia.Methods: A standardized ASTA (Arrhythmia - Specific Questionnaire in Tachycardia and Arrhythmias) questionnaire was used to collect quantitative data. The research group consisted of adult patients diagnosed with hearth arrhythmia, hospitalized at the Department of Cardiology of the Ceske Budejovice Hospital (Nemocnice České Budějovice a.s.). A total of 127 valid questionnaires were used for data processing.Results: The research revealed that the most common symptom of arrhythmia in 58% cases was rapid heartbeat, irregular heartbeat, and a sense of heart failure. Most respondents agreed with the claim that heart rhythm disorder makes it impossible for them to perform work, study, and perform daily life activities. No statistically significant differences were found in the evaluation of the influence of the arrhythmia duration on the patients' quality of life.Conclusions: Arrhythmia duration in the selected sample does not affect the overall health status and quality of life measured by the ASTA series questionnaires. Arrhythmia restricts the patient to perform work tasks, study, and perform daily life activities.

Cryoenergy is the most commonly used method of lesion formation in patients who have undergone surgical ablation of atrial fibrillation. Despite frequent use, the clinical effect of cryoenergy in endocardial and epicardial approaches is unknown.To compare the effect of various cryoenergy applications on the postoperative incidence of sinus rhythm and completeness of lesions performed.A total of 55 patients underwent concomitant atrial fibrillation surgical ablation using cryoenergy under various conditions: epicardially during cardiac arrest, epicardially on beating heart, and endocardially. In the postoperative period, patients were invited to attend an electrophysiological examination to assess the completeness of surgical ablation lesions and, if necessary, to complete catheter ablation.Twenty-four patients underwent epicardial ablation on the arrested heart (group 1), 12 patients underwent epicardial ablation on the beating heart (group 2), and 19 patients underwent endocardial ablation (group 3). In the electrophysiological examination, sinus rhythm was present in 71% vs. 83% vs. 89% of patients, respectively. The completeness of pulmonary vein isolation was confirmed in 31% vs. 25% vs. 95% of patients, complete box lesions in 15% vs. 0% vs. 79% of patients, respectively.Despite the similar clinical effect of surgical ablation in all three approaches, the morphologically most effective use of cryoenergy is endocardial ablation. This approach has a very good result. Our findings further support the endocardial use of cryoenergy during surgical ablation of atrial fibrillation.Krioenergia jest najczęściej stosowaną metodą wytwarzania blizn u pacjentów poddawanych ablacji chirurgicznej z powodu migotania przedsionków. Pomimo popularności tej metody efekt kliniczny stosowania krioenergii z dostępu wsierdziowego i nasierdziowego nie jest znany.Porównanie wpływu różnych zastosowań krioenergii na pooperacyjne występowanie rytmu zatokowego i kompletność zabiegu.U łącznie 55 pacjentów wykonano jednoczesną ablację chirurgiczną migotania przedsionków z wykorzystaniem krioenergii: od strony nasierdzia po zatrzymaniu krążenia, od strony nasierdzia na bijącym sercu i od strony wsierdzia. W okresie pooperacyjnym pacjentów poproszono o zgłoszenie się na badanie elektrofizjologiczne serca, aby ocenić kompletność chirurgicznej ablacji zmian oraz w razie potrzeby uzupełnić ablację cewnikową.U 24 pacjentów przeprowadzono ablację od strony nasierdzia po zatrzymaniu krążenia (grupa 1.), u 12 pacjentów – ablację od strony nasierdzia na bijącym sercu (grupa 2.), a u 19 pacjentów – ablację z dostępu wsierdziowego (grupa 3.). W badaniu elektrofizjologicznym rytm zatokowy stwierdzono u odpowiednio 71%, 83% i 89% pacjentów. Kompletną izolację żyły płucnej potwierdzono u odpowiednio 31%, 25% i 95% pacjentów, a uszkodzenia typu „pudełka” (Pomimo zbliżonego efektu klinicznego ablacji chirurgicznej we wszystkich trzech metodach, z morfologicznego punktu widzenia najbardziej skuteczne jest stosowanie krioenergii w ablacji wsierdziowej. Technika ta daje bardzo dobry efekt. Uzyskane wyniki potwierdzają zasadność stosowania krioenergii od strony wsierdzia podczas ablacji chirurgicznej migotania przedsionków.

Objectives: This study sought to evaluate the safety and short-term performance of a novel catheter for very high power–short duration (vHPSD) ablation in the treatment of paroxysmal atrial...

Introduction Stroke is one of the most feared complications during catheter ablation of atrial fibrillation (AF). While symptomatic thromboembolic events are rare, magnetic resonance imaging (MRI) may identify asymptomatic (ie, silent) cerebral lesions (SCLs) following pulmonary vein isolation (PVI) procedures. Methods and Results The REDUCE‐TE Pilot was a prospective multicenter, single‐arm observational study investigating the incidence of SCL in patients with symptomatic paroxysmal AF undergoing PVI with a novel gold‐tip, externally irrigated ablation catheter. After ablation, cerebral diffusion‐weighted MRI and a postablation follow‐up were performed at 1 to 3 days after the ablation procedure. A neurocognitive test was done before and after ablation. The primary study endpoint was the occurrence of one or more new SCLs. Secondary study endpoints included neurocognitive status, procedural success rate, and periprocedural complications including symptomatic thromboembolic events. A total of 104 patients were enrolled (69% male, mean age: 61.5 ± 9.7 years, mean CHA2DS 2‐VASc score: 1.7 ± 1.2). Postprocedural MRI examination was performed in 97 patients, and in nine of them (9.3%; 95% CI: 4.3‐16.9%) a total of 11 SCLs were detected. Univariate analyses did not reveal any significant predictor for new SCLs. Nonsignificant trends were observed for low activated clotting time during ablation and for international normalized ratio value outside the range of 2 to 3 at ablation. There was no evidence of significant deterioration of neurocognitive function after PVI. In four patients, a pericardial tamponade was noted but all patients fully recovered during follow‐up. Conclusions Ablation of AF using a novel gold‐tip, externally irrigated ablation catheter, resulted in SCLs in approximately one out of 10 patients without a measurable effect on neurocognitive function.

