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Introduction: The implantation of a cardioverter-defibrillator (ICD) is an established method of sudden cardiac death (SCD) prevention. The value of ICD therapy in secondary prevention of SCD is unquestionable. Precise identification of high-risk patients and ICD use for primary prevention of SCD, especially in patients with hypertrophic cardiomyopathy (HCM), remain controversial. Problems include the high prevalence of complications associated with ICD implantation and optimal selection of ICDs., Aim: To estimate the frequency and type of complications after ICD implantations in HCM patients in a long-term follow-up., Method: The efficacy and safety of ICD therapy were estimated in 46 HCM patients with devices implanted for a secondary (n-18) or primary prevention (n-28) of SCD., Results: During the mean follow-up period of 28.2+/-26.1 months (from 2 to 68) appropriate ICD interventions occurred in 10 (55%) patients of the secondary prevention group and in 3 (10%) patients of the primary prevention group. Complications were documented in 15 (33%) patients. The most frequent were inappropriