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Background: Minimal evidence is available of the reduction in healthcare utilization of remote care in ICD patients over a longer period of follow-up., Objectives: This study compared healthcare utilization up to 3 year follow-up in implantable cardioverter-defibrillator (ICD) patients with remote care compared to conventional care., Methods: We conducted a retrospective cohort study of patients who received a single or dual-chamber ICD or cardiac resynchronization therapy-defibrillator (CRT-D) between 2016 and 2018. Patients with remote care and patients were compared with patients with received conventional care (control group). The primary endpoint was a composite of cardiac follow-up visits, ICD follow-up visits, telephone consultations, emergency department (ED) visits and hospital admissions and was defined as total healthcare utilization. The secondary endpoints were the individual care activities and one-year all-cause mortality., Results: A total of 497 patients were included in the study, of which 299 patients were allocated to the remote care and 198 patients to the control group. Mean follow-up was 815 ± 279 days. Remote care was associated with a significantly lower rate of adjusted total healthcare utilization in comparison to the control group that sustained for 3 subsequent follow-up years (IRR = 0.78, 95% CI [0.67 to 0.92], p < .01). One-year all-cause mortality was similar between the remote care and control group (respectively 3.0% vs. 5.5%, p = .29)., Conclusions: Compared to the standard follow-up of in-office care, a remote care program was associated with a sustained lower rate of planned and unplanned healthcare utilization up to 3 subsequent years after ICD/CRT-D implantation., (© 2021 Wiley Periodicals LLC.)

Objective: Patients with heart disease are at increased risk for sudden cardiac death. Guidelines recommend an implantable loop recorder (ILR) for symptomatic patients when symptoms are sporadic and possibly arrhythmia-related. In clinical practice, an ILR is mainly used in patients with unexplained syncope. We aimed to compare the clinical value of an ILR in patients with heart disease and a history of syncope versus those with non-syncopal symptoms., Methods: In this observational single-centre study, we included symptomatic patients with heart disease who received an ILR. The primary endpoint was an actionable event which was defined as an arrhythmic event leading to a change in clinical management. The secondary endpoint was an event leading to device implantation., Results: One hundred and twenty patients (mean age 47±17 years, 49% men) were included. The underlying disease substrate was inherited cardiomyopathy (31%), congenital heart disease (28%), channelopathy (23%) and other (18%). Group A consisted of 43 patients with prior syncope and group B consisted of 77 patients with palpitations and/or near-syncope. The median follow-up duration was 19 months (IQR 8-36). The 3-year cumulative event rate was similar between groups with regard to the primary endpoint (38% vs 39% for group A and B, respectively, logrank p=0.54). There was also no difference in the 3-year cumulative rate of device implantation (21% vs 13% for group A and B, respectively, logrank p=0.65)., Conclusion: In symptomatic patients with heart disease, there is no difference in the yield of an ILR in patients presenting with or without syncope., Competing Interests: Competing interests: S-CY has received a research grant from Medtronic. Other authors have no relevant affiliations or financial involvement with any organisation or entity with a financial interest or financial conflict with the subject matter or materials discussed in this manuscript., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Although catheter ablation (CA) is an accepted therapeutic option for atrial fibrillation (AF), data is lacking concerning the long-term thromboembolic event (TE) and mortality rate of patients after unsuccessful CA for AF., Objective: The aim of the current study was to detect the long-term TE and mortality rate of patients with successful CA (group A) of AF and compared those with unsuccessful ablation (group B)., Methods: Following a 4-years of follow-up (FU) 330 patients were included into the groupA, and 105 patients into the group B. Primary outcome was defined as all stroke/TIA occurrence. Secondary outcome was considered as all-cause mortality and stroke - and TIA only occurrence., Results: Seventeen patients developed a stroke/TIA during a median of 5.8 [5.1-7.3] years of FU. In the group A 8 (2.4%) patients developed a stroke/TIA during a FU of 2037 person-years (incidence rate 3.92 per 1000 person-years), compared to 9 patients in the group B during a FU of 726 person-years (incidence rate 12.4 per 1000 person-years). The crude HR for primary outcome was 2.84 (95% CI 1.078-7.48) in the group B compared with the group A. Cumulative TIA-alone incidence (3.97, CI 1.10-14.34, p=0.035) and the annualized TIA-alone incidence rate was significantly higher in the group B. (p=0.029). Neither the mortality rate nor the incidence rate of stroke-alone differed significantly among the groups., Conclusions: The risk of all stroke/TIA and TIA-alone is higher among patients after unsuccessful CA of AF compared to those after successful ablation.

