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Aims: The aim of the study was to assess efficacy and safety of a novel method of multisite atrial pacing, incorporating Bachmann's bundle (BB) and coronary sinus (CS) ostium pacing, which was implemented for the first time in atrial fibrillation (AF) patients with intra-atrial conduction delay., Methods and Results: This follow-up study included 97 patients with drug refractory symptomatic AF, sinus node dysfunction, sinus P-wave > or = 120 ms, and normal atrioventricular conduction. Pacing efficacy was assessed on the basis of two main endpoints: successful rhythm control and the absence of documented or symptomatic AF. During the mean 2.3 +/- 0.7 years of follow-up, the survival rate was 99%, pacing maintenance rate 97%, and the need for re-operation 5%. Rhythm control efficacy was 90%, and 14 patients had no evidence of recurrent AF. After implantation, the mean number of anti-arrhythmic drugs used (P < 0.0001), the need for cardioversion (P < 0.01), and the incidence (P < 0.0001) and duration (P < 0.001) of AF-related hospitalizations decreased. P-wave duration with multisite atrial pacing was shorter than during sinus rhythm, BB, and CS pacing (P < 0.0001)., Conclusion: A novel method of multisite atrial pacing is safe, provides effective long-term rhythm control, and decreases the necessity for adjunctive therapies in patients with refractory AF and intra-atrial conduction delay.

Objectives: We aimed to test the maximum voltage-guided cavotricuspid isthmus (CTI) ablation technique during ongoing atrial flutter., Background: Former pathological and electrophysiological studies clarified that the cavotricuspid isthmus is composed of distinct muscular bundles, which are responsible for the conduction of electrical activation. Based on this observation, a maximum voltage-guided ablation technique (MVGT) was developed. This technique was assessed during pacing from the coronary sinus and was reported to be a feasible method to reach bidirectional isthmus block without the need for a complete anatomic ablation line., Methods: This was a prospective, randomized single center study. Twenty patients underwent CTI ablation during atrial flutter. In group I (10 pts) CTI ablation was performed with complete anatomical ablation line. In group II (10 pts) ablation was guided by the highest amplitude potentials on the CTI sequentially until bidirectional isthmus block was reached. The following parameters were compared: acute success rate, procedure time, fluoroscopy time, number of radiofrequency (RF) applications and total RF duration., Results: In all patients, atrial flutter terminated during ablation. Bidirectional isthmus block could be achieved in all pts. Procedure time was shorter in group II (107 +/- 40 vs 68 +/- 19 min, p < 0.01). Significantly less fluoroscopy was used in group II (22.6 +/- 10.6 vs 12.1 +/- 3.8 min, p < 0.01). There were less RF applications in group II (27.1 +/- 21.5 vs 5.9 +/- 2.4, p < 0.001)., Conclusions: (1) The major finding of this study is that MVGT is a feasible method even during ongoing atrial flutter. (2) Our data confirm that MVGT is an effective technique for CTI ablation with considerable decrease in procedure and fluoroscopy times.

Cardiac resynchronization improves survival and functional class of patients with advanced chronic heart failure. Placement of a stimulation electrode in the coronary sinus via the left subclavian vein is not always possible and other alternatives are required, above all when it concerns upgrading a previous device. This paper presents the case of a patient with a pacemaker/defibrillator and occlusion of both subclavian veins who had a stimulation electrode successfully placed in the coronary sinus via the right internal jugular.