Uvod: Srdecni resynchronizacni lecba (SRL) snižuje mortalitu a morbiditu u selektovaných pacientů s chronickým srdecnim selhanim. Prvni prospektivni registr ukazal, že indikace SRL jsou extrapolovany i na skupiny pacientů, ktere v randomizovaných studiich nebyly dostatecnou měrou zastoupeny. Byly dokumentovany take znacne rozdily v implantacnich technikach mezi jednotlivými regiony i staty. Cilem tohoto clanku je podat přehled o druhem mezinarodnim registru ESC CRT Survey II a srovnani dat z tohoto registru s daty ziskanými samostatně za Ceskou republiku (CR).Metody a výsledky: Registr vznikl jako spolecna iniciativa Evropske asociace pro srdecni rytmus (EHRA) a Asociace pro srdecni selhani (HFA). Zahrnul celkem data od 11 088 pacientů ze 42 clenských zemi Evropske kardiologicke spolecnosti (CZEKS). CR (14 participujicich center, z toho deset aktivnich) přispěla do registru celkem 931 pacienty (průměrný věk 69,4 ± 9,9 roku, 23 % žen). Průměrne implantacni doby a skiaskopicke casy byly v CR významně kratsi. Byly zde take významně castěji implantovany biventrikularni defibrilatory ve srovnani s biventrikularnimi kardiostimulatory (OR 1,74, 95% CI 1,47-2,05, p < 0,0001). SRL implantuje v CR castěji elektrofyziolog (OR 6,18, 95% CI 4,56-8,37, p < 0,0001), pacienti maji na EKG meně casto blokadu leveho Tawarova ramenka (OR 0,54, 95% CI 0,47-0,62), maji castěji fibrilaci sini (OR 1,32, 95% CI 1,15-1,51, p < 0,001) a meně je u nich využivano telemedicinske sledovani (OR 0,41, 95% CI 0,34-0,49, p < 0,0001).Zavěr: Druhý registr SRL poskytl cenný zdroj informaci o soucasne klinicke praxi v indikaci a výsledcich SRL. Srovnani dat CR s průměrem CZEKS nas řadi mezi přednich deset zemi co do poctu výkonů, jejich uspěsnosti a extremně nizkeho poctu perioperacnich komplikaci. Rozsiřeni dalkoveho sledovani pacientů se SRL je vsak u nas ve srovnani s CZEKS stale poměrně nizke. U velke casti pacientů je stale indikovana SRL z jiných důvodů, než odpovida doporuceni s nejlepsi evidenci.

Pocet pacientů s implantabilnimi kardiovertery-defibrilatory (ICD) neustale narůsta. Nově se v peci o tyto pacienty uplatňuje telemedicinske sledovani (Home MonitoringTM, HM).Metodika: Výzkum probihal kvantitativni metodou technikou dotaznikoveho setřeni. Byl ziskan soubor 150 konsekutivnich pacientů s ICD sledovaných systemem HM (HM+) a 150 konsekutivnich pacientů s ICD, kteři byli sledovani standardni technikou (HM-). Dotazniky byla zkoumana kvalita života (QoL) (EQ-5D-3L), mira anxiety, deprese (HADS) a subjektivni vnimani přinosu systemu HM a organizace dalkove pece.Výsledky: Způsob sledovani ICD přimo neovlivnil QoL (p = NS). Na zakladě celkoveho skore byl zaznamenan trend k lepsimu hodnoceni QoL pacienty ve skupině HM+ oproti skupině HM- (68,6 ± 19,0 vs. 64,6 ± 16,5, p = 0,09). Výsledky tež neodhalily významne rozdily mezi skupinami pacientů HM- a HM+ ve výskytu anxiety a deprese. Z hlediska subjektivniho vnimani přinosu systemu HM a organizace dalkove pece byl zaznamenan nejvýraznějsi rozdil (p < 0,0001) mezi skupinami pacientů v jimi preferovanem způsobu sledovani: 54,9 % pacientů ze skupiny HM- by si přalo být raději sledovano dalkově a 45,1 % by setrvalo u stavajiciho ambulantniho sledovani, zatimco ve skupině HM+ by pouze 6,7 % pacientů preferovalo namisto dalkoveho sledovani osobni kontrolu u lekaře. Skupina HM+ preferovala využivani dalkoveho systemu sledovani (p = 0,007) a stejně tak měla kladný nazor na dalkově provaděnou lekařskou peci (p = 0,034).Zavěr: Způsob sledovani implantovaných ICD přistrojů významně neovlivňuje QoL, anxietu ci depresi u pacientů s ICD. Pacienti s ICD sledovani systemem HM maji vysokou adherenci k dalkově provaděne lekařske peci a jen velmi neradi by o výhody spojene s timto způsobem sledovani ICD přisli.

Background To date, there are no data from randomized controlled studies on the benefit of cardiac resynchronization therapy (CRT) when implanted as an upgrade in patients with a previous device as compared to de novo CRT. In the CRT Survey II we compared the baseline data of patients upgraded to CRT (CRT-P/CRT-D) from a previous pacemaker (PM) or implantable cardioverter-defibrillator (ICD) to de novo CRT implantation. Methods and results In the European CRT Survey II, clinical practice data of patients undergoing CRT and/or ICD implantation across 42 European Society of Cardiology (ESC) countries were collected between October 2015 and December 2016. Out of a total of 11 088 patients, 2396 (23.2%) were upgraded from a previous PM or ICD and 7933 (76.8%) underwent de novo implantation. Compared to de novo implantations, upgraded patients were older, more often male, more frequently had ischaemic heart failure aetiology, atrial fibrillation, reduced renal function, worse heart failure symptoms, and higher N-terminal pro-B-type natriuretic peptide levels. Upgraded patients were more often PM-dependent and less frequently received CRT-D. Total peri-procedural, in-hospital complications and length of hospital stay were similar. Upgraded patients were less frequently treated with heart failure medication at discharge. Conclusion Despite a lack of evidenced-based data, close to one quarter of all CRT implantations across 42 ESC countries were upgrades from a previous PM or ICD. Despite older age and worse symptoms, the CRT implantation procedures in upgraded patients were equally frequently successful and complications similar to de novo implantations. These results call for more studies.

In our recent paper (1) we tried to identify predictors of arrhythmia recurrence in patients undergoing a hybrid ablation procedure consisting of both an epicardial and endocardial radiofrequency (RF) ablation, performed in a delayed sequential manner, in patients with persistent atrial fibrillation (AF), with the majority presenting with long-standing persistent arrhythmia (87%). By design, our cohort of patients consisted of one of the “less curable” forms of arrhythmia, especially if treated using only conventional catheter ablation techniques. The majority of our patients might very well have been precluded from receiving invasive therapy if they had been assessed just for a catheter ablation, particularly in less experienced centers.

Uvod: Lecba perzistujici a dlouhodobě perzistujici fibrilace sini (FS) katetrizacni ablaci (KA) v dlouhodobem horizontu selhava. Jednou z možnosti, jak překonat limitace KA, je hybridni přistup.Cil: Systematicky demonstrovat elektrofyziologicke nalezy u pacientů podstupujicich hybridni chirurgický zakrok pro FS.Metody: Pacienti s perzistujici ci dlouhodobě perzistujici FS podstoupili epikardialni thorakoskopickou radiofrekvencni (RF) izolaci plicnich žil (PŽ) pomoci klesťoveho instrumentaria AtriCure, ktera byla doplněna vytvořenim linearnich lezi v leve sini (LS) pomoci linearniho pera, discizi Marshallova ligamenta a exkluzi ouska LS pomoci specialniho klipu (AtriClip). S odstupem dvou až tři měsiců po výkonu podstoupili vsichni pacienti elektrofyziologicke vysetřeni (EFV) a RF KA s cilem endokardialně eliminovat připadne recidivy elektrickeho vedeni do/z PŽ nebo napřic linearnimi lezemi.Výsledky: Do studie bylo zařazeno celkem 70 pacientů (49 mužů), median 63,5 roku. EFV bylo provedeno za 87 dnů (median) od primarniho thorakoskopickeho výkonu. 76 % pacientů mělo v době EFV normalni sinusový rytmus (SR), 7 % typický flutter sini, 11 % siňovou tachykardii a 6 % FS. Levostranne PŽ byly nalezeny izolovane u významně mensi casti pacientů ve srovnani s pravostrannými PŽ (75,7 % vs. 91,4 %, p < 0,001). Vsechny PŽ byly izolovany u 68,6 % pacientů. Dokoncena izolace zadni stěny LS byla nalezena jen u 22,9 % pacientů. Izolace PŽ byla endokardialni KA dokoncena ve vsech připadech. Izolaci zadni stěny LS se KA v druhem kroku hybridniho výkonu podařilo dosahnout u 91,4 % pacientů. Mista nejcastějsi rekondukce levostranných PŽ se nachazela na stropě LS a na hrance mezi levou horni PŽ a ouskem LS, u pravostranných PŽ byla nejcastějsi rekondukce na stropě a zadni stěně LS. Typicke misto recidivy elektrickeho vedeni stropni linkou nebylo možne urcit - u větsiny pacientů musela být endokardialni ablacni linie vedena v cele jeji delce. U dolni spojujici leze byla typickým mistem rekondukce oblast jedne třetiny linie přilehle k prave dolni PŽ.Zavěr: Izolace pravostranných PŽ provaděna epikardialně je významně castěji uspěsnějsi než izolace levostranných PŽ. Epikardialni linearni aplikace RF energie pod přimou kontrolou zraku nevede ve velke větsině připadů k vytvořeni permanentnich lezi. Kardiochirurgove mohou diky nasim zavěrům zaměřit svou pozornost na typicka mista rekondukce a dalsimi "bonusovými" RF aplikacemi v těchto oblastech dosahnout vyssi uspěsnosti výkonu.

Uvod: Lecba perzistujici a dlouhodobě perzistujici fibrilace sini (FS) katetrizacni ablaci v dlouhodobem horizontu selhava. Jednou ze soucasných možnosti, jak překonat limitace katetrizacni ablace, je hybridni přistup.Cil: Zjistit bezpecnost a střednědobou uspěsnost lecby pacientů s perzistujici a dlouhodobě perzistujici FS hybridni metodou.Metody: Pacienti podstoupili epikardialni thorakoskopickou radiofrekvencni (RF) izolaci plicnich žil (PŽ) za pomoci klesťoveho instrumentaria AtriCure, ktera byla doplněna vytvořenim linearnich lezi v leve sini (LS) pomoci linearniho pera, disrupci Marshallova ligamenta a exkluzi ouska LS pomoci specialniho klipu (AtriClip). S odstupem dvou až tři měsiců po výkonu podstoupili vsichni pacienti elektrofyziologicke vysetřeni (EFV) a RF katetrizacni ablaci s cilem endokardialně eliminovat připadne recidivy elektrickeho vedeni do/z PŽ nebo napřic linearnimi lezemi a eliminovat vsechny spontanni i inducibilni siňove arytmie. V naslednem obdobi byly recidivy arytmii hodnoceny pomoci sedmidenniho holterovskeho monitorovani provaděneho v prvnim roce každe tři měsice a nasledně každých sest měsiců.Výsledky: Do studie bylo zařazeno celkem 70 pacientů (49 mužů, median 63,5 roku). Elektrofyziologicke vysetřeni bylo provedeno za 87 dnů (median) od primarniho thorakoskopickeho výkonu. Sestasedmdesat procent pacientů mělo v době EFV normalni sinusový rytmus (SR), 7 % typický flutter sini, 11 % siňovou tachykardii a 6 % FS. Výsledkem dokonceneho hybridniho přistupu byla izolace vsech PŽ v 100 % připadů a dosaženi blokady vedeni napřic vsemi zamýslenými linearnimi lezemi u 88,6 % pacientů. Po 12 měsicich od zakroku bylo stabilniho SR dosaženo u 77,1 % pacientů bez jakekoliv antiarytmicke lecby ci reablaci. Racionalni kontroly arytmie bylo dosaženo u 95,5 % pacientů po průměrnou dobu sledovani 936 ± 432 dnů.Zavěr: Sekvencni hybridni přistup představuje v soucasne době patrně nejucinnějsi a po překonani ucebni křivky i bezpecnou metodu invazivni lecby perzistujici a dlouhodobě perzistujici FS s extremně nizkým poctem recidiv arytmie ve střednědobem horizontu po zakroku. Zavedeni hybridnich přistupů do klinicke praxe vyžaduje nutnost komplexni spoluprace kardiologickeho a kardiochirurgickeho týmu.

Atrial fibrillation (AFib) is related to a high risk of stroke. The main role in etiopathogenesis is played by the left atrial appendage (LAA). As many as 95 % of thrombi in nonvalvular atrial fibrillation are located in the appendage. Prevention of stroke then consists in permanent anticoagulation which, however, has its limits and risks. An alternative method is the left atrial appendage occlusion. In our report, we would like to present a new possibility of the closure using the epicardial system AtriClip (AtriCure). In the period beginning in July 2012 - September 2015 we performed LAA closure in 101 patients. A mean age of 65 ± 6 years, 47 women, CHA2DS2 VASc (O) 2.47 (0-6). Monitoring 1 837 (O 18.5) months. A concomitant procedure was performed in 37 patients, endoscopic MAZE plus clip in 57 patients, and 7 patients underwent stand-alone implantation of the clip. The clip was implanted from full sternotomy, minitoracotomy or through thoracoscopy. Clip loading, residual recess and endoleak were assessed through endoscopic ultrasound according to the Cleveland criteria. The perioperative success rate of loading reached 98 %. The clip was loaded with a neck greater than 1 cm in 2 patients. No migration of the clip occurred, no endoleak was detected and no thrombus at the appendage base was detected. One case of periprocedural stroke was recorded. Within follow-up monitoring TIA occurred in 4 patients and no stroke was recorded. Epicardial LAA occlusion using the AtriClip system is a safe and reproducible method of LAA occlusion and an important alternative in the prevention of stroke.Key words: atrial fibrillation - occlusion of left atrial appendage - stroke.

Background/Introduction The novel catheter with 6 thermocouples for real-time temperature monitoring during irrigated radiofrequency ablation was designed to potentially enhance safety and effectiveness of the Smart Touch Surround Flow (STSF) catheter by incorporating real-time temperature sensing. A supplementary, novel algorithm was developed to modulate power to maintain target temperature during high power/short duration ablation (90W, 4s). Purpose This sub-analysis was performed to examine consistency and reproducibility of the procedural efficiencies and acute success of the novel catheter with optimized temperature control and microelectrodes in treating paroxysmal atrial fibrillation (PAF) across multiple sites from two initial feasibility studies, in standard (QMODE) and high power/short duration (QMODE+) temperature-control ablation modes. Methods The QDOT-MICRO (QMODE, NCT02944968; N=42) and QDOT-FAST (QMODE+, NCT03459196; N=52) studies were both prospective, non-randomized multi-center, clinical investigations completed across 6 and 7 centers, respectively, in Europe. Procedural efficiencies and acute success (PVI via entrance block) was examined across sites within the study. Results In the QDOT-MICRO study, median procedure time (105–155 min), RF ablation time (27.7–39.5 min), and fluoroscopy times (2.2–8 min) during QMODE ablation were similar across the 6 sites. In QMODE+ ablation, median procedure time, RF ablation time, and fluoroscopy times all fall within (84–134 min), (4.8–9.7 min) and (1.1–9.6 min), respectively, across the 7 sites. Fluid delivery by the study catheter was low in both studies: QDOT-MICRO 547±278mL (mean ± SD); QDOT-FAST 382±299. mL (mean ± SD); which is 39.1 and 57.4% lower, respectively, than reported in the SMART SF trial. Esophageal temperature probe was used in the majority of patients (30/42 for QDOT MICRO and 51/52 for QDOT-FAST). Acute PVI was successful in 100% of patients in both studies with no deaths or unanticipated AEs. Conclusion(s) In both feasibility studies, procedural efficiencies were reproducible across study sites in both QMODE and QMODE+, with 100% acute success and good safety outcomes. Efficiencies are likely to improve with further experience. These results need to be confirmed in larger trials. Acknowledgement/Funding Both Studies are Company Sponsored Studies funded by Biosense Webster, Inc.

