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Background: The aim of the study was to assess long-term incidence of atrial fibrillation (AF) in cardiac resynchronization (CRT) recipients with and without prior arrhythmic history, factors predisposing to arrhythmia, as well as to evaluate the prognostic power of cumulative arrhythmia burden, duration of the longest episode and the number of episodes., Methods: Device-collected data on AF episodes during 24 months in 96 participants of a randomized CRT-trial were analyzed (15% in NYHA class IV, sinus rhythm, median left ventricular ejection fraction 24% and QRS 169 ms). Blindly adjudicated major adverse cardiac events (MACE) and any-cause death were censoring variables., Results: Two-year incidence of AF was 70%, including 66% of patients without previous AF history. No baseline characteristics distinguished those who developed new onset AF. Percent of time spent in AF, but not number of episodes predicted mortality (adjusted hazard ratio [HR] 1.05 ± 95% confidence interval CI 1.01-1.10) and MACE incidence (HR 1.03 ± 1.01-1.07; p = 0.03). Duration of the longest episode also predicted mortality (HR 1.06 ± 1.01-1.12; both p = 0.03). Prognostic impact of AF load was marked only in patients with slower ventricular response (< 98/min), but was independent from CHADS2 scores, pacing burden, or prior atrioventricular nodal ablation., Conclusions: Seven out of 10 CRT-patients had AF within 2 years, including two-thirds of subjects without arrhythmic history. No baseline features distinguished those who developed new onset AF. Arrhythmia burden and duration of the longest episode, but not number of episodes influenced outcomes in CRT-patients, irrespectively from pacing burden or prior atrioventricular node ablation.

Introduction: Because data on contrast-induced acute kidney injury (CI-AKI) in patients undergoing cardiac resynchronization therapy (CRT-D) are scarce, we aimed to assess the incidence, natural course and prognostic importance of this syndrome in CRT recipients., Methods: Study population consisted of 100 consecutive patients enrolled into the Triple Site Versus Standard Cardiac Resynchronization (TRUST CRT) trial, who were treated with CRT-D. Two patients were excluded up to 3 months after randomization and not analysed further. CI-AKI was defined as a rise in serum creatinine of at least 26.5 μmol/L (0.3 mg/dL) within 48 h after contrast exposure, or at least 50% increase from the baseline value during index hospital stay with CRT-D implantation according to KDIGO Clinical Practice Guideline for Acute Kidney Injury., Results: Among 98 subjects of TRUST CRT trial, 10 patients (10.2%) developed CI-AKI after CRT-D implantation. In patients with glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) on admission, the incidence of CI-AKI was almost twofold (15.4%) higher than in subjects with GFR ≥60 (8.3%). CRT-D recipients with CI-AKI had significantly higher mortality rate (50.0%) compared to those without CI-AKI (17.0%) during 30 months of follow-up (logrank p = 0.012). Multivariate Cox regression analysis showed CI-AKI as significant and independent risk factor for death in CRT-D recipients (hazard ratio 5.71; 95% CI 5.16-6.26; p = 0.001)., Conclusions: Contrast-induced acute kidney injury is a serious and frequent procedural complication of CRT-D implantation with a significant negative influence on long-term survival. The results suggest that clinical evaluation regarding renal function should be considered in CRT-D recipients, both before and after device implantation.

Background: The aim of the study was to assess the impact of atrial fibrillation (AF) with and without the need for atrioventricular junction (AVJ) ablation on outcomes in patients undergoing cardiac resynchronization therapy (CRT)., Methods: A single center cohort of 200 consecutive CRT patients was divided into three groups: 1) AF with CRT pacing < 95% in which AVJ ablation was performed (AF-ABL, n = 40; 20%), 2) AF without the need for AVJ ablation (AF-non ABL, n = 40; 20%), 3) sinus rhythm (SR, n = 120; 60%). All patients were assessed before CRT implantation and at 6-month follow-up. Positive clinical response to CRT was considered alive status without the need for heart transplantation and improvement ≥ 1 NYHA after 6 months. The comparative analysis among all study groups with respect to response-rate and long-term survival was performed., Results: The 6-month response-rate in both AF-ABL and AF-nonABL was significantly lower than in SR (52.5 and 50 vs.77.5%, respectively; both p < 0.017), though there were no differences in baseline characteristics among study groups apart from higher baseline NT-proBNP levels in AF-ABL. However, after adjustment for this confounder, and despite optimal CRT pacing burden in study groups, the remote all-cause mortality during median follow-up of 36.1 months was significantly higher in AF-ABL than in SR (adjusted HR = 2.57, 95% CI 1.09-6.02, p = 0.03). What is more, no difference in long-term survival between SR and AF-nonABL was observed., Conclusions: Despite the improvement of CRT pacing burden and thus response-rate up to the level of AF subjects without the need for ablation, the long-term survival of AF patients requiring AVJ ablation remains still worse than in SR.

Background: The aim of this study was to evaluate the value of device-based diagnostic parameters in predicting ventricular arrhythmias in cardiac resynchronization therapy (CRT) recipients., Methods: Ninety-six CRT-D patients participating in TRUST CRT Trial were analyzed. The inclusion criteria were: heart failure in NYHA ≥ 3 class, QRS ≥ 120 ms, LVEF £ 35% and significant mechanical dyssynchrony. Patients were divided into those with (n = 31, 92 arrhythmias) and without (n = 65) appropriate ICD interventions within follow-up of 12.03 ± 6.7 months. Daily monitored device-based parameters: heart rate (HR), thoracic impedance (TI), HR variability and physical activity were analyzed in 4 time windows: within 10, 7, 3 days and 1 day before appropriate ICD interventions., Results: A consistent pattern of changes in three monitored factors was observed prior to arrhythmia: 1) a gradual increase of day HR (from 103.43% of reference within 10-day window to 105.55% one day before, all p < 0.05 vs. reference); 2) variations in night HR (104.75% in 3 days, 107.65% one day before, all p < 0.05) and 3) TI decrease (from 97.8% in 10 days to 96.81% one day before, all p < 0.05). The combination of three parameters had better predictive value, which improved further after exclusion of patients with atrial fibrillation (AF). The predictive model combining HR and TI together with LVEF and NT-proBNP was more prognostic than the model involving LVEF and NT-proBNP alone (difference in AUC 0.05, 95% CI 0.0005-0.09, p = 0.04)., Conclusions: Daily device-monitored parameters show significant variations prior to ventricular arrhythmia. Combination of multiple parameters improves arrhythmia predictive performance by its additive value to baseline risk factors, while presence of AF diminishes it.

Background and Aim: Currently, cardiac resynchronisation therapy (CRT) is recommended only for New York Heart Association (NYHA) class IV ambulatory patients. However, some recent reports have suggested that CRT could also be beneficial for end-stage inotrope-dependent heart failure (HF) NYHA class IV patients. In this report, we summarise the results of CRT implantation in a group of 11 HF inotrope-dependent patients who were not candidates for urgent orthotopic heart transplantation (OHT)., Methods and Results: Between August 2006 and June 2011, 11 end-stage inotrope-dependent HF patients with wide QRS complex, ineligible for urgent OHT, were implanted with CRT in the Silesian Centre for Heart Diseases in Zabrze. Dependence on inotropic therapy was defined as an inability to stop the infusion of the drug without the occurrence of hypotension, oligooranuria and/or hypoxaemia. All patients were successfully implanted with CRT and subsequently weaned from inotropes in a median time of two (1-17) days. Mean QRS duration shortened from 190 ± 34 ms at baseline to 142 ± 25 ms (p < 0.001) after the procedure. Average left ventricular ejection fraction increased from 19 ± 4% to 25 ± 4% (p < 0.001). All patients were discharged from hospital. Median hospital stay after the procedure was ten (5-56) days. During the median follow-upof 1,212 (182-2,048) days, four patients died (one due to arrhythmic storm, three others due to progressive pump failure). During that period, 57 adequate device interventions occurred in three patients, including 52 therapies in one fatal case., Conclusions: CRT can be an alternative for end-stage inotrope-dependent HF patients with wide QRS who are ineligible for urgent heart transplantation.

Aims: The aim of the study was to assess the predictive value for outcomes of various response criteria currently used in patients undergoing cardiac resynchronization therapy (CRT)., Methods and Results: Data from TRUST CRT randomized trial in patients with New York Heart Association (NYHA) III-IV class, QRS ≥ 120 ms, ejection fraction ≤ 35%, and mechanical dyssynchrony was analysed. Ninety-seven subjects who survived 6 months after implantation of CRT-defibrillator were classified as responders or non-responders depending on 15 criteria used in most of the previous trials. Blindly adjudicated data on major adverse cardiac events (MACEs) within 1 year after classification were used to calculate the predictive value of response criteria. After adjustment for baseline confounding variables only eight criteria were significantly predictive for future MACEs. Sensitivity and specificity ranged substantially for clinical (32-94% and 26-63%) and echocardiographic criteria (40-93% and 22-70%, respectively). The most powerful clinical predictor was >a NYHA class reduction ≥ 1 [adjusted relative risk (RR) 4.41 for non-responders; 95% confidence interval (CI) 1.75-11.04, P = 0.002], while the strongest echocardiographic predictor was a reduction in the left ventricular end-systolic index by > 15% (RR 3.49; 95% CI 1.59-7.64, P = 0.002). A combination of these two criteria did not improve the predictive value of a single parameter. Both criteria showed multiple significant interactions with baseline patients' characteristics., Conclusion: Only some of the commonly used response criteria predict outcome in patients undergoing CRT. The predictive value varies substantially across different criteria, with a higher sensitivity observed for the clinical parameters and a higher specificity observed for echocardiographic parameters. Combining various criteria adds little to their prognostic value. The predictive accuracy of various criteria can be different in various subgroups due to multiple interactions with baseline characteristics. CLINICALTRIALS. GOV IDENTIFIER: NCT00814840.

Background: Impaired renal function is a marker of poor prognosis in patients with acute myocardial infarction (AMI). The aim of the study was to assess the incidence and independent predictors of stroke in population of patients with AMI treated invasively and concomitant impaired renal function (IRF)., Methods: We analyzed 2,520 consecutive AMI patients admitted to our Center between 2003 and 2007 and treated with percutaneous coronary intervention. The whole population was divided into patients with IRF, defined as glomerular filtration rate < 60 mL/min/1.73 m(2) or contrast induced nephropathy (IRF group, n = 933; 37.02%) and patients without IRF (control group, n = 1587; 62.98%). The IRF group was subjected to further analysis. Data on long-term follow-up were screened to identify the patients who experienced stroke., Results: During median of 25.5 months of follow-up 52 (2.07%) the patients experienced stroke - 33 (3.54%) in the IRF group and 19 (1.2%) patients in the control group. The risk of major adverse cardiovascular events in the IRF group, including repeated AMI (68.8 vs.14.9%, p < 0.001) and death (45.5 vs. 25.1%, p < 0.05) was significantly higher in patients with stroke. Previous stroke (HR 6.85), female gender (HR 3.13), as well as STEMI anterior (HR 2.55) were independent risk factors of stroke in this population., Conclusions: Patients with AMI treated invasively and concomitant IRF were at higher risk of stroke occurrence in the future. Stroke was associated with poor outcome in the studied population. Independent predictors of stroke in patients with IRF and AMI treated invasively were different from commonly recognized stroke predictors.

76 years old patient after the ICD implantation as a primary prevention of sudden cardiac death was admitted to the hospital because of the electrical storm which presented in ECG as a variety ventricular arrhythmia. Because of patients&rsquo; resistance for pharmacological treatment and antiarrhythmic therapies delivered from ICD, we performed an ablation and implemented the resynchronization therapy of the heart.

We present a case of 33-year-old woman suffered from palpitations and syncope. ECG was normal at the rest and showed irregular tachycardia with wide QRS complex (HR > 300/min) during the effort. The patient was admitted to our department in order to perform detailed diagnostics and therapy. Based on electrophysiological study we found and ablated numerous concealed accessory pathways. During 1 year observation patient stay assymptomatic.

Introduction: This substudy was to assess implantation feasibility and long-term safety of triple-site resynchronization therapy (CRT) in a series of consecutive patients included in a randomized trial., Methods and Results: One hundred consecutive patients enrolled into Triple-Site Versus Standard Cardiac Resynchronization Therapy Randomized Trial were analyzed. Eligibility criteria included NYHA class III-IV, sinus rhythm, QRS ≥ 120 milliseconds, left ventricular ejection fraction ≤35%, and significant mechanical dyssynchrony. Patients were randomized in a 1:1 ratio to conventional or triple-site CRT with defibrillator-cardioverter. After 12 months of resynchronization 30% of patients with conventional resynchronization and 12.5% with triple-site CRT were in NYHA functional class III or IV (P < 0.05). Implantation of triple-site systems was significantly longer (median 125 minutes vs 96 minutes; P < 0.001), with higher fluoroscopic exposure, especially in patients with very enlarged left ventricle or pulmonary hypertension. Implantation success-rate was similar in the triple-site and conventional group (94% vs 98%; P = NS); however, additional techniques had to be used in a greater proportion of the triple-site patients (33.3% vs 16%; P < 0.05). Long-term lead performance tests revealed significantly higher pacing threshold and lower impedance in the triple-site group. The 1-year incidence of serious, CRT-related adverse events was similar in triple-site and conventional group (20.8% vs 30%; P = NS)., Conclusions: Triple-site CRT is associated with more pronounced functional improvement than standard resynchronization. This form of pacing is equally safe and feasible as the conventional CRT. However, triple-site procedure is more time-consuming, associated with higher radiation exposure and the need to use additional techniques. Triple-site resynchronization is associated with less favorable electrical lead characteristics., (© 2012 Wiley Periodicals, Inc.)

To assess the incidence of atrial fibrillation (AF) and the clinical impact of AF types on outcomes in patients with acute myocardial infarction (AMI) treated invasively, we analyzed 2,980 consecutive patients with AMI admitted to our department from 2003 through 2008. Data collected by the insurer were screened to identify patients who died during the median follow-up of 41 months. AF was recognized in 282 patients (9.46%, AF group); the remaining 2,698 patients (90.54%) were free of this arrhythmia (control group). The AF group was divided into 3 subgroups: prehospital paroxysmal AF (n = 92, 3.09%), new-onset AF (n = 109, 3.66%), and permanent AF (n = 81, 2.72%). In-hospital and long-term mortalities were significantly higher (p <0.001 for the 2 comparisons) in the AF than in the control group (14.9% vs 5.3%, 37.2% vs 17.0%, respectively). Long-term mortality was significantly higher (p <0.001 for the 2 comparisons) in the new-onset AF (35.8%) and permanent AF (54.3%) groups than in the control group but did not differ significantly between the prehospital AF and control groups (21.7% vs 17.0%, p = NS). Considering types of arrhythmia separately, only permanent AF (hazard ratio 2.59) was an independent risk factor for death in the studied population. In conclusion, AF occurs in 1 of 10 patients with AMI treated invasively, with nearly equal distributions among prehospital, new-onset, and permanent forms. Although arrhythmia is a marker of worse short- and long-term outcomes, only permanent AF is an independent predictor for death in this population., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Prediction of recurrent malignant ventricular tachyarrhythmias after insertion of a implantable cardioverter-defibrillator (ICD) is challenging. Microvolt T-wave alternans (MTWA) seems to be a promising marker of such events in ICD recipients., Aim: To assess prognostic significance of MTWA and other noninvasive parameters in the prediction of major arrhythmic events after ICD implantation., Methods: This prospective study included 155 patients (121 male, age 59 ± 11 years) in whom ICD was implanted for secondary prevention of a sudden cardiac death. In all patients, clinical evaluation along with estimation of ejection fraction, MTWA measurement using the HearTwave Cambridge Heart system, and determination of the corrected QT interval (QTc) and QT dispersion (QTd) based on resting ECG were performed 3 days before ICD implantation. Using 24-h Holter monitoring, cardiac arrhythmias, QT interval, QT dynamicity, QT variability (QTSD) and heart rate variability (HRV) time domain parameters were determined. MTWA results were categorised, based on the accepted criteria, as positive, negative or indeterminate. In further analyses, positive and indeterminate MTWA results were grouped together as abnormal or non-negative tests [MTWA+], while negative MTWA results were considered normal [MTWA-]. During the follow-up (mean duration 21.6 ± 11.6 months), major arrhythmic cardiac events (MACE), defined as death and/or the need for ablation and/or heart transplantation due to malignant ventricular tachyarrhythmias, were recorded., Results: During the follow-up, MACE occurred in 17 (11%) patients. Abnormal MTWA before ICD implantation was found significantly more frequently in patients with MACE as compared to patients without MACE. Multivariate Cox regression analysis identified abnormal MTWA and QTSD as independent risk factors for MACE, with hazard ratios of 10.82 (95% CI 9.76-11.88; p〈 0.05) and 1.08 (95% CI 1.05-1.08), respectively. Significant differences in MACE-free survival rate with regard to MTWA results (abnormal vs normal MTWA) were shown during the follow-up (p〈 0.001). The negative predictive value of normal MTWA for MACE was 98.6%. When both MTWA and QTSD were combined, the positive predictive value increased to 35%, with a sensitivity of 82% and specificity of 81%. The probability of MACE with normal results of both these tests was 2.3%., Conclusions: Abnormal MTWA is a strong independent predictor of MACE in ICD recipients, and QTSD is a weaker predictor. In the prediction of MACE after ICD implantation, the highest predictive value was noted for abnormal MTWA combined with QTSD. Normal values of these two parameters were associated with a low probability of MACE. These results suggest that standardised MTWA evaluation can be useful for risk stratification in the clinical practice.

Background: The concept of a hybrid approach, combining the most effective techniques of surgical and endocardial catheter ablation has resulted in the creation of the convergent ablation procedure. This novel, pericardioscopic, hybrid approach can be an effective option for highly symptomatic patients with persistent atrial fibrillation (PSAF) and longstanding persistent atrial fibrillation (LSPAF) for whom standalone surgical or endocardial ablation procedures offer sometimes unsatisfactory outcomes., Aim: To assess the safety, efficacy and effectiveness of a hybrid epicardial and endocardial radiofrequency ablation for the treatment of PSAF and LSPAF., Methods: Single-centre, prospective, non-randomised clinical study. Between August 2009 and December 2011, 27 patients with PSAF (n = 5) and LSPAF (n = 22) underwent hybrid ablation (HABL). Mean age was 52.52 ± 11.27 years, and the mean EHRA class was 2.5; 14 (51.8%) patients had a history of electrical cardioversion (n = 6) or catheter ablation (n = 8). Five patients had left ventricular ejection fraction (LVEF) of less than 35%. Mean AF duration for all patients was 3.46 ± 2.5 years. All patients were on antiarrhythmic drugs (AAD) and oral anticoagulation. Patients were scheduled for three, six and 12 month follow-up with seven day Holters, REVEAL® XT and ECHO measurements., Results: The HABL procedure was feasible in all patients. At six months post procedure, 72.2% (13/18) of patients were in SR, and 66.5% (12/18) were off class I/III AADs. Four patients were in AF and one patient developed right atrial flutter. At one year post procedure, 80% (8/10) of patients were in SR and off class I/III AADs. At two year post procedure, 100% (6/6) of patients were in SR and off class I/III AADs. Rapid change in left ventricular function was noted in patients with low LVEF (≤ 35%) prior to the procedure. Patients with LVEF +40% had less apparent improvement., Conclusions: Hybrid, epicardial and endocardial, radiofrequency ablation is feasible and safe, effectively restoring sinus rhythm in the vast majority of patients with PSAF and LSPAF.

Background: The purpose of this study was to assess the effectiveness of cardiac resynchronization therapy (CRT) in terms of outflow tract gradient reduction and functional improvement in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) requiring implantable cardioverter-defibrillator (ICD) implantation., Methods: Eleven consecutive symptomatic HOCM patients with a significant (≥40 mmHg) gradient and indications for ICD, but without indications for resynchronization, underwent CRT-D implantation. Nine of them (four female, median age of 50 years) in whom the procedure succeeded were screened for New York Heart Association (NYHA) class, outflow gradient, mechanical dyssynchrony, QRS-width change, and 6-minute walking distance (6MWD) and peak oxygen consumption (VO(2)peak) improvement after 6 months and remotely., Results: After 6 months of pacing, NYHA class decreased (median 1 vs 2, respectively); peak (33 vs 84 mmHg) and mean (13 vs 38 mmHg) outflow tract gradients were reduced; and QRS width (143 vs 105 ms), intraventricular dyssynchrony (35 vs 55 ms), and VO(2)peak (19.5 vs 14.2 mL/kg/min) increased significantly (all P < 0.05) compared to baseline. In six of nine patients (67%), the peak gradient was reduced >50% and reached <40 mmHg. After a median of 36 months, the outflow gradient decreased even more (8 mmHg) and was significantly (P < 0.05) lower than after 6 months of CRT., Conclusions: These preliminary data suggest that CRT seems to be an effective method of reducing the outflow tract gradient and improving the functional status of symptomatic HOCM patients requiring ICD implantation. Our findings need to be confirmed by more extensive studies.

Objectives: To compare the impact of the efficacy of percutaneous coronary intervention (PCI) on prognosis in ST and non-ST elevation myocardial infarction (STEMI and NSTEMI) patients with respect to infarct-related artery (IRA)., Background: The significance of the efficacy of PCI in STEMI and NSTEMI depending on the type of IRA has yet to be clarified., Methods: Study population consisted of 2,179 STEMI and 554 NSTEMI consecutive patients treated with urgent PCI. The efficacy of PCI (TIMI [thrombolysis in myocardial infarction] 3 vs. TIMI < 3) was assessed with regard to the type of IRA (left anterior descending artery, circumflex artery [Cx] or right coronary artery). The mean follow-up was 37.5 months., Results: The rate of unsuccessful PCI was similar in STEMI and NSTEMI irrespectively of IRA (14.1 vs. 17.7%; P = 0.062). In STEMI, unsuccessful PCI was associated with significantly higher early (23.1 vs. 5.6%; P < 0.001) and late (29.9 vs. 12.8%; P < 0.001) mortality regardless of IRA. In NSTEMI, the inefficacious PCI significantly increased early (19.0% vs. 0.9%; P < 0.001) and late (27.3% vs. 6.3%; P < 0.001) mortality only in patients with Cx-related infarction. Unsuccessful PCI of IRA was an independent risk factor for death in STEMI (HR 1.64; P < 0.05), but not in NSTEMI (P = 0.64). Further analysis showed that whilst unsuccessful PCI of any vessel in STEMI is an independent risk factor for death, in NSTEMI this applies to unsuccessful PCI of Cx only., Conclusions: The significance of unsuccessful PCI of IRA seems to be different in STEMI and NSTEMI. Unsuccessful PCI is an independent risk factor for death in STEMI regardless of IRA and in NSTEMI with the involvement of Cx., (Copyright © 2010 Wiley-Liss, Inc.)

Background: Right ventricular (RV) dysfunction in chronic heart failure (HF) is associated with poor prognosis. Cardiac resynchronization therapy (CRT) is an established method of improving prognosis in HF. However, the majority of known indices predictive of response to CRT are based on left ventricular (LV) assessment. The authors hypothesized that baseline RV function and tissue Doppler-derived dyssynchrony may have incremental value over LV dyssynchrony measures for predicting CRT response., Methods: In this retrospective study, echocardiographic examinations were performed in 90 patients before pacemaker implantation and up to 18 months afterward. CRT results were evaluated using clinical criteria (death, hospitalization for decompensation, change in New York Heart Association class ≥1, and 10% decreases in both peak ventilatory oxygen uptake and 6-min walking distance) and reverse remodeling (>15% reduction in LV end-systolic volume)., Results: Baseline RV dyssynchrony during isovolumic contraction of 26 msec facilitated the segregation of responders from nonresponders with 85% sensitivity and 100% specificity, as well as synchrony in peak deformation of 54 msec, with 89% sensitivity and 67% specificity. The minor axis of the RV inflow tract predicted reverse remodeling after CRT with sensitivity of 73% and specificity of 58% with a cutoff value of 35 mm. According to the clinical criteria, LV indices (end-diastolic and end-systolic volumes) and interventricular delay gave an overall R(2) value of 0.20 (86.2% correctly classified patients; area under the curve, 0.80). The addition of RV dyssynchrony parameters (measured in peak strain and isovolumic contraction peak velocities) significantly increased the power of the model (R(2) = 0.86; 100% of patients correctly classified; area under the curve, 1; P for change in R(2) < .0001)., Conclusions: The value of baseline RV function analysis is incremental to LV indices for the prediction of clinical response to CRT but not reverse remodeling. RV synchronous longitudinal deformation and RV dyssynchronous isovolumic velocity are independent predictors of clinical response to CRT., (Copyright © 2011 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Background: The concept of cardiac resynchronisation therapy (CRT) is based on biventricular pacing in symptomatic, chronic heart failure (HF) patients with systolic left ventricular (LV) dysfunction and QRS ≥ 120 ms. The response to CRT is determined by clinical and echocardiographic parameters. The change of biochemical status (e.g. natriuretic peptides or metalloproteinase levels) caused by CRT is not well explored., Aim: To analyse the clinical and haemodynamic changes caused by CRT in relation to patients' biochemical status and to assess factors determining a favourable response to CRT., Methods: Fifty patients with chronic systolic HF (NYHA IV: two patients), wide QRS complex (160 ± 31 ms) and reduced LV ejection fraction (26 ± 5.8%) under optimal pharmacotherapy, who underwent CRT, were enrolled. Data on NT-proBNP and C-reactive protein serum levels, as well as standard echocardiography with tissue Doppler measurements, were collected before CRT and after six months of pacing. The levels of matrix metalloproteinase-9 (MMP-9) were assessed in a subgroup of 18 patients. Patients were regarded as responders if LV end-systolic volume decreased by 10% compared to baseline., Results: Thirty five (70%) patients responded favourably to CRT. Cardiac resynchronisation therapy resulted in an improvement of max. ventilatory oxygen uptake (12.9 ± 3.8 vs 16.6 ± 4.7 mL/kg/min; p < 0.05), a of NT-proBNP decrease (2,579 ± 2,598 vs 1,339 ± 1,088 pg/mL, p < 0.05), and decrease of atrio-, inter- and intra-LV dyssynchrony. A greater baseline dyssynchrony was observed in responders. A decrease of MMP-9 level following CRT was observed in 12 (67%) patients. Significant MMP-9 decrease was observed only in the subgroup of ischaemic HF patients (26,100 ± 7,624 pg/mL vs 23,360 ± 6,258 pg/mL; p = 0.03). In patients with MMP-9 decrease during CRT, a lower C-reactive protein concentration at baseline was observed (2.12 ± 1.6 vs 4.7 ± 4.1 mg/L). The reduction in LV end-diastolic diameter correlated with the changes in MMP-9 level (r = 51; p = 0.03). Baseline left atrial end-diastolic diameter measured in parasternal long-axis view £ 46 mm had a sensitivity of 83% and a specificity of 67% in predicting MMP-9 decrease (AUC 0.83; 95% CI 0.59-0.96)., Conclusions: The CRT induces favourable myocardial remodelling, resulting in NT-proBNP level decrease, improvement of regional and global biventricular function, and MMP-9 level reduction, in ischaemic HF patients. The changes of MMP-9 level may be predicted by baseline left atrial end-diastolic diameter and correlate with LV end-diastolic diameter change during CRT.