Background: Anxiety has been associated with adverse clinical outcomes in patients who have received an implantable cardioverter defibrillator (ICD). However, results are inconclusive likely due to different measures being used to assess anxiety. Hence, the current study aims to examine the prevalence and the association between anxiety, ventricular tachyarrhythmia's (VTa's) and all-cause mortality, respectively., Methods: Patients who received an ICD for the first time were recruited from 6 Dutch referral hospitals as part of the WEBCARE trial. Patients filled in validated questionnaires (GAD-7, STAI-S, HADS-A, ANX4, ICDC, FSAS) to assess their baseline anxiety symptomatology. Logistic regression analysis and Cox Regression analysis were performed to examine the association between anxiety with 1) VTa's and 2) mortality, respectively., Results: A total of 214 Patients were included in the analysis with mean age 58.9 and 82.7% being male. The prevalence rates of anxiety varied depending on which questionnaire was used 12.4% (GAD-7), 17.5% (HADS-A), and 28.1% (STAI-S). (Cox) Regression analysis revealed that none of the anxiety measures was associated with VTa's or all-cause mortality in the current sample. Stratifying the sample by gender, the analysis showed that GAD-7, STAI-S, and ANX4 scores were associated with increased risk of VTa's but only in male patients., Conclusions: Prevalence rates of anxiety varied depending on the measurement tool used. No significant association between anxiety and VTa's and all-cause mortality was observed in the total sample. GAD-7, STAI-S, and ANX4 were associated with increased risk for VTa's but only in male patients., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Risk stratification within the ICD population warrants the examining of the role of protective- and risk factors. Current study examines the association between Type D personality, pessimism, and optimism and risk of ventricular tachyarrhythmias (VTa's) and mortality in patients with a first-time ICD 6 years post implantation., Methods: A total of 221 first-implant ICD patients completed questionnaires on optimism and pessimism (Life Orientation Test) and Type D personality (Type D scale DS14) 10 to 14 days after implantation. VTa's and all-cause mortality 6 years post implant comprised the study endpoints., Results: Ninety (40.7%) patients had experienced VTa's and 37 (16.7%) patients died, 12 (5.4%) due to a cardiac cause. Adjusted logistic regression analysis showed that pessimism was significantly associated with increased risk of VTa's (OR = 1.09; 95% CI = 1.00-1.19; p = .05). Type D personality (OR = 1.05; 95% CI = 0.47-2.32; p = .91) and optimism (OR = 1.00; 95% CI = 0.90-1.12; p = .98) were not associated with VTa's. None of the personality types were associated with mortality., Conclusion: Pessimism was associated with VTa's but not with mortality. No significant association with either of the endpoints was observed for Type D personality and optimism. Future research should focus on the coexistent psychosocial factors that possibly lead to adverse cardiac prognosis in this patient population., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected heart failure patients, but decision-making regarding selection of CRT-defibrillator or CRT-pacemaker is an ongoing debate., Objective: The purpose of this study was to construct predictive models and scoring systems for implantable cardioverter-defibrillator (ICD) therapy and death without ICD therapy (prior death)., Methods: We pooled 2 prospective cohorts of CRT-D patients with primary prevention indication and used Fine and Gray models to develop independent prognostic models for time to first ICD therapy (event of interest) or death without prior ICD therapy (competing event). We defined CRT-D benefit as a high probability of ICD therapy combined with moderate/low probability of prior death., Results: Seven hundred twenty patients were included. Median follow-up was 7.2 years, and 247 patients (34%) died. Cumulative incidence of ICD therapy/prior death at 5 years was 24%/17%. In multivariable models, higher New York Heart Association classes, diuretic use, and ischemic cardiomyopathy were predictors of ICD therapy (hazard ratio 1.89 [1.30-2.75], 1.91 [1.12-3.24], and 1.40[1.02-1.92], respectively) but not of prior death. Males with comorbidities (cancer, renal failure, peripheral artery disease, body mass index >30) or systolic blood pressure ≤100 were at higher risk for prior death. Higher age was associated with lower risk of ICD therapy but higher risk of prior death. One-quarter of patients had low predicted benefit from CRT-D implantation using a scoring system for the dual prediction of appropriate ICD therapy and death without appropriate ICD-therapy., Conclusion: Different factors predict ICD therapy or prior death in CRT-D patients using competing risk models. Scoring allows identifying patients with predicted low benefit of CRT-D (low chance of ICD therapy, high chance of prior death)., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: The subcutaneous implantable cardioverter-defibrillator (S-ICD) was developed to defibrillate ventricular arrhythmias, avoiding drawbacks of transvenous leads. The global EFFORTLESS S-ICD (Evaluation oF FactORs ImpacTing CLinical Outcome and Cost EffectiveneSS of the S-ICD) registry is collecting outcomes in 985 patients during a 5-year follow-up., Objectives: The primary goal of the EFFORTLESS registry is to determine the safety of the S-ICD by evaluating complications and inappropriate shock rate., Methods: This is the first report on the full patient cohort and study endpoints with follow-up ≥1 year. The predefined endpoints are 30- and 360-day complications, and shocks for atrial fibrillation or supraventricular tachycardia., Results: Patients were followed for 3.1 ± 1.5 years and 82 completed the study protocol 5-year visit. Average age was 48 years, 28% were women, ejection fraction was 43 ± 18%, and 65% had a primary prevention indication. The S-ICD system and procedure complication rate was 4.1% at 30 days and 8.4% at 360 days. The 1-year complication rate trended toward improvement from the first to last quartile of enrollment (11.3% [quartile 1]) to 7.8% [quartile 2], 6.6% [quartile 3], and 7.4% [quartile 4]; quartile 1 vs. quartiles 2 to 4; p = 0.06). Few device extractions occurred due to need for antitachycardia (n = 5), or biventricular (n = 4) or bradycardia pacing (n = 1). Inappropriate shocks occurred in 8.1% at 1 year and 11.7% after 3.1 years. At implant, 99.5% of patients had a successful conversion of induced ventricular tachycardia or ventricular fibrillation. The 1- and 5-year rates of appropriate shock were 5.8% and 13.5%, respectively. Conversion success for discrete spontaneous episodes was 97.4% overall., Conclusions: This registry demonstrates that the S-ICD fulfills predefined endpoints for safety and efficacy. Midterm performance rates on complications, inappropriate shocks, and conversion efficacy were comparable to rates observed in transvenous implantable cardioverter-defibrillator studies. (Evaluation oF Factors ImpacTing CLinical Outcome and Cost EffectiveneSS of the S-ICD [The EFFORTLESS S-ICD Registry]; NCT01085435)., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: After catheter ablation there is often a discrepancy between acute and chronic success rates. We aimed to evaluate major determinants for lesion quality and understand different manifestations of lesion structures., Methods: In a canine thigh muscle model radiofrequency (RF) current was delivered for 60 seconds at 30 W (n = 39) or 50 W (n = 18) with 15-g contact force. A second-generation 12-hole gold open irrigation catheter (SGIT) and a first-generation six-hole platinum-iridium catheter (FGIT; Biotronik, Berlin, Germany) were used. Electrode and tissue temperatures (at the surface and 3.5-mm and 7-mm depth) were recorded and lesion dimensions were measured. Lesions with steam pops were excluded. Histological examination was performed to evaluate homogeneity of the lesions. Inhomogeneity was defined as a visual multiband lesion pattern indicating different histological characteristics., Results: In total 57 lesions were created. Seventeen lesions were excluded (steam pops) and 40 lesions were analyzed. A total number of 11 homogeneous and 29 inhomogeneous lesions were identified. Using the SGIT catheter 16.7% of the lesions was homogeneous and 83.3% inhomogeneous; for FGIT it was 43.8% and 56.2% (P = 0.065), respectively. Homogeneous lesions had lower volumes as compared to inhomogeneous lesions (514.0 ± 198.8 vs 914.8 ± 399.1 mm, P = 0.003). Multiple logistic regression analysis indicated that the SGIT catheter is a significant predictor for inhomogeneous lesions (odds ratio 6.5, 95% confidence interval 1.1-38.8; P = 0.040) independent from power setting and flow rate., Conclusions: The development of inhomogeneous lesions after acute RF ablation is associated with higher lesion volumes and the use of the second-generation irrigation gold-tip catheter., (©2014 Wiley Periodicals, Inc.)