Background: Catheter ablation procedures have recently become a widely accepted method for treating cardiac arrhythmias, and referrals for these procedures have been steadily increasing. As a result, it is now common that sheath removal is handled as a nursing procedure. Regardless of who performs the sheath removal, it is important to extract ablation sheaths without any early or late complications. Objective: The aim of this randomised study was to determine the safety of sheath extraction after heparin reversal with low-dose protamine sulfate in patients undergoing radiofrequency catheter ablation for atrial fibrillation and whether these sheaths can be safely removed by nurses. Methods: Eighty-one patients were randomly assigned to either receiving protamine to reverse heparin after an ablation ( n=40) or to the standard protocol without heparin reversal ( n=41). Nurse-led sheath removal was done in the cath lab (protamine group) or on the ward (standard group) as soon as activated partial thromboplastin time dropped below 60 s. All adverse events, groin compression time, immobilisation time and procedure characteristics were recorded. Results: The manual compression time for the standard group was significantly longer than for the protamine group (15.9 ± 2.5 vs. 21.9 ± 3.1 minutes, PConclusion: Fewer and milder complications and shorter immobilisation times were reported with protamine reversal compared to the conventional method. Staff nurses can safely remove femoral venous sheaths after a radiofrequency ablation for atrial fibrillation.

Uvod: Telemedicinske sledovani pacientů s implantabilnimi kardiovertery-defibrilatory (ICD) je dnes obecně považovano za bezpecnějsi, ucinnějsi a ekonomicky výhodnějsi. Cilem prace bylo posoudit dlouhodobý ekonomický přinos dalkoveho sledovani pacientů s nově implantovaným ICD za pomoci systemu Home Monitoring™ (HM) ve srovnani se standardni ambulantni peci v podminkach CR.Metody: Pacienti byli randomizovani k dalkovemu sledovani systemem HM s dennimi automatickými přenosy dat a ambulantni kontrolou v intervalu 12 měsiců (HM+) nebo ke standardnim ambulantnim kontrolam (HM-). Stanoveni nakladů bylo provedeno na zakladě uctů zdravotnich pojisťoven, přimých nakladů pacientů a provoznich nakladů systemu HM jako průměrně vynaložene na jednoho pacienta a měsic sledovani.Výsledky: Sledovano bylo celkem 198 pacientů po dobu v průměru 37,4 ± 15,2 měsice. Ve skupině HM+ byl za dobu sledovani redukovan pocet planovaných kontrol o 48 % (p < 0,001). Ve skupině HM+ byla zaznamenana významně kratsi delka hospitalizace. Nakladova data byla ziskana celkem u 75 % pacientů. Ve skupině HM- byly zaznamenany vyssi naklady za ambulantni peci (223 ± 99 Kc vs. 189 ± 93 Kc, p = 0,039) i transport zdravotni dopravni službou (640 ± 314 Kc vs. 367 ± 187 Kc, p = 0,003). Při zapocteni nakladů na provoz systemu HM k ambulantni peci a přepravě nebyl rozdil mezi skupinami signifikantni, ale pokud byla do nakladů promitnuta take uhrada výkonu dalkove monitorace a pořizeni domaci pacientske jednotky, byl již průměrný naklad vyssi pro skupinu HM+ (541 ± 188 Kc vs. 401 ± 332 Kc, p = 0,002). Nakladově neutralni by v takovem připadě zůstal za předpokladu hrazene přepravy vsech pacientů k ambulantnim kontrolam.Zavěr: System HM byl dosud v CR u pacientů s jedno- nebo dvoudutinovými ICD z hlediska vynaložených výdajů nakladově výhodný pro zdravotni pojisťovny. Při kalkulaci teto uhrady na vrub platců zdravotni pece by system HM zachoval nakladovou neutralitu pouze v připadě hrazene přepravy větsiny pacientů. Klinický prospěch dalkove monitorace bezprostředně plyne z kontinuity sledovani, možnosti velmi casne detekce udalosti a patřicne lekařske intervence, proto se domnivame, že system HM by měl být hrazen automaticky u vsech pacientů s implantovaným ICD, byť za cenu v kontextu celeho zdravotnickeho rozpoctu nevýznamneho navýseni nakladů.

Background:\ud \ud Cardiac resynchronisation therapy (CRT) reduces morbidity and mortality in appropriately selected patients with heart failure and is strongly recommended for such patients by guidelines. A European Society of Cardiology (ESC) CRT survey conducted in 2008–2009 showed considerable variation in guideline adherence and large individual, national and regional differences in patient selection, implantation practice and follow-up. Accordingly, two ESC associations, the European Heart Rhythm Association and the Heart Failure Association, designed a second prospective survey to describe contemporary clinical practice regarding CRT.\ud Methods and results:\ud \ud A survey of the clinical practice of CRT-P and CRT-D implantation was conducted from October 2015 to December 2016 in 42 ESC member countries. Implanting centres provided information about their hospital and CRT service and were asked to complete a web-based case report form collecting information on patient characteristics, investigations, implantation procedures and complications during the index hospitalisation. The 11 088 patients enrolled represented 11% of the total number of expected implantations in participating countries during the survey period; 32% of patients were aged ≥75 years, 28% of procedures were upgrades from a permanent pacemaker or implantable cardioverter-defibrillator and 30% were CRT-P rather than CRT-D. Most patients (88%) had a QRS duration ≥130 ms, 73% had left bundle branch block and 26% were in atrial fibrillation at the time of implantation. Large geographical variations in clinical practice were observed.\ud Conclusion:\ud \ud CRT Survey II provides a valuable source of information on contemporary clinical practice with respect to CRT implantation in a large sample of ESC member states. The survey permits assessment of guideline adherence and demonstrates variations in patient selection, management, implantation procedure and follow-up strategy.

Background Automated algorithms may identify focal (FA) and rotational (RoA) activations during persistent atrial fibrillation (PeAF). Objective Methods To evaluate an automated algorithm for characterizing and assessing significance of FA/RoA. Eighty-six PeAF ablation patients (1411 maps) were analyzed. Maps were obtained with a 64-electrode basket using CARTOFINDER, which filters/annotates atrial unipolar electrograms over 30 seconds. Operators ablated FA/RoA followed by pulmonary vein isolation (PVI). The automated algorithm was retrospectively applied using QS patterns to identify FA and sequential activation gradients for RoA without phase mapping. Algorithm-identified FA and RoA were validated against blinded adjudicators. Ablation of algorithm-identified FA/RoA was related to procedural AF termination. Results Conclusion 73% +/- 18% of electrodes (65% +/- 11% atrial surface area) were adequate for analysis. Compared with adjudicators, the algorithm had a sensitivity of 84% for FA and 86% for RoA. There were 4 +/- 2 FA and 2 +/- 2 RoA per patient. FA occurred 8 +/- 6 times during the 30-second window (cumulative duration 8 +/- 6 seconds). RoA occurred 5 +/- 3 times (median 2, consecutive rotations) with a cumulative duration of 3 +/- 2 seconds. Compared to patients without procedural AF termination, patients with termination had more FA ablated (75% vs 38%, P = 0.006). AF termination was not predicted by percentage of RoA ablated although there was a trend towards a higher percentage of left atrial RoA ablated (P = 0.06). An automated algorithm had high sensitivity for FA and RoA. Acute AF termination was associated with FA ablation but not RoA ablation. Future studies need to define the significance of FA and RoA and whether they are overlapping or separate mechanisms.