The implantable cardioverter-defibrillator (ICD), when implanted in the late phase of myocardial infarction (MI) in the primary prevention of sudden cardiac death, reduces total mortality by 23-31%. Current guidelines recommend ICD implantation at least 40 days after MI. Despite optimal MI therapy, the risk of sudden cardiac death or cardiac arrest remains highest within the first 30 days after index infarction. Two randomized trials with ICD implantation early after MI failed to show the reduction of total mortality in a long-term follow-up study. The decrease of sudden cardiac death incidence was counterbalanced by an increase of nonsudden deaths, which may have been caused by the augmentation of heart failure deaths in ICD groups, presumably due to ICD interventions. Therefore, optimizing ICD appears to be the most important issue influencing the long-term outcome.

The significance of anemia in patients with acute myocardial infarction (AMI) treated with percutaneous coronary intervention (PCI) remains controversial. The aim of the present study was to evaluate the effect of anemia on the short- and long-term prognosis of patients with AMI treated with PCI, including high-risk subgroups. The study group consisted of 1,497 consecutive patients with AMI treated in the acute phase with PCI. Anemia was defined using World Health Organization criteria (hemoglobin level <13 g/dl for men and <12 g/dl for women). The study population was divided into 2 major groups (patients with [n = 248, 16.6%] and without [n = 1,249, 83.4%] anemia) and 6 subgroups (diabetes mellitus, impaired renal function, age >70 years, left ventricular dysfunction, incomplete revascularization, and multivessel disease). A comparative analysis was performed between both groups within the whole population and within the particular subgroups. Significantly greater 30-day (13.2% vs 7.3%), 1-year (20.5% vs 11.3%), and total (24.1% vs 12.7%; all p <0.05) mortality rates were observed in the anemic group. Multivariate analysis identified anemia as an independent predictor of any-cause death in the whole population during the observation period (covariate-adjusted hazard ratio 1.46, 95% confidence interval 1.31 to 1.61, p <0.05). Anemia was significantly associated with excessive long-term mortality in the multivessel disease group (adjusted hazard ratio 1.54, 95% confidence interval 1.34 to 1.74) and in the incomplete revascularization group (hazard ratio 1.67, both p <0.05). In conclusion, anemia on admission in patients with AMI treated in the acute phase with PCI was independently associated with increasing short- and long-term mortality, especially in the subgroups with incomplete revascularization and multivessel disease., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: The prevalence of diabetes mellitus (DM) and chronic kidney disease (CKD) is rapidly increasing. Both comorbidities are considered significant risk factors for cardiovascular complications. The aim of the study was to evaluate the impact of DM with and without CKD on prognosis in patients with acute myocardial infarction (AMI) treated invasively., Material/methods: This single-center prospective study encompassed 3334 AMI-patients without cardiogenic shock, who were divided into 2 major groups: 999 patients with type 2 DM diagnosed prior to or during index hospitalization, and 2335 non-diabetics. All diabetic patients were divided with respect to their renal status into: diabetics with CKD (DM-CKD; n=264) and without (DM-nCKD; n=735). Short- and long-term outcomes were compared between study groups. Independent predictors of death and composite end-point were selected with multivariate Cox-regression model., Results: Mortality rates were significantly higher in DM group compared to nDM in all observation periods. DM-CKD was associated with excessive total mortality (35.6%) when compared to DM-nCKD (11.6%, P<0.001) and to nDM (9.8%, P<0.001). Mortality and major adverse cardiovascular event rates did not differ significantly between DM-nCKD and nDM groups. Diabetes coexisting with CKD was one of the strongest independent risk factors for death (hazard ratio 1.93; confidence interval 1.79-2.07; P<0.001)., Conclusions: The prognosis in diabetics with AMI is significantly related to renal function. Diabetics without CKD had similar prognosis to non-diabetics. Multivariate analyses showed that unlike diabetes without renal dysfunction, DM-CKD was an independent risk factor for cardiovascular complications and total mortality.

Aim: This study evaluated the impact of hyperuricemia (HUR) on outcome in patients with different types of impaired renal function (IRF) and acute myocardial infarction (AMI) treated invasively., Methods: Out of 3,593 consecutive AMI patients treated invasively, 1,015 IRF patients were selected. The IRF group consisted of patients with baseline kidney dysfunction (BKD group) and/or patients with contrast-induced nephropathy (CIN group). HUR was defined as a serum uric acid concentration (SUAC) >420 μmol/l (>7 mg/dl). Independent predictors of death and major adverse cardiovascular events (MACE) were selected by the multivariate Cox-regression model., Results: Remote mortality rates were higher in HUR patients: IRF (32.7 vs. 18.6%), BKD (41.3 vs. 25.9%), CIN (35.4 vs. 16.7%); all p < 0.001. HUR was an independent predictor of death in BKD (hazard ratio (HR) 1.38, p < 0.05). Each 100-μmol/l increase in SUAC was associated with a significant increase of HR for mortality: 1.087 in IRF patients, 1.108 in BKD patients, 1.128 in CIN patients; all p < 0.05. Remote major adverse cardiovascular event rates were higher in HUR patients: IRF (55.4 vs. 48.9%), CIN (56.8 vs. 48%); both p < 0.05., Conclusions: In AMI patients treated invasively, an increase in SUAC is an independent predictor of death within all types of renal dysfunction; HUR defined as SUAC >420 μmol/l (>7 mg/dl) is a predictor only in BKD patients., (Copyright © 2010 S. Karger AG, Basel.)

Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients with heart failure (HF), lowered LV ejection fraction, and wide QRS. However, many patients (< or =40%) do not respond to this form of pacing. TRUST CRT is a prospective, single-center, randomized, single-blind, parallel, and controlled study that has been designed to treat patients with moderate to severe HF (NYHA III-IV), QRS > or =120 ms, sinus rhythm, LV dysfunction (EF < or = 35%), and signs of mechanical dyssynchrony., Objective: The primary objective will evaluate the 6-month's combined endpoint of alive status, freedom from hospitalization for HF or heart transplantation, relative > or =10% increase in LV ejection fraction, > or =10% in peak oxygen consumption, and > or =10% in 6-minute walking distance., Methods: Patients with HF receiving optimal pharmacotherapy, with LV dysfunction, mechanical dyssynchrony, wide QRS and sinus rhythm will be randomized in a 1: 1 fashion to standard or triple-site CRT-D. Patients will be followed for 1 week, 1, 3, and 6 months during a blind phase, then every 6 months until study completion. One hundred patients will be enrolled by the study center., Conclusions: TRUST CRT is a randomized, clinical trial in CRT candidates to evaluate the effectiveness of triple-site pacing versus standard resynchronization in patients with HF.