Background: WEB-Based Distress Management Program for Implantable CARdioverter defibrillator Patients (WEBCARE) is a Web-based randomized controlled trial, designed to improve psychological well-being in patients with an implantable cardioverter defibrillator (ICD). As in other Web-based trials, we encountered problems with attrition and adherence., Objective: In the current study, we focus on the patient characteristics, reasons, and motivation of (1) completers, (2) those who quit the intervention, and (3) those who quit the intervention and the study in the treatment arm of WEBCARE., Methods: Consecutive first-time ICD patients from six Dutch referral hospitals were approached for participation. After signing consent and filling in baseline measures, patients were randomized to either the WEBCARE group or the Usual Care group., Results: The treatment arm of WEBCARE contained 146 patients. Of these 146, 34 (23.3%) completed the treatment, 88 (60.3%) dropped out of treatment but completed follow-up, and 24 (16.4%) dropped out of treatment and study. Results show no systematic differences in baseline demographic, clinical, or psychological characteristics between groups. A gradual increase in dropout was observed with 83.5% (122/146) completing the first lesson, while only 23.3% (34/146) eventually completed the whole treatment. Reasons most often given by patients for dropout were technical problems with the computer, time constraints, feeling fine, and not needing additional support., Conclusions: Current findings underline the importance of focusing on adherence and dropout, as this remains a significant problem in behavioral Web-based trials. Examining possibilities to address barriers indicated by patients might enhance treatment engagement and improve patient outcomes., Trial Registration: Clinicaltrials.gov: NCT00895700; http://www.clinicaltrials.gov/ct2/show/NCT00895700 (Archived by WebCite at http://www.webcitation.org/6NCop6Htz).