Background: The aim of the study was to evaluate whether the sequential hybrid approach combining surgical CryoMaze followed by the radiofrequency (RF) catheter ablation can improve freedom from atrial arrhythmias. Methods: Thirty-five patients with persistent atrial fibrillation underwent a CryoMaze procedure in conjunction with cardiac surgery for structural heart disease. Three months after surgery, all patients underwent a 7-day electrocardiogram Holter followed by an electrophysiological study and mapping of the left and right atria. All pulmonary veins were reisolated and all ablation lines were completed, if necessary, using RF energy. Patients were followed-up at 3 months, 6 months, and 12 months after the catheter ablation. Results: Before the mapping study and RF ablation, nine patients (26%) had ongoing atrial fibrillation or atrial tachycardia, 10 patients (28%) had paroxysmal atrial tachyarrhythmia, and 16 patients (46%) had sinus rhythm on the 7-day Holter monitoring. During the electrophysiological procedure, complete cryoablation lines around the left pulmonary veins were found in 29 patients (83%), around the right pulmonary veins in 25 patients (71%), between the superior veins in 20 patients (57%), between the inferior veins in 27 patients (77%), across the mitral isthmus in 12 patients (34%), and across the cavotricuspid isthmus in one patient (3%). Arrhythmia-free survival rate of antiarrhythmic drugs after reisolation of the veins and completion of the lines was 86% at 12 months. Conclusion: Ablation lines created using surgical CryoMaze are often incomplete. Sequential surgical CryoMaze procedures followed by catheter ablation significantly increase freedom from arrhythmia in patients with persistent atrial fibrillation.

Objective Left atrial appendage (LAA) plays a crucial role in the etiopathogenesis and the prevention of the stroke in patients with nonvalvular atrial fibrillation (AF). This paper presents our first experience with thoracoscopic LAA occlusion using an external clip. Methods We performed a total of 30 LAA occlusions with the AtriClip from left thoracoscopy approach during the period from July 2012 to July 2013. AtriClip was implanted during the bilateral thoracoscopic radiofrequency (RF) as part of left atrial ablation procedure. Results Among the 30 procedures, AtriClip was once periprocedurally partially positioned. In the remaining procedures, the implantation was successful without complications. Of the 30 patients, 29 underwent transesophageal echocardiography and computer tomography examination at 3 months after the procedure. Apart from the patient with the partial clip placement, a residual pouch of 18 mm was detected in another patient. In the remaining group (28/30 patients, 93%), the exclusion was complete. No migration or any other clip implantation-related complications occurred during the follow-up. None of the patients experienced an embolization event. Conclusions Endoscopic AtriClip implantation appears to be a reproducible and safe method of LAA occlusion, with a minimal risk and a high efficiency. In our opinion, the AtriClip implantation is a reasonable part of thoracoscopic AF treatment and should be considered as an alternative tool for stroke risk reduction in patients with AF.

Background Recent advances in 3D mapping systems, such as simultaneous visualization of multiple catheters and contact force measurement, have allowed a significant reduction in fluoroscopic times during radiofrequency (RF) ablation (RFA) procedures. The objective was to investigate whether RFA of paroxysmal atrial fibrillation (PAF) using the CARTO 3 system (Biosense Webster, Diamond Bar, CA, USA) and intracardiac echocardiography (ICE) can be performed safely without fluoroscopy. Methods and Results Eighty patients with PAF were randomized in a 1:1 ratio to undergo either fluoroscopically guided pulmonary vein isolation (PVI) (X+) or PVI without fluoroscopy (X−). In the X− fluoroscopy group, catheter placement, transseptal puncture, left atrial geometry reconstruction, and PVI were accomplished solely using ICE imaging and CARTO mapping. The total procedure duration and RF application time in both the X− and X+ groups were comparable (92.5 ± 22.9 minutes vs 99.9 ± 15.9 minutes, P = 0.11 and 1785 ± 548 seconds vs 1755 ± 450 seconds, P = 0.79, respectively). Zero fluoroscopic time was achieved in all patients in the X− group with the exception of one patient, where 8 seconds of fluoroscopy was needed to assess proper position of the guide-wire in the femoral vein. No serious procedure-related complications were recorded and no differences in arrhythmia-free survival at 12 months were found between the groups. Conclusion RFA using ICE imaging and the CARTO 3 mapping system with contact force measurement is capable of eliminating fluoroscopy in patients undergoing PVI. Exclusion of fluoroscopic imaging does not seem to compromise patient safety and does not affect overall procedure duration, RF application time, or mid-term efficacy.

Background— Long-term efficacy of catheter-based treatment of persistent atrial fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently, but their efficacy has never been systematically tested. Methods and Results— Seventy patients (median age, 63.5 years) with persistent atrial fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein isolation, linear ablation, Marshal ligament disruption, and exclusion of the left atrial appendage. The procedure was followed by electroanatomic mapping and ablation (EAM) 2 to 3 months later. Only 76% of patients were in normal sinus rhythm at the beginning of EAM. All 4 pulmonary veins and the left atrium posterior wall were found isolated in 69% and 23% of patients, respectively. Arrhythmia-free survival off antiarrhythmic drugs 12 months after EAM was 77%. Using previously ineffective antiarrhythmic drugs and reablation procedures, arrhythmia free-survival increased to 97% during follow-up (mean, 936±432 days; range, 346–1509 days). The majority of arrhythmia recurrences occurred during the first 12 months after EAM. In a multivariable-adjusted estimates, left atrium volume >165 mL, absent normal sinus rhythm at admission for EAM, and inducibility of any sustained tachyarrhythmia at the end of EAM procedure were identified as independent correlates of atrial fibrillation recurrence. Conclusions— Our report demonstrated that the majority of patients after epicardial ablation, using bipolar radiofrequency instruments, required endocardial catheter ablation to complete the linear ablation lesions and a significant proportion of patients required spot-ablations to complete electric pulmonary vein isolation. Noninducibility of any arrhythmia after a staged hybrid procedure seemed to be the strongest correlate of long-term arrhythmia-free survival. Clinical Trial Registration— URL: www.ablace.cz . Unique identifier: cz-060520121617.