Background: The primary objectives of this study were to compare the implantation course of triple-site (double left-single right) and conventional cardiac resynchronization devices. The secondary target was to assess mid-term outcomes of both types of cardiac resynchronization therapy (CRT)., Methods: Fifty-four patients with NYHA classes III-IV, left ventricular EFor=120 ms were included; 27 received triple-site pacemakers (TRIV group), 27 conventional CRT devices (BIV group). Procedural course, clinical data, QRS duration, echocardiographic parameters, peak oxygen consumption (VO2max) and 6-minute walking distance (6MWD) were screened for inter-group differences., Results: Procedure duration was higher in TRIV than in BIV group (197.6 vs. 137.6 min, P<0.001), fluoroscopy exposure and complication-rates were similar. After 3 months of CRT, triple-site pacing was associated with a more significant (P<0.05) NYHA class reduction (by 1.4 vs. 1.0 class, respectively), increase in VO(2) max (2.9 vs. 1.1 mL/kg/min) and 6MWD (98.7 vs. 51.6 m) than conventional CRT. A higher EF and more improved intraventricular synchrony were observed in the TRIV than in the BIV group. The response rate in the TRIV group was 96.3% vs. 62.9% in the conventional group (P=0.002). Triple-site stimulation was an independent predictor of response to CRT (adjusted odds ratio 26.4, P=0.01)., Conclusions: Triple-site resynchronization appears to be more beneficial than conventional CRT. Upgrade to triple-site CRT may be considered in non-responders to standard resynchronization.

Background: Cardiac resynchronization therapy (CRT) improves the clinical status of patients with heart failure (HF), though its effects on heart rate turbulence (HRT) are unknown., Methods: We measured HRT indices in 58 recipients of CRT systems (mean age = 56 +/- 9 years, 41 men) in New York Heart Association HF functional class III-IV, and with a left ventricular (LV) ejection fraction < or =35%. At 6 months of follow-up, 42 patients were responders and 13 nonresponders to CRT, and three patients died suddenly. The HRT indices turbulence onset (TO%) and turbulence slope (TS ms/RR interval) were calculated from digital 24-hour electrocardiogram before and after 6 months of CRT. TO > or = 0% and TS < or = 2.5 ms/RR interval were considered abnormal., Results: Mean TO in the entire population was 0.4 +/- 1.5 before CRT, and decreased to -0.8 +/- 7.0 during the 6 months of CRT (ns). TS increased significantly from 2.0 +/- 1.7 at baseline, to 3.9 +/- 3.1 (P < 0.05), and a significantly lower proportion of patients had abnormal HRT indices at 6 months. In contrast to the significant increase observed in responders, not significant change in TS was observed among the nonresponders., Conclusions: During 6 months of CRT, improvements in HRT indices and a decrease in the proportion of patients with abnormal HRT were observed. CRT may have beneficial effects on baroreflex sensitivity.

Microvolt T-wave alternans (MTWA) is a promising non-invasive method of evaluating repolarization abnormalities. Its presence is strongly related to the occurrence of malignant ventricular tachyarrhythmias and is therefore regarded as a risk marker for sudden cardiac death. Most recent studies have described the usefulness of MTWA in selecting patients who may benefit from a cardioverter-defibrillator. This study presents two cases of patients suffering from ischemic cardiomyopathy, who underwent an MTWA test. Episodes of ventricular tachycardia occurred immediately after the end of the tests, with abnormal results.

Background: Radiofrequency current ablation (RFCA) is a safe and efficient method of treatment in adult patients with symptomatic arrhythmias. Recently RFCA is being also used in the treatment of children with cardiac arrhythmias, however its value in this set of patients is poorly documented. Aims of our study were to assess the feasibility and safety of RFCA procedures in children with symptomatic supraventricular and ventricular arrhythmias, and to identify the parameters which influence the probability of acute success and RFCA course., Methods: Consecutive 110 patients aged less than 18, who underwent RFCA due to the symptomatic arrhythmias at our center were included into a retrospective analysis. The patients presented mainly with the preexcitation syndrome (57%), 13.6% had ectopic ventricular arrhythmias, in 17.3% nodal reentrant tachycardia, in 8.2% intraatrial reentry tachycardia (IART), whereas in 5.4% ectopic atrial tachycardia (EAT) was diagnosed. Three patients had multiple arrhythmias. In ten subjects congenital heart defect was diagnosed in the past, which was treated surgically in 8. Analyzed parameters included: RFCA success-rate, procedure duration, fluoroscopy-time, perioperative complications and arrhythmia recurrence-rate during 6 months follow-up., Results: Ablation was successful in 101 (91.8%) patients and abolished 104 out of 113 (92%) treated arrhythmias. Out of 9 patients with unsuccessful RFCA, three had congenital heart defect. Two complications occurred intra-operatively in two patients: in one patient pneumothorax was observed following jugular vein puncture, which resolved spontaneously without the need of drainage, in the second patient transient atrioventricular conduction block occurred during radiofrequency current application. Mean procedure duration in the studied population was 118.9 +/- 46 min, fluoroscopy exposure equaled 22.3 +/- 17min. In twelve patients (10.9%) arrhythmia recurred during the follow-up period. The longest procedure duration was observed in patients with EAT and IART, the longest fluoroscopy-time in subjects with IART, whereas the shortest fluoroscopy was observed in patients with the ventricular ectopic arrhythmias. Success-rates, complications, and recurrence-rates did not differ irrespectively from arrhythmia treated. The only independent predictor of unsuccessful RFCA was the presence of congenital cardiac defect (adjusted OR 0.15, p<0.05). The presence of cardiac defect, procedure performed without electroanatomic mapping system and less experienced operators were the parameters associated with longer fluoroscopic exposure., Conclusions: Radiofrequency current ablation is a safe and efficient method of treatment in children with arrhythmias. The presence of congenital heart defect was a factor influencing unfavorably the probability of successful RFCA. Procedural course was related to the experience of electrophysiology team, the use of advanced mapping systems and presence of cardiac defect.

Background: The impact of radiofrequency current ablation (RFCA) on left ventricular (LV) systolic and diastolic function in patients with atrioventricular nodal re-entrant tachycardia (AVNRT) is not well established yet., Methods: The study group consisted of 25 patients (18 W, mean age 43 +/- 11) with recurrent episodes of AVRT without any concomitant diseases. The control group was formed of 25 healthy volunteers. In both study and control groups, transthorasic echocardiography (TTE) and Doppler were performed in order to assess LV systolic and diastolic function. In AVNRT syndrome patients, TTE was followed by electrophysiology study and RFCA. TTE was repeated after six months in the study group., Results: Significant differences were found between the study and control groups with regard to LV systolic (FS--fractional shortening: 37 +/- 4 vs. 42 +/- 6%, p = 0.001; ESV--end-systolic volume: 19 +/- 4 vs. 17 +/- 4 ml/m(2), p = 0.03; EF--ejection fraction: 55 +/- 5 vs. 62 +/- 4%, p = 0.001) and diastolic function (E wave: 69 +/- 17 vs. 84 +/- 15 cm/s, p = 0.002; E/A: 1.09 +/- +/- 0.42 vs. 1.38 +/- 0.27, p = 0.005; DT--duration difference between A and AR waves: 7 +/- 29 vs. -28 +/- 13 ms, p = 0.001; DT--deceleration time of E wave: 223 +/- 34 vs. 177 +/- 27 ms, p = 0.001; IVRT--isovolumic relaxation time: 105 +/- 15 vs. 86 +/- 11 ms, p = 0.001; E/A while Valsalva manoeuvre: 0.93 +/- 0.35 vs. 1.25 +/- 0.16, p = 0.001; AR--atrial reversal velocity: 27 +/- 7 vs. 14 +/- 11 cm/s, p = 0.001) variables. In 6-month follow-up decrease in LVESV (19 +/- 4 vs. 17 +/- 4 ml, p < 0.03) and increase in EF (55 +/- 5 vs. 62 +/- 4%, p < 0.001) was noted. Doppler analysis showed an increase in E wave (69 +/- 17 vs. 79 +/- 20 cm/s, p < 0.02), E/A ratio (1.09 +/- 0.42 vs. 1.30 +/- 0.27, p < 0.006) and decrease in A wave (68 +/- 13 vs. 63 +/- 10 cm/s, p < 0.02), DT (223 +/- 34 vs. 179 +/- 22 ms, p < 0.001), IVRT (105 +/- 15 vs. 89 +/- 11 ms, p < 0.001) and DT (7 +/- 29 vs. -13 +/- 28 ms, p < 0.001)., Conclusions: Successful RFCA of slow atrioventricular conduction pathway in patients with AVNRT and AVRT results in improvement of LV systolic and diastolic function.