Several new devices for the treatment of heart failure (HF) patients have been introduced and are increasingly used in clinical practice or are under clinical evaluation in either observational and/or randomized clinical trials. These devices include cardiac contractility modulation, spinal cord stimulation, carotid sinus nerve stimulation, cervical vagal stimulation, intracardiac atrioventricular nodal vagal stimulation, and implantable hemodynamic monitoring devices. This task force believes that an overview on these technologies is important. Special focus is given to patients with HF New York Heart Association Classes III and IV and narrow QRS complex, who represent the largest group in HF compared with patients with wide QRS complex. An overview on potential device options in addition to optimal medical therapy will be helpful for all physicians treating HF patients.

Introduction: Knowledge about predictive factors for mortality and (in)appropriate shocks in cardiac resynchronization therapy with a defibrillator (CRT-D) should be available and updated to predict clinical outcome., Methods: We retrospectively analyzed 543 consecutive patients assigned to CRT-D in 2 tertiary medical centers. The aim of this study was to assess risk factors for all-cause mortality, appropriate and inappropriate shocks., Results: Mean follow-up time was 3.2 (±1.8) years. A total of 110 (20%) patients died, 71 (13%) received ≥1 appropriate shocks, and 33 (6.1%) received ≥1 inappropriate shocks. No patients received a His bundle ablation and biventricular pacing percentage was not analyzed. Multivariable Cox regression analysis showed that a history of atrial fibrillation (AF) (HR 1.74 CI 1.06-2.86), higher creatinine (HR 1.12; CI 1.08-1.16), and a poorer left ventricular ejection fraction (LVEF) (HR 0.97; CI 0.94-1.01) independently predict all-cause mortality. In the entire cohort, history of AF and secondary prevention were independent predictors of appropriate shocks and variables associated with inappropriate shocks were history of AF and QRS ≥150 milliseconds. In primary prevention patients, history of AF also predicted appropriate shocks as did ischemic cardiomyopathy and poorer LVEF. History of AF, QRS ≥150 milliseconds, and lower creatinine were associated with inappropriate shocks in this subgroup. Appropriate shocks increased mortality risk, but inappropriate shocks did not., Conclusion: In symptomatic CHF patients treated with CRT-D, history of AF is an independent risk factor not only for mortality, but also for appropriate and inappropriate shocks. Further efforts in AF management may optimize the care in CRT-D patients., (© 2013 Wiley Periodicals, Inc.)