Long-term efficacy of catheter-based treatment of persistent atrial fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently but their true efficacy has never been systematically tested.Seventy patients (median age 63.5 years) with persistent atrial fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein (PV) isolation, linear ablation, Marshal ligament disruption, and exclusion of the left atrial appendage. The procedure was followed by electroanatomic mapping 2 to 3 months later.Only 76% of patients were in sinus rhythm at the beginning of electroanatomic mapping. Right PVs were found isolated in a higher proportion of patients compared with left PVs (75.7% versus 91.4%, p0.001). All four PVs and the left atrial posterior wall were isolated in 68.6% and 22.9% of patients, respectively. Most of the gaps around left PVs were localized in the superior and anterior quadrants, whereas in right PVs, the gaps were found predominantly on the roof and posterior wall. A typical site of reconduction on the inferior connecting line was the segment adjacent to the right inferior PV. No typical reconduction sites were found on the roof line, as 58.5% of patients required completion of the roof line along its full length.Epicardial PV isolation was successful in the majority of patients, but was underwhelming with regard to isolation of the left PVs. Effective epicardially placed linear lines were rare. Our results highlight the significant limitations associated with a single-stage surgical approach and underline the necessity for a two-staged hybrid approach in the treatment of persistent atrial fibrillation.

OBJECTIVES: The treatment of persistent and long-standing persistent atrial fibrillation (AF) has unsatisfactory results using both medical therapy and/or catheter ablation, where incomplete ablation lines remain a significant problem. This study evaluates the feasibility, efficacy and safety of the sequential, two-staged hybrid treatment combining thoracoscopic surgical and transvenous catheter AF ablation. METHODS: Thirty patients with persistent and long-standing persistent AF underwent surgical thoracoscopic radiofrequency (RF) ablation procedure using a predefined protocol (pulmonary veins isolation, box lesion, isthmus line lesion, dissection of the ligament of Marshall, left atrial appendage exclusion with an epicardial clip and ganglionated plexi ablation) followed by diagnostic catheterization and RF ablation 3 months later. In this session, electrical mapping of the left atrium was performed and any incomplete isolation lines were completed. Mitral and cavotricuspid isthmus ablation lines were performed during this session as well. RESULTS: The preoperative mean duration time of AF was 33 ± 27 months with 17% patients with persistent and 83% patients with longstanding persistent AF. The mean size of the left atrium was 48 ± 5 mm. The complete surgical ablation protocol was achieved in 97% of patients, with no death, and no early stroke or pacemaker implantation in the early postoperative period. In 63% of patients, the left atrial appendage was excluded with an epicardial clip. An endocardial touch-up for achievement of bidirectional block of pulmonary veins was necessary in 10 patients (33%) and on the box, (roof and floor) lesions in 20 patients (67%). Freedom from atrial fibrillation was 77% after surgical ablation and 93% after the completed hybrid procedure.

A new implantable cardiac monitor (BioMonitor, Biotronik) with a continuous remote monitoring option was prospectively implanted in patients with suspected arrhythmias or for therapy control after atrial fibrillation (AF) ablation. A three-lead ECG detection was intended to make the implantation more independent of the implantation site and the electrical heart axis. Because noise is a frequent problem in implantable cardiac monitors, an active noise detection algorithm was implemented. The aim of the trial was to evaluate the clinical performance of the device. The device performance was evaluated in a prospective nonrandomized multicenter study with a follow-up of 12 months. Study endpoints were device-related serious adverse events at 3 months, appropriate QRS detection in direct comparison with synchronized Holter ECG recordings, sensitivity and positive predictive value of arrhythmia detection in comparison with Holter ECG and independent of it, and noise burden during the entire follow-up period. The implantation was successful in all 152 patients. Two device-related serious adverse events (pocket infections) occurred by 3 months. The mean QRS amplitude of 0.3 ± 0.2 mV at implantation remained stable over 12 months. QRS sensing performance indicated little over- and undersensing in most patients. More than 80 % of the patients had more than 22 h of noise-free monitoring per day. BioMonitor effectively detects patients with bradycardia, tachycardia, AF, or asystole. Active noise detection seems to reduce the transmission of meaningless data without diminishing the positive predictive value of the device.

Atrial fibrillation is common in patients with structural heart disease who are undergoing cardiac surgery. Surgical CryoMaze has been shown to be an effective treatment in several trials, but success rates have varied considerably, between 47–95 %. The sequential hybrid approach, combining surgical CryoMaze followed by radiofrequency catheter ablation, can achieve high freedom from atrial arrhythmias, even when rigorous methods to detect arrhythmias after the procedure are used. However, data from randomized trials comparing hybrid ablations to surgical ablations alone are lacking. The SurHyb study is a prospective, multicenter, randomized study. Patients with persistent or long-standing persistent atrial fibrillation will be randomized to either surgical CryoMaze alone or surgical CryoMaze followed by catheter ablation 3 months post-surgery. The primary outcome measure is arrhythmia-free survival without class I or III antiarrhythmic drugs, which will be evaluated using 7-day ECG Holter monitoring at 24 months. A total of 260 patients will be investigated from three medical centers in the Czech Republic to obtain the relevant information. This is the first randomized study that compares surgical CryoMaze alone with the staged hybrid surgical CryoMaze followed by catheter ablation in patients with persistent or long-standing persistent atrial fibrillation. These results will contribute to the optimization of the treatment for these patients. Czech Clinical Trials Registry, cz-301020151253 . Registered on 30 October 2015.

IntroductionPulmonary vein isolation (PVI) is considered to be a cornerstone of invasive therapy of paroxysmal atrial fibrillation (PAF). However, numerous technologies appeared on the market during last 10 years and besides typical “point-by-point” ablation, other “single-burn” technologies or remote navigation emerged.GoalThe aim of this article is to summarize single center experience with PVI using different technologies.Methods and resultsThe study was conducted in partially retrospective and mainly prospective manner. Consecutive cohorts of patients with PAF were followed after their index procedure using four different systems (CARTO XP, pulmonary vein ablation catheter (PVAC), CARTO3 and Sensei robotic system). After 3 month blanking period, repeated 7 day-Holters were carried out every 3 months following the index procedure, which consisted of catheter-based radiofrequency PVI. Documented episodes of AF lasting >60s on any of these 7-day Holters were considered a failure of treatment. Using of the PVAC technology was associated with the shortest procedure duration when compared to any other system (p

Decreased autonomic function is known to be predictive of death, especially in chronic heart failure (CHF) patients. We sought to report mid-term heart rate and heart rate variability (HRV) changes after cardiac resynchronization therapy (CRT), using a continuous device-based measurement, which should facilitate daily management of CHF patients. Stored data were retrieved for 92 CHF patients who were enrolled in a prospective multicentre study and received a CRT pacemaker capable of continuous assessment of HRV. This parameter was recorded daily as a footprint plot, a graphic visualization of the distribution of HRV. Decreases in mean heart rate (from 75.4±11.7 to 71.4±8.4 bpm) and increases in HRV as attested by footprint area (from 33.5±13.5% to 40.7±14.5%) were statistically significant after 12 months follow-up ( p p