Background: Atrioventricular reentrant tachycardia (AVRT) is the most common tachycardia, accounting for 70% of regular narrow-QRS arrhythmias in children. Because of the potential disadvantages of a life-long drug therapy and relatively favourable results from radiofrequency catheter ablation (RFCA) therapy in adults, the indications for ablation therapy in children with preexcitation syndrome (PS) need to be considered., Aim: To assess efficacy and safety of RFCA in children and adolescents with PS., Methods: The study population consisted of 302 consecutive, symptomatic, drug-refractory patients with PS undergoing RFCA. Two age groups were selected: 52 patients younger than 19 years (24 females, age 15.38+/-2.53 years); and 250 adults (115 females, age 38.67+/-13.1 years). In all study patients electrophysiological study and radiofrequency catheter ablation were performed. Comparative analysis between groups was performed with respect to procedure duration, fluoroscopy exposure time, location of accessory pathways (AP), success rate, recurrences and complications., Results: No significant differences between the groups were noted with respect to procedure duration and exposure time. Success and recurrence rates did not differ between the two-age groups. The mean procedure time for children was 124.12+/-43.48 min (range 45-285) and for adults - 126.3+/-61.49 min (range 25-330) (NS). The mean fluoroscopy time for children was 27.95+/-16.86 min (range 4-75) and for adults - 31.27+/-25.51 min (range 1-131) (NS). The initial RF ablation procedure was successful in 48 (92.31%) children and in 233 (93.2%) adults (NS). Recurrence rate was 12.5% (6 patients) in children vs. 8.58% (20 patients) in adults (NS). In one child (1.92%) and in two adult patients (0.8%) serious complication occurred (NS). Electrophysiological study revealed significantly more frequent presence of the right free wall and right antero-septal AP in children than in adults (21.15 vs. 7.6%, and 17.31 vs. 5.2%, respectively, p <0.01). In adults more frequent left antero-lateral AP was detected: 32.4 vs. 7.69%, p <0.01., Conclusions: Radiofrequency catheter ablation is a safe and efficient procedure in paediatric patients with preexcitation syndrome. Effectiveness, safety, recurrence rate and RFCA procedural aspects, including total procedure time and fluoroscopy time, are comparable in paediatric patients with PS and in adults.

Background: It has been shown that successful reperfusion improves in-hospital and long-term outcome of patients with acute myocardial infarction (AMI). Nevertheless, some patients are still at high risk due to AMI despite achievement of reperfusion. Impaired renal function (IRF) is one of the recently recognised risk factors in this population. However, the prognostic value of different types of IRF in patients with AMI treated with percutaneous coronary intervention (PCI) has not been well characterised., Aim: To evaluate the prognostic value of different types of IRF in AMI patients treated with PCI., Methods: The single centre AMI registry encompassed 1486 consecutive AMI patients treated with PCI, who were followed for a mean of 29.7 months. Subjects with at least 1 measurement of serum creatinine >133 micromol/l (>1.5 mg/dl) during hospitalisation were selected (n=194; 13.1%) and incorporated into the IRF group. The control group consisted of 1292 (86.9%) subjects with normal renal function. The IRF patients were divided into subgroups: contrast-induced nephropathy--CIN (n=90; 6.1%); and chronic kidney disease--CKD (n=66; 4.4%). Thirty-eight patients from the IRF group (2.6%) had normal value of serum creatinine on admission and did not match criteria of CIN. Patients with creatinine value >133 micromol/l on admission were incorporated into the CKD group. CIN was defined as a serum creatinine level <134 micromol/l on admission and a 25% increase of that parameter, with a value >133 micromol/l within 48 hours after PCI. Among CIN patients 2 subgroups were identified with respect to coexisting diabetes mellitus: CIN-DM and CIN-nDM (both n=45; 3.05%)., Results: Remote mortality rate was significantly higher in the IRF group (38.7%) and in particular subgroups--CKD (51.5%), CIN-DM (46.7%), CIN-nDM (28.9%)--than in controls (10.3%, p <0.001 for all study groups vs. controls). Multivariate analysis identified IRF as an independent predictor of any-cause death in the whole population [hazard ratio (HR) 2.23; 95% CI 1.99-2.47, p <0.001]. All defined types of IRF had a significant and independent influence on remote survival in the study population (CIN-DM - HR 3.52; 95% CI 3.23-3.81; CIN-nDM--HR 2.60; 95% CI 2.29-2.91; CKD--HR 1.98; 95% CI 1.68-2.28)., Conclusions: Impaired renal function and all defined types of renal impairment have been shown to worsen the long-term prognosis of AMI patients treated with PCI. The most important risk factor of mortality is CIN in diabetic patients, which is associated with an over 3.5-fold increase of death hazard in this study population.

We present a case of a 10-year-old boy with hypertrophic cardiomyopathy, intraventricular pressure gradient of 104 mmHg, and indications for prophylactic ICD implantation. Based on intraoperative pressure measurements, the child was implanted with biventricular ICD. During 2.5 months of observation, the patient's functional status improved significantly, as shown by subjective and objective parameters and, moreover, the pressure gradient fell to 12 mmHg. Significant electrical and mechanical cardiac dyssynchrony appeared parallel to clinical improvement.

We report on a case of a 62-year-old patient with symptomatic heart failure and severe ventricular electrical and mechanical dyssynchrony, who was implanted percutaneously with a triple site (dual-left single-right) resynchronization device. At 3-months follow-up, the patient's functional status improved significantly as shown by subjective and objective tests. Furthermore, this mode of pacing has allowed nearly complete inter- and intraventricular mechanical resynchronization.

Background: The role of incomplete revascularization (ICR) in patients with acute myocardial infarction (AMI) is controversial. We evaluated the impact of ICR on short- and long-term outcome in patients with AMI and multivessel disease (MVD) treated with percutaneous coronary interventions (PCI) during index hospital stay., Methods: Single-center observational study covered 798 patients with MVD selected from 1486 consecutive patients with AMI treated with PCI. At discharge, 605 (75.8%) of the patients still had at least 1 diseased artery (ICR group); in 193, complete revascularization (CR) has been achieved (CR group). Any-cause mortality rate and major adverse cardiac events (MACE) during hospitalization, within a follow-up period of 30 days and 29.7 months, were compared between both groups in the whole population and within the high-risk subgroups. Propensity model to predict the probability of CR according to 16 variables was used., Results: Mortality and MACE rates were significantly higher in ICR group than among completely revascularized subjects during short- and long-term observation (remote mortality 18.5% vs 7.2%, MACE 53.1% vs 24.3%, both P < .001). Higher mortality rate was also observed within the subgroups with diabetes (25.2% vs 4.8%), renal dysfunction (44.1% vs 13.8%), and lowered ejection fraction (26.5% vs 10.5%, all P < .05). Propensity-adjusted multivariate analysis showed that ICR was a significant and strong predictor of remote death (propensity-adjusted hazard ratio 2.01, 95% CI 1.71-2.31, P = .02) and MACE (hazard ratio 2.08, 95% CI 1.90-2.26, P < .001)., Conclusions: Incomplete revascularization is a strong and independent risk factor of death and MACE in patients with AMI treated with PCI.

Background: Atrioventricular reentrant tachycardia (AVRT) in patients with preexcitation syndrome (PS) is the main cause of paroxysmal regular arrhythmias in children and adolescents. While the previously published data most commonly concern clinical consequences of PS in adults, few researchers have evaluated the problem in children and adolescents. The aim of the study was to compare the clinical course of PS between the population of children and adolescents below 19 years of age and the population of adult patients., Method: The study population consisted of 302 consecutive PS patients managed between January 2001 and June 2005 with radiofrequency catheter ablation (RFCA). The study population was divided into two groups: Group 1 consisting of 52 patients aged 15.38 years on average (7-18 +/- +/- 2.53) and Group 2 consisting of 250 adult patients aged 38.67 years on average (19-72 +/- 13.1)., Results: Patients from Groups 1 and 2 experienced their first episode of AVRT at the mean age of 13.3 years and 29.1 years, respectively (p < 0.05). The mean annual numbers of AVRT episodes in Groups 1 and 2 were 12.97 (range, 2-96; median, 8) and 8.86 (range, 2-25; median, 6), respectively (p = non-significant). Two patients from Group 1 (3.85%) and 42 patients from Group 2 (16.8%) experienced episodes of atrial fibrillation (AF) (p < 0.05). Location of the accessory pathways (AP): In Group 1, the right free wall and anteroseptal AP locations were significantly more common [11 (21.15%) and 9 (17.31%) patients, respectively, vs.q 19 (7.6%) and 13 (5.2%) patients in Group 2; p < 0.01]. In Group 2, the left anterolateral AP location was more common [81 (32.4%) vs. 4 (7.69%) in Group 1; p < 0.01]., Conclusions: In children and adolescents with PS, a significantly lower incidence of AF was found. In Group 1, RFCA was performed significantly more frequently due to the development of AVRT caused by right free wall and right anteroseptal AP, while in the group of adults, the left anterolateral AP location was found more commonly. (Cardiol J 2007; 14: 384-390).