Introduction: We evaluated clinical outcome and incidence of (in)appropriate shocks in consecutive chronic heart failure (CHF) patients treated with CRT with a defibrillator (CRT-D) according to functional response status. Furthermore, we investigated which factors predict such functional response., Methods and Results: In a large teaching hospital, 179 consecutive CHF patients received CRT-D in 2005-2010. Patients were considered functional responders if left ventricular ejection fraction (LVEF) increased to ≥ 35% postimplantation. Analysis was performed on 142 patients, who had CRT-D as primary prevention, complete data and a baseline LVEF <35%. Endpoints consisted of all-cause mortality, heart failure (HF) hospitalizations, appropriate shocks and inappropriate shocks. Median follow-up was 3.0 years (interquartile range [IQR] 1.6-4.4) and median baseline LVEF was 20% (IQR 18-25%). The functional response-group consisted of 42 patients. In this group no patients died, none were hospitalized for HF, none received appropriate shocks and 3 patients (7.1%) received ≥ 1 inappropriate shocks. In comparison, the functional nonresponse group consisted of 100 patients, of whom 22 (22%) died (P = 0.003), 17 (17%) were hospitalized for HF (P = 0.007), 17 (17%) had ≥ 1 appropriate shocks (P = 0.003) and 8 (8.1%) received ≥ 1 inappropriate shocks (P = 0.78). Multivariable analysis showed that left bundle branch block (LBBB), QRS duration ≥ 150 milliseconds and no need for diuretics at baseline are independent predictors of functional response., Conclusion: Functional responders to CRT have a good prognosis and rarely need ICD therapy. LBBB, QRS duration ≥ 150 milliseconds and lack of chronic diuretic use predict functional response., (© 2012 Wiley Periodicals, Inc.)

Background: Epicardial pacing lead implantation is the currently preferred surgical alternative for left ventricular (LV) lead placement. For endocardial LV pacing, we developed a fundamentally new surgical method. The trans-apical lead implantation is a minimally invasive technique that provides access to any LV segments. The aim of this prospective randomized study was to compare the outcome of patients undergoing either trans-apical endocardial or epicardial LV pacing., Methods: In group I, 11 end-stage heart failure (HF) patients (mean age 59.7 ± 7.9 years) underwent trans-apical LV lead implantation. Epicardial LV leads were implanted in 12 end-stage HF patients (group II; mean age 62.8 ± 7.3 years). Medical therapy was optimized in all patients. The following parameters were compared during an 18-month follow-up period: LV ejection fraction (LVEF), LV end-diastolic diameter (LVEDD), LV end-systolic diameter, and New York Heart Association (NYHA) functional class., Results: Nine out of 11 patients responded favorably to the treatment in group I (LVEF 39.7 ± 12.5 vs 26.0 ± 7.8%, P < 0.01; LVEDD 70.4 ± 13.6 mm vs 73.7 ± 10.5 mm, P = 0.002; NYHA class 2.2 ± 0.4 vs 3.5 ± 0.4, P < 0.01) and eight out of 12 in group II (LVEF 31.5 ± 11.5 vs 26.4 ± 8.9%, P = < 0.001; NYHA class 2.7 ± 0.4 vs 3.6 ± 0.4, P < 0.05). During the follow-up period, one patient died in group I and three in group II. There was one intraoperative LV lead dislocation in group I and one early postoperative dislocation in each group. None of the patients developed thromboembolic complications., Conclusions: Our data suggest that trans-apical endocardial LV lead implantation is an alternative to epicardial LV pacing., (©2011, The Authors. Journal compilation ©2012 Wiley Periodicals, Inc.)