Introduction: Catheter ablation for paroxysmal atrial fibrillation is widely used for patients with drug-refractory paroxysms of arrhythmia. Recently, novel technologies have been introduced to the market that aim to simplify and shorten the procedure. Aim: To compare the clinical outcome of pulmonary vein (PV) isolation using a multipolar circular ablation catheter (PVAC group), with point-by-point PV isolation using an irrigated-tip ablation catheter and the CARTO mapping system (CARTO group; CARTO, Biosense Webster, Diamond Bar, CA, USA). Methods: Patients with documented PAF were randomized to undergo PV isolation using PVAC or CARTO. Atrial fibrillation (AF) recurrences were documented by serial 7-day Holter monitoring. Results: One hundred and two patients (mean age 58 ± 11 years, 68 men) were included in the study. The patients had comparable baseline clinical characteristics, including left atrial dimensions and left ventricular ejection fraction, in both study arms (PVAC: n = 51 and CARTO: n = 51). Total procedural and fluoroscopic times were significantly shorter in the PVAC group (107 ± 31 minutes vs 208 ± 46 minutes, P < 0.0001 and 16 ± 5 minutes vs 28 ± 8 minutes, P < 0.0001, respectively). The AF recurrence was documented in 23% and 29% of patients in the PVAC and CARTO groups, respectively (P = 0.8), during the mean follow-up of 200 ± 13 days. No serious complications were noted in both study groups. Conclusions: Clinical success rates of PV isolation are similar when using multipolar circular PV ablation catheter and point-by-point ablation with a three-dimensional (3D) navigation system in patients with PAF, and results in shorter procedural and fluoroscopic times with a comparable safety profile. (PACE 2010; 33:1039–1046)

International audience; AIMS: The aim of this study was to investigate the 12-month incidence, predictive factors, and prognosis of sustained ventricular tachycardia (VT) in chronic heart failure patients implanted with biventricular pacemakers without a back-up defibrillator (CRT-P), assessed by continuous intracardiac ventricular electrograms. METHODS AND RESULTS: The Mona Lisa study, a prospective, multicentre, cohort study, designed to determine the incidence of sustained VT and its prognostic impact in CRT-P recipients within the year after implant enrolled 198 patients with moderate or severe chronic heart failure, despite optimal pharmacological therapy. An independent committee reviewed the data from all arrhythmic episodes as well as causes of death according to predefined criteria. During a mean follow-up of 9.8 +/- 3.1 months after implantation, 8 patients experienced at least one episode of sustained VT [4.3%; 95% confidence interval (CI), 1.1-7.5] and 21 deaths occurred, giving a 12-month mortality rate of 11.7% (95% CI, 6.4-16.9). The presence of sustained VT was associated with a high risk of sudden cardiac death (SCD) and the lowest 12-month overall survival (P < 0.0001). CONCLUSION: The incidence of sustained VT remains relatively low in the first year after CRT-P implantation, but when present appears closely associated with short-term adverse outcomes, especially SCD. This emphasizes the possible value of remote monitoring to detect high-risk patients for urgent upgrading.

Introduction: The benefits conferred by cardiac resynchronization therapy (CRT) are markedly influenced by the left ventricular (LV) lead placement. Little is known regarding the optimal right ventricular (RV) stimulation site. Study Objective: To compare the long-term outcomes of CRT in patients with RV leads placed in the mid-septal region versus the apex. Methods and Results: This nonrandomized, observational study included 117 patients with standard indications for CRT. The LV lead was implanted on the postero-lateral or lateral LV wall, while the RV lead was implanted at the apex (n = 82) or in the mid-septum (n = 35). Both groups were similar with respect to baseline clinical, demographic, and echocardiographic characteristics. After 12 months of CRT, the rates of clinical response to CRT were similar in both groups (63% vs. 66%), and similar degrees of reverse LV remodeling and LV resynchronization were observed on echocardiography and color tissue Doppler imaging. A ≥30% relative increase in LV ejection fraction (EF) occurred in 76% of patients in the RV apex group, versus 49% of patients in the RV mid-septum group (P = 0.05). A ≥45% left ventricular ejection fraction (LVEF) was measured at 12 months in 40% of patients in the RV apex group, versus 31% in the RV mid-septum group (ns). Conclusions: RV mid-septal stimulation was not associated with a higher rate of response to CRT or greater improvement in LV function compared to RV apical stimulation.

Aims To compare both short- and long-term stability and pacing parameters of CS leads. Long-term maintenance of coronary sinus (CS) pacing lead position has not yet been assessed by serial X-ray digital imaging. Methods and results Using X-ray digital imaging in anteroposterior and left lateral views, we performed analysis of the CS lead position at the end of the implantation procedure, 48 h following implantation and after 12 months in 93 consecutive patients. Attain OTW leads, QuickSite leads and EasyTrak leads were implanted in 44, 12 and 37 cases, respectively. X-ray detectable late CS lead dislodgement was observed in 8 cases (8.6%) during 12-months follow-up. Dislodgment was once accompanied by loss of capture and need for repositioning. Another two major dislodgements occurred without any threshold change. Five (5.4%) minor dislocations occurred with either a decrease or an increase in pacing threshold. Left ventricular (LV) pacing threshold was changed by ≥ 1 V after 12 months in 14 patients (15%) when compared to values 48 h after implantation. All but one case of ≥ 1 V threshold change (either positive or negative) occurred without any radiological evidence of lead displacement. LV pacing threshold was significantly higher than RV pacing threshold at both baseline and during follow-up. Leads from all three manufacturers had comparable pacing thresholds 12 months following implantation. Conclusion The position of CS leads may change during 1-year follow-up. However, it rarely required reoperation in the selected group of patients. Long-term pacing parameters between different manufacturers are comparable. Increase in pacing threshold is not a reliable marker of CS lead dislodgement.

Background: Bifocal pacing (BFP) has been proposed as a feasible alternative to cardiac resynchronization therapy. Aim: To evaluate BFP in patients with severe heart failure and significant intraventricular conduction delay and to compare it with biventricular pacing (BVP). Methods: Echocardiographic examination including TDI and invasive measurement of haemodynamics was performed under basal conditions, during BFP and during BVP. Results: Fifty patients were included: 29 with ischaemic heart disease (IHD), 21 with idiopathic dilated cardiomyopathy (IDCM). LV dp/dtmax increased during BFP compared to the basal state (13.4%, 95% CI 9.2–17.6%, p

Background Catheter ablation of persistent atrial fibrillation yields an unsatisfactorily high number of failures. The hybrid approach has recently emerged as a technique that overcomes the limitations of both surgical and catheter procedures alone. Methods and Results We investigated the sequential (staged) hybrid method, which consists of a surgical thoracoscopic radiofrequency ablation procedure followed by radiofrequency catheter ablation 6 to 8 weeks later using the CARTO 3 mapping system. Fifty consecutive patients (mean age 62±7 years, 32 males) with long‐standing persistent atrial fibrillation (41±34 months) and a dilated left atrium (>45 mm) were included and prospectively followed in an unblinded registry. During the electrophysiological part of the study, all 4 pulmonary veins were found to be isolated in 36 (72%) patients and a complete box‐lesion was confirmed in 14 (28%) patients. All gaps were successfully re‐ablated. Twelve months after the completed hybrid ablation, 47 patients (94%) were in normal sinus rhythm (4 patients with paroxysmal atrial fibrillation required propafenone and 1 patient underwent a redo catheter procedure). The majority of arrhythmias recurred during the first 3 months. Beyond 12 months, there were no arrhythmia recurrences detected. The surgical part of the procedure was complicated by 7 (13.7%) major complications, while no serious adverse events were recorded during the radiofrequency catheter part of the procedure. Conclusions The staged hybrid epicardial–endocardial treatment of long‐standing persistent atrial fibrillation seems to be extremely effective in maintenance of normal sinus rhythm compared to radiofrequency catheter or surgical ablation alone. Epicardial ablation alone cannot guarantee durable transmural lesions. Clinical Trial Registration URL: www.ablace.cz Unique identifier: cz‐060520121617