Background: We sought to evaluate the influence of atrio-ventricular reentrant tachycardia (AVRT) on atrial pressures during tachycardia and the presence of atrial fibrillation (AF) in patients with preexcitation syndrome., Methods: The study population consisted of 88 patients (37 females, mean age 37.3 years) with left-sided accessory pathway and AVRT induced during electrophysiologic study. The AF-inducible group consisted of 32 patients with sustained episodes of AF provoked during electrophysiologic study, whereas the noninducible group comprised 56 patients without AF., Results: We found significantly higher values of maximal and mean left (LAP) and right (RAP) atrial pressures in the AF group compared with noninducible group: LAP max 32.0 versus 20.8, LAP mean 21.6 versus 13.2, RAP max 15.2 versus 11.5, RAP mean 8.2 versus 6.2 respectively (P < 0.001). When analyzing the effect of AVRT on atrial pressures, we found a significant (P < 0.001) negative correlation between anterograde conduction times during tachycardia and LAP max and LAP mean in the whole population, but a significant positive correlation between retrograde conduction time and left atrial pressures. Similar effects of AVRT on the right atrial pressures were found., Conclusions: Atrial pressures during AVRT, which depend on the electrophysiological features of tachycardia, play an important role in the genesis of atrial fibrillation in patients with preexcitation syndrome.

Background: Incessant tachycardia may result in left ventricular (LV) systolic dysfunction. Little is known about the influence of atrioventricular tachycardia (AVRT) and atrioventricular nodal re-entrant tachycardia (AVNRT) on LV systolic and diastolic function. The aim of the study was to assess LV systolic and diastolic function and factors affecting LV systolic and diastolic performance in patients with AVRT and AVNRT., Material: The study group included 90 patients (40 male, 50 female, mean age 40 +/- 12 years) with symptomatic narrow-QRS tachycardia. After an invasive electrophysiology study (EPS) had been performed, these were divided into two groups: one (AVNRT) of 25 patients with AVNRT and the other (WPW) of 65 patients with AVRT. The control group consisted of 50 healthy volunteers (23 male, 27 female, mean age 39 +/- 13 years). In all three groups transthoracic echocardiography was performed in order to assess LV systolic and diastolic function., Results: LV fractional shortening (FS) (WPW: 32 +/- 6%, AVNRT: 36 +/- 4%, p < 0.005) and ejection fraction (EF) (WPW: 54 +/- 7%, AVNRT: 55 +/- 5%, p < 0.001) were significantly decreased in the study groups compared to the control group (FS: 40 +/- 5%, EF: 62 +/- 4%). FS was significantly increased in the AVNRT compared to the WPW patients (p < 0.005). LV diastolic dysfunction was found in 20 (80%) of the AVNRT and 55 (83%) of the WPW group and in none of the patients from the control group. A positive correlation was found between diastolic dysfunction and the scale of recurrence of AVRT (R = 0.67, p < 0.05) and AVNRT (R = 0.52, p < 0.05)., Conclusions: AVNRT and AVRT may lead to development of LV systolic and diastolic dysfunction. LV diastolic dysfunction is related to the frequency of AVRT or AVNRT recurrence. (Cardiol J 2007; 14: 160-166).

Background: Cardiac arrhythmias as a late complication following congenital heart surgery are encountered more and more frequently in clinical practice. The use of new electrophysiological methods of visualisation and mapping improves the efficacy of radio-frequency (RF) ablation of these arrhythmias., Aim: To assess patterns of atrial arrhythmias following congenital heart surgery and to examine the efficacy of RF ablation using the electro-anatomical CARTO system., Methods: Electrophysiological diagnostic study and RF ablation were performed in 24 consecutive patients (mean age 36+/-18 years) who had atrial arrhythmias following congenital heart surgery. The mechanism of arrhythmia (ectopic or reentrant) and strategy of RF ablation procedure were based on the results of the right atrial map performed during index arrhythmia., Results: The patients were divided into five groups according to the type of congenital heart surgery. The ASD group consisted of 17 patients who had undergone in the past surgery due to atrial septal defect, four patients had a history of surgery due to ventricular septal defect (VSD group), and one patient each had undergone surgery due to corrected transposition of the great arteries (ccTGA), tetralogy of Fallot (TF) or dual-outflow right ventricle (DORV). During diagnostic electrophysiological study typical atrial flutter (AFL) was diagnosed in nine patients from the ASD group, atypical AFL in three ASD patients, and ectopic atrial tachycardia (EAT) in six ASD patients. In one patient EAT was induced after ablation of typical AFL. Of the VSD patients, three had atypical AFL, and one had typical AFL. The patient following surgery for ccTGA had atypical AFL and EAT, whereas in the two remaining patients (DORV and TF) atypical AFL was demonstrated. The efficacy of the first session of RF ablation was 83% and no complications were observed. The efficacy of RF ablation of typical AFL was 90%, atypical AFL 78%, and EAT 86% (NS). During the long-term follow-up (24+/-17 months) arrhythmia recurrences were noted in 2 (10%) out of 20 patients who were effectively treated during the first RF ablation session., Conclusions: Reentry is the most common electrophysiological mechanism of incisional tachycardias, followed by ectopic atrial tachycardia. RF ablation using the electro-anatomical CARTO system is effective and safe in this group of patients.

Background: Cardiac resynchronization therapy (CRT) becomes a "gold standard" in therapy of selected patients with advanced heart failure. We set out to evaluate the feasibility and safety of percutaneous interventions within coronary sinus (CS) and their effect on the success rate of left ventricular (LV) lead implantation during CRT., Methods: The study analyzed eight consecutive patients with the indications for CRT, who needed additional procedures within CS to overcome technical problems during left ventricular (LV) electrode implantation. The analyzed group consisted of three subgroups: patients in whom percutaneous balloon angioplasty within CS was needed (n = 4); patients with acute instability of the lead, requiring stenting of the vein to fix the electrode (n = 2); and patients with the stenting of CS due to late dislocation of the lead (n = 2). Success rate, procedure duration, fluoroscopy, complications, and electrical parameters of leads were analyzed., Results: Success rate of the procedures was 87.5%; additional interventions increased overall efficacy of CRT implantation at our center from 88% to 98% (P < 0.05). Procedure duration (155.0 minute) and fluoroscopy time (42.5 minute) remained acceptable for the patient and operator; however, both were higher than in the procedures performed routinely in our hospital. Electrical properties of the LV leads were stable and within normal ranges during the observation period. We noted two local dissections of CS during the procedure, which remained clinically silent., Conclusion: Percutaneous interventions within CS seem to be feasible and safe treatment options, which can improve the short- and long-term success rates of CRT.

Introduction: LocaLisa is a novel system for anatomical mapping. It enables an assessment of the three-dimensional position of electrodes within cardiac chambers without fluoroscopy. With this technique it may be possible to reduce radiation exposure during catheter-based ablation procedures., Aim: To evaluate the efficacy and safety of ablation procedures performed using the LocaLisa mapping system in patients with atrioventricular nodal reentrant tachycardia (AVNRT)., Methodology: This study evaluated the course of the first 26 ablations performed using the LocaLisa system (studied group). The control group involved 30 consecutive patients with AVNRT treated with the conventional ablation technique that was routinely used prior to the introduction of the novel system into clinical practice., Results: In the studied group procedural duration was 72.4+/-24.9 minutes, in the control group 80.1+/-18.2 minutes (NS). However, radiation exposure was significantly lower in the examined group -- 74.4+/-109.2 mGy compared to 184.8+/-59.9 mGy in the control group (p <0.05). All procedures were successful. No complications related to the ablation were observed., Conclusions: Employment of the LocaLisa mapping system enables the reduction of fluoroscopic exposure without any decrease of efficacy or elevation of risk of any complications during AVNRT ablations.

We report on two patients treated with cardiac resynchronization therapy, in whom early (intra-operatively, 64-year-old man) and late (4 months post-operatively, 57-year-old woman) instability of the left ventricular (LV) lead occurred. In order to stabilize the electrodes, stents were deployed in both patients within the coronary sinus, into the space between the lead and the wall of the vein effectively pinning the lead to the wall. During 3 and 5 months of follow-up, the electrodes remained stable and allowed for successful resynchronization in both cases. Stenting within the coronary sinus seems to be a safe method for LV lead stabilization, which can substantially increase the success rate of resynchronization therapy. This new approach, although promising, has to prove its safety and should not be practised routinely until long-term follow-up data are available.