Aims: Steering soft, flexible catheters using an external magnetic field could have advantages for heart catheterization, especially for therapy of tachyarrhythmias. Our aims were to assess the feasibility of magnetic navigation to Koch's triangle and reliable ablation of atrioventricular nodal re-entry tachycardia (AVNRT) with a magnetic catheter., Methods and Results: Consecutive patients with AVNRT were mapped and ablated with a magnetically enabled catheter (Helios I or II), with, respectively, one and three magnets at the tip. The catheter was remotely advanced with the Cardiodrive system and orientated with the Navigant control system. After initial positioning with the external magnets, adjustment was made in 5 degrees steps. Success rates, procedure, and fluoroscopy times were analysed, and compared with a local contemporary series of conventional AVNRT ablations. Magnetic navigation was feasible in all 20 patients. Targets were easily reached. Catheters remained stable in position during accelerated junctional rhythms. Ablation was successful in 18/20 procedures (90%). No significant complications occurred. Median patient fluoroscopy time was 12 min, median physician fluoroscopy time was 4 min. Fluoroscopy times tended to be shorter than that in the conventionally treated group. Procedure duration decreased significantly over time, median procedure time was similar to that in the conventional group., Conclusion: AVNRT can be successfully mapped and ablated using magnetic navigation. A learning curve was evident, unrelated to catheter type, but to increasing operator experience. Physician radiation times were one-third of patient times. No complications occurred. Procedure time is comparable with that of conventional ablation.

In the September 2003 issue of the Netherlands Heart Journal, the wrong figures where inserted in this article. The article is reprinted here with the correct figures., Background: Atrial fibrillation (AF) is the most frequently encountered arrhythmia. Radiofrequency pulmonary vein (PV) ablation is promising for symptomatic paroxysmal AF, but is associated with a significant risk of PV stenosis., Objectives: To assess the efficacy of cryothermal PV ablation and the incidence of PV stenosis., Methods: Highly symptomatic patients with paroxysmal or persistent AF were eligible for cryothermal ablation. Multislice spiral CT scans were performed before, and three months after ablation. AF burden was assessed using transtelephonic ECG recording and by telephone enquiry., Results: An attempt was made to isolate 27 PVs in 15 patients. In total, 20 PVs could be isolated (74% acute success). No significant difference in PV diameter was seen before and after ablation. Five out of 12 patients with paroxysmal AF were completely without AF after one ablation procedure. An additional two patients reported a significant reduction in symptoms. In the three patients with persistent AF no improvement was reported., Conclusion: Cryothermal PV ablation was effective in isolation of the targeted PVs. It appears to be safe, as no PV stenosis was seen in this study three months after the ablation. Taking into account a learning curve, we consider the clinical results to be very promising.

Background: Biphasic rectilinear shocks are more effective than monophasic shocks for transthoracic atrial defibrillation and for ventricular arrhythmias during electrophysiological testing. We undertook the present study to compare the efficacy of 100 J rectilinear biphasic waveform shocks with 150 J monophasic damped sine waveform shocks for transthoracic defibrillation of true ventricular fibrillation during defibrillation threshold testing (DFT). The second aim of the study was to analyse the influence of patch positions on the efficacy of defibrillation., Methods: 50 episodes of 14 patients (age ranging from 37 to 82 years) who underwent DFT testing were randomised for back-up shocks with either a sequence of 100 and 200 J biphasic waveform, or a sequence of 150 and 360 J conventional monophasic shocks. A binary search protocol was used at implantation and before hospital discharge. Patients were also randomised to an anteroposterior position versus a right-anterior-apical position. A crossover was performed between implantation and pre-hospital discharge for biphasic versus monophasic sequence as well as for the 2 different positions., Results: After failed internal shocks, 27 episodes were treated with biphasic, and 23 with monophasic shocks. The first attempt by the external device did not terminate II episodes (2 biphasic, 9 monophasic). The first shock efficacy was significantly greater with biphasic than with monophasic shocks (p < 0.02). The overall success rate was 93% with biphasic shocks and 64% with monophasic shocks. In multivariate regression analysis including patch position, arrhythmia duration, type of waveform, testing order and session, only waveform was associated with successful defibrillation (p < 0.02)., Conclusion: For transthoracic defibrillation of ventricular fibrillation, low-energy rectilinear biphasic shocks are more effective than monophasic shocks. The position of the defibrillation shock pads has no influence on the biphasic shock efficacy, but anteroposterior pad position is more effective using monophasic shocks.