Bifocal pacing (BFP) has been proposed as a more feasible alternative of cardiac resynchronization therapy (CRT).To evaluate BFP in patients with severe congestive heart failure and significant intraventricular conduction delay and to compare it with biventricular pacing (BVP).Both echocardiographic examination including tissue Doppler imaging and invasive measurements of cardiac hemodynamics was performed under basal conditions and during BFP and BVP.50 patients were included: 29 patients with ischemic heart disease (IHD), 21 patients with idiopathic dilated cardiomyopathy (IDCM). Left ventricular (LV) pressure gradient (dp/dt max) increased during BFP compared to the baseline (13.4 %, 95 % CI 9.2-17.6 %, p0.0001) and a further increase was achieved during BVP (29.5 %, 95 % CI 23.7-35.4 %, p0.0001). A significant correlation was found between the distance of the right ventricular apical and outflow tract leads and percentage of dp/dt max increase in IDCM patients (r = 0.72, p0.001), but not in IHD patients. Interventricular mechanical delay (IVMD) decreased in BFP compared to baseline (43 +/- 22 ms vs. 53 +/- 31 ms, p = 0.006). BVP produced even shorter IVMD (22 +/- 19 ms, p0.0001). In all patients, the regional systolic contraction times were significantly shortened, corresponding with prolongation of the respective regional diastolic filling times during both BFP (p0.05 for all segments) and BVP (p0.001 for all segments). The effect of BVP on regional systole shortening was more pronounced.BFP improves LV hemodynamics by decreasing the inter- and intraventricular conduction delays. The leads in the right ventricle should be placed at the longest achievable distance. BVP is superior to BFP.

A sixty-year-old man with previous history of coronary artery disease was admitted due to progressive worsening of dyspnoea at exertion (NYHA III functional class) and no angina. Coronary angiography confirmed occlusion of the right coronary artery which was naturally bypassed by homocollaterals with TIMI 3 flow to the peripheral branches. The lesion was not technically suitable for percutaneous angioplasty. The left coronary artery was without stenosis. On echocardiography, both the left ventricle and the left atrium were dilated and hemodynamically significant mitral regurgitation was present. Surface ECG showed a left bundle branch block with repeated runs of monomorphic ventricular ectopic beats (PVC). Radiofrequency catheter ablation of the focus in the posteroseptal region of the left ventricle underneath the mitral valve was performed using electroanatomical mapping system. After the procedure, mitral regurgitation decreased and reverse remodeling of the left ventricle and the left atrium occurred with concomitant significant clinical improvement of the patient. The authors discuss several treatment strategies: mitral valve repair surgery combined with revascularization, implantation of a biventricular ICD system or elimination of the focus of monomorphic VT runs by radiofrequency catheter ablation as a possible causal approach in the treatment of PVC-induced cardiomyopathy.

Biventricular pacing nowadays represents a recognized method of nonpharmacological treatment of severe congestive heart failure refractory to medication. A growing number of biventricular implants is likely to bring an increasing demand for the extraction of specially designed coronary sinus (CS) leads for left ventricular pacing. There is a lot of data regarding conventional pacing or defibrillation lead extractions, but only very limited experience with the CS lead extractions. We describe the pathological-anatomical findings of a woman who died after 26 months postimplantation due to refractory ventricular fibrillation with focus on the left ventricular pacing lead course and feasibility of extraction.

Aims: To determine the systemic thrombogenic effect of radiofrequency catheter isolation of the pulmonary veins (PVI) in the treatment of atrial fibrillation. Methods and Results: We studied endothelial damage marker (von Willebrand factor [vWf]), fibrinolysis markers (tissue plasminogen activator [t-PA], plasminogen activator inhibitor-1 [PAI-1]) and coagulation activation markers (D-dimer [DD]) in 30 patients (pts) undergoing PVI. Heparin was administered continuously after double transseptal puncture in all pts. Concentrations of vWf and t-PA were significantly increased after accomplishing PVI compared to the baseline values, and elevated levels persisted 24 hours later (p < 0.01). PAI-1 levels decreased following PVI compared to the baseline levels (p = 0.02). PAI-1 levels normalized 24 hours after the procedure. DD increased continuously during the procedure with the peak following PVI (p < 0.01). Higher DD concentrations persisted 24 hours later (p = 0.02). In a multivariate analysis, total procedure time correlated significantly with the peak vWf and DD concentrations, while total RF energy dose correlated only with peak vWf (r = 0.82). Time to heparin administration correlated with DD levels prior to the first RF pulse (r = 0.83, p < 0.01) as well as after PVI (r = 0.75, p < 0.01). A group of patients heparinized within the first hour of the PVI procedure had normal preablation DD levels and significantly mitigated DD levels following PVI compared to the group of patients heparinized later (p < 0.01). Conclusions: Pulmonary vein ablations cause an increased systemic procoagulant state as reflected by fibrin turnover, fibrinolysis activation and endothelial perturbation. The activation of the coagulation cascade could be decreased by early heparin administration.

Background: In patients with biventricular pacing (BIV), triple-site pacing (TSP), i.e. standard biventricular cathodal pacing of the right and the left ventricle plus additional anodal capture of the right ventricle, is sometimes present. Aims: To evaluate the incidence of TSP phenomenon, to examine TSP-related QRS changes, and to assess the effect of TSP on intraventricular resynchronization by means of tissue Doppler imaging (TDI). Methods and results: 23 patients with a first generation biventricular device (Medtronic 8040) and 16 patients with a new generation device (Medtronic 8042) were evaluated to look for the presence of TSP. TSP was found in 6 patients (26%) with the Medtronic 8040 (group I) and in 13 patients (81%) with the Medtronic 8042 device (group II). QRS duration decreased by 10 to 20 ms and QRS amplitude of leads I and aVL increased in almost all patients in group I during TSP modality. In group II, QRS morphology, duration and amplitude did not change as obviously. TDI analysis of the left ventricular (LV) basal segments showed significant shortening of the systole, together with a corresponding prolongation of the diastole, at the inferior wall of the LV, during TSP compared to standard BIV in all patients (p < 0.01). Other LV segments did not show any change. Qualitative TDI electro-mechanical activation pattern of all LV segments improved in 22%, while it remained unchanged in 72%. Conclusions: TSP phenomenon can be identified in approximately a quarter of patients with the first-generation biventricular devices on the basis of the QRS morphology changes. In the second-generation biventricular pacemakers it can be demonstrated in the vast majority of patients. TSP may increase the effectiveness of cardiac resynchronization therapy by counteracting the regional activation delay located at the inferior wall of the LV.

A case study of a patient suffering from severe chronic congestive heart failure resulting from ischemic cardiomyopathy in whom a biventricular (BiV) pacing system was implanted is reported. After a 1-year follow-up, left ventricular (LV) ejection fraction improved dramatically from an initial 15% to 60%, left ventricular end-diastolic diameter decreased, as did left atrial dimension. Tissue Doppler data and acute hemodynamic measurements taken during the biventricular pacemaker implantation procedure are presented. The case represents an exceptional example of left ventricular reverse remodeling with practically normalized left ventricular function after 1 year of synchronized pacing.