Aim of the Study: Was to estimate an influence of acute cellular rejection on electrophysiologic parameters of allograft and remnants of recipient's heart, in patients after orthotopic heart transplantation (OHT)., Patients and Methods: Analysis was performed in 25 OHT recipients (24M/1F, age 48.4 +/- 9 y., ischemic time 197 +/- 51 min., donor age 30 +/- 9 y.), who underwent electrophysiological study (EPS), along with elective endomyocardial biopsy (EMB), scheduled for the 1st month after the surgery. Results of EPS were correlated with a degree of rejection, assessed with the ISHLT grading system. Grades > or =3A were considered a significant cellular rejection., Results: ISHLT grade 0 was observed in 8 patients, grade 1A or 1B in 12 patients, and 3A in 5 patients. Frequency of transplanted heart rhythm (TH-R) was 691.3+/- 37 ms in patients with ISHLT grade 0, 690.4 +/- 41 ms in patients with grade 1A or 1B, and 744.4 +/- 668 ms in individuals with 3A rejection (p < 0.04, for difference between 0 and 3A groups). Intraatrial conduction time (IntrtaCT) was significantly shorter in grade 3A group (20.4 +/- 1.6 ms), when compared with patients without rejection (36.2 +/- 4.9 ms, p < 0.03), or with 1A or 1B rejection (41.5 +/- 13 ms, p < 0.032). Also interatrial conduction time (InterCT) was the shortest in patients with 3A rejection (53.8 +/- 4.3 ms), when compared with ISHLT grade 0 group (78.5 +/- 7.6 ms, p < 0.02) and 1A/1B group (74.1 +/- 12 ms, p < 0.023). The other characteristics of atria, ventricles and AV-junction performance were comparable in all patients., Conclusions: TH-R, IntraCT and InterCT should be considered as the markers of significant cellular rejection in patients after OHT. Further analysis involving higher number of patients is warranted.

Background: Radiofrequency (RF) ablation of typical atrial flutter (AFL) is a well-established method of treatment. Although its efficacy is high, a search for new, more effective techniques is continuing. These new methods include modern systems for electro-anatomical mapping and new types of ablating electrodes such as cooled-tip or dual-sensor catheters., Aim: To assess the efficacy of RF ablation of typical AFL with the use of electro-anatomical mapping system CARTO and to compare the effectiveness of various ablating catheters., Methods: The study group consisted of 60 consecutive patients who underwent RF ablation of typical AFL with the use of the CARTO system. In 35 patients standard ablating electrodes were used, in 15 -- cooled-tip catheters (Thermo-Cool), and in 10 -- Dual-Sensor catheters., Results: Overall efficacy of RF ablation was 96.6%. In two procedures which occurred ineffective, standard ablating electrodes were used. In 4 (6.6%) patients a recurrence of AFL was noted -- also these patients had RF ablation performed with the use of standard ablating electrodes. None of the patients had procedure-related complications., Conclusions: RF ablation of typical AFL with the use of electro-anatomical system CARTO is effective, safe and associated with reduced fluoroscopy time. The use of cooled-tip or dual sensor ablating electrodes further enhances efficacy of the procedure.

Background: Ventricular ectopy or ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT) are the most common forms of arrhythmias in patients with structurally normal heart. Pharmacological treatment is effective in no more than 50% of patients, whereas radio-frequency catheter ablation (RFCA) offers a much higher success rate., Aim: To assess early and late outcome in patients with RVOT arrhythmias treated with RFCA combined with electro-anatomical mapping system (CARTO)., Methods: The study group consisted of 34 consecutive patients (mean age 38.8+/-12.0 years, range 21-52 years, 11 males, 23 females) with symptomatic arrhythmias originating from RVOT, who underwent RFCA in our department between December 2001 to July 2003. RFCA was performed with the use of the CARTO system. The power of RF current was set at 40 Watts, duration -- 90 seconds, and maximal temperature -- 55 degrees C. In order to assess short- and long-term RFCA efficacy, a 24-hour Holter ECG monitoring was performed before RFCA and shortly after the procedure as well as one and three months afterwards. Effective RFCA was defined as the reduction of ventricular ectopy <1000 / 24 hours in Holter monitoring performed just after the procedure., Results: Holter ECG monitoring performed after RFCA showed that the procedure was effective in 30 (88.2%) patients. In the remaining four patients no significant reduction in the frequency of ventricular ectopy was noted, however, no complex ventricular arrhythmias were present. In none of the patients neither early nor late complications were observed. The mean follow-up duration was 15.6 months (range 5-26 months). During Holter ECG monitoring performed one and three months after RFCA, a recurrence of frequent ventricular ectopy (7139 beats / 24 hours) was found in one patient, however, without complex arrhythmias. The remaining patients, in whom RFCA was found to be effective at Holter ECG monitoring performed just after the procedure, continue to be free from arrhythmia and do not require antiarrhythmic agents., Conclusions: RFCA with the use of the CARTO system is effective and safe in the treatment of arrhythmias originating from RVOT.

The aim of this study was to compare the electrophysiological features of tachycardia between WPW patients with and without AF. The study population consisted of 114 patients with WPW syndrome and reciprocating tachycardia during electrophysiological study. Two groups were selected: group I with AF during the procedure(n = 42)and the control group n = 72 without AF (group II). Cycle length (V-V interval), antero A-V, retrograde V-A conduction time during tachycardia and indexes V-A/V-V were analyzed. In addition, the relation between antero-, retrograde conduction time, and V-V was evaluated. Selection of the most predictive factor for AF presence was performed using regression analysis. Significant differences between the two groups were observed. These included a higher rate of tachycardia, shorter anterograde conduction time, A-V/V-V-indexes, longer retrograde conduction time, and V-A/V-V-indexes in group I compared with group II. Significant, positive correlations between anterograde conduction time and V-V were present in both groups, but retrograde conduction correlated significantly with the V-V-interval only in group II and group I (r = 0.37 vs r =-0.01, respectively). Significant, negative correlations between A-V and V-A conduction time in all analyzed points has been found to exist in group I (r =-0.45 for the point of maximal preexcitation [PMP]), whereas there were no significant correlations between these parameters in group II (r = 0.04). The most powerful AF predictor has been identified as the V-A/V-V index. The presence of AF in WPW syndrome may be associated with discrete patient characteristics. Ventricular activation occurs earlier, and atrial later, in the tachycardia cycle in AF than in patients free of AF. The different ability of the accessory pathway for adaptation to tachycardia rate changes in group I causes prolonged retrograde conduction over the pathway while the tachycardia rate increases.

Background: Microwave energy ablation is one of the newer therapeutic options for surgically treating patients with chronic atrial fibrillation (AF) concomitant with mitral valve disease. The aim of this study was to retrospectively evaluate potential risk factors that may have influenced early as well as remote outcome in a set of patients undergoing microwave energy ablation for chronic AF., Methods: Patients (n = 42) underwent ablation on an arrested heart concomitant with mitral valve surgery. Twelve patients also underwent tricuspid valve repair or replacement. Logistic regression analyses were performed to evaluate effect of potential risk factors on postablation rhythm status at discharge and at latest follow-up examination., Results: With control for age, patients with recurrent AF at discharge (10/42 [24%]) tended to have preoperative AF of significantly longer duration (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.15-2.35; P = .01) and greater left atrial diameter (OR, 1.14; 95% CI, 1.03-1.26, P = .01) than patients in sinus rhythm (32/42 [76%]). At latest follow-up examination, risk of AF was significantly heightened with longer duration of preoperative AF (OR, 1.47; 95% CI, 1.09-1.96; P = .01) and larger left atrium (OR, 1.12; 95% CI, 1.02-1.23; P = .02) after adjustment for age, length of follow-up time, and presence of early arrhythmia recurrence., Conclusions: Results for this consecutive series of patients indicated that early and late success after surgical energy ablation may be associated with discrete patient characteristics. Longer arrhythmia duration and greater left atrial diameter seem to be factors independently influencing early and remote success, and there seems to be a self-protective effect of the presence of sinus rhythm at discharge. Further study would be valuable to confirm our findings.

The patients with WPW syndrome demonstrate wide scale of clinical manifestation, from asymptomatic course to sudden cardiac death. Among this patients it is possible to identify the small group of patients with rare kind of atrioventricular reentrant tachycardia named permanent junctional reciprocating tachycardia (PJRT) associated with increased risk of development tachycardia-induced cardiomyopathy. This patients should be successful treated by radiofrequency catheter ablation (RFCA). Aim of the study was assessment of efficacy and safety of RFCA procedure in patients with preexcitation syndrome and PJRT. Analyzed group consisted of 7 patients with PJRT selected from 163 consecutive patients with symptomatic WPW--syndrome undergo electrophysiological study (EPS) and RFCA. Analyzed group consist of 4 women and 3 men. Mean age of patients was 22.71 SD +/- 7.99 (from 14 to 38 years). Every patients underwent EPS and RFCA simultaneously. Success-rate in first session was 71.42% (5 patients were successful ablated). Two women underwent second ablation one who has recurrent symptomatic arrhythmia and another who initially was unsuccessfully treated in first session. This two additional procedures were successful. RFCA-duration time was average 107.85 minutes SD +/- 21.95 (min-80, max-145 min) and fluoroscopy--time amount from 28 min to 55 min average 38.58 min (SD +/- 11.14). Among analyzed patients we did not noticed any complications during ablation procedure. Patients with PJRT could be safe and successfully treated using RFCA.