Background: Hybrid therapy for atrial fibrillation class 1C and class III antiarrhythmic drugs (AAD) can convert atrial fibrillation (AF) into an isthmus-dependent atrial flutter (AFL) in more than 10% of patients. Hybrid pharmacological and ablative therapy offers a safe and effective approach to achieving and maintaining sinus rhythm. We evaluated the efficacy of this hybrid approach in the management of paroxysmal or persistent AF., Methods: Eighteen patients with symptomatic AF treated with AAD and typical anticlockwise/clockwise AFL underwent radiofrequency (RF) ablation of AFL with an anatomical approach., Results: RF ablation was successful in all patients. All but one patient continued with AAD. Four patients (22%) had recurrences of AFL. Two of them also had a recurrence of AF. Another three patients had recurrences of AF only, and finally, one patient developed an atrial tachycardia more than one year after the procedure. In conclusion, 11 patients (61%) did not experience recurrences of AF/AFL after tricuspid valve annulus (TV)-inferior caval vein (IVC) isthmus ablation with continuing antiarrhythmic drugs., Conclusion: Hybrid pharmacological and ablative therapy is a safe and effective treatment for the management of patients with symptomatic AF.

Aims: Transcatheter radiofrequency ablation of the atrio-ventricular (AV) node followed by ventricular pacing has been shown to improve symptoms and quality of life of patients with atrial fibrillation (AF). It is assumed that function improves, but this has been less well demonstrated. The aim of this study was to assess the long-term effect of AV node ablation and ventricular pacing on left ventricular ejection fraction (LVEF) in patients with permanent AF., Methods and Results: All 12 patients studied had permanent AF for at least 12 months (mean age 70 years, range 41 to 78). LVEF was determined 6 days and 3 months after AV node ablation by radionuclide ventriculography, at a paced rate of 80 beats . min (-1). Cardiac dimensions were measured by means of transthoracic echocardiography. No major changes in pharmacological therapy were made during 3 months follow-up period. LVEF showed a significant deterioration after 3 months follow-up period for the group (47.5 +/- 14.4%; 6 days after ablation vs 43.2 +/- 13.7%; 3 months after ablation, P < 0.05). There were no significant differences in left ventricular cavity dimensions directly after AV node ablation and 3 months later (LVEDD 51.2 +/- 10.7 mm vs 52.6 +/- 8.6 mm, P = NS: LVESD: 36.1 +/- 14.2 mm vs 36.6 +/- 9.7 mm, P = NS). Left atrial size did not show reduction 3 months after AV node ablation (50.8 +/- 13.6 mm vs 51.0 +/- 14.1 mm, P = NS)., Conclusion: The restoration of a regular ventricular rhythm following AV node ablation for patients in permanent AF does not result in improvement in left ventricular function.

In patients with Wolff-Parkinson-White syndrome, right anteroseptal accessory pathways are uncommon and run from the atrium to the ventricle in close anatomic proximity to the normal AV conduction system. Radiofrequency catheter ablation is the first-line therapy for elimination of these accessory pathways. Although the initial success rate is high, there is a potential risk of inadvertent development of complete heart block, and the recurrence rate is relatively high. The capability of cryothermal energy to create reversible lesions (ice mapping) at less severe temperatures provides a potential benefit in ablation of pathways located in a complex anatomic area, such as the mid-septum and anteroseptum.

Background: The implantable cardioverter defibrillator (ICD) has become a widely accepted therapy for patients with severe life-threatening ventricular tachyarrhythmias. The aim of this study was to illustrate the possible advantages of ICDs with respect to survival and clinical events., Methods and Results: Between 1998 and 2000, 92 patients (aged 58±15 years; ejection fraction 36±15%; coronary artery disease 71%) were treated with an ICD in combination with an endocardial lead system. Benefit of the ICD was estimated as the difference between total cardiac death and the projected death rate of fast ventricular tachyarrhythmias (>200 bpm), assuming that most fast ventricular tachyarrhythmias would have been fatal without termination by the ICD. Adverse events were classified according to European standards. The cardiac mortality rate was 5.5% and 9.8%, at one and two years respectively. The recurrence rate of fast VT (>200 bpm) was 22.4% and 30.2%, at one and two years respectively. The observed difference between cardiac death and projected death was very significant (p=0.002) and suggests a clear benefit from ICD implantation. Low ejection fraction (<35%) and NYHA class ≥II correlated with a higher projected death. The most common adverse event was inappropriate therapy (18%)., Conclusion: The results from our small series support the existing data that especially patients with poor ejection fraction (<35%) benefit from ICD implantation. The adverse event rate was low. However, inappropriate therapy remains a matter of concern. Given the high workload of correct screening and follow-up, we expect that the actual number of centres in the Netherlands permitted to implant ICDs will be unable to cope with the widening spectrum of ICD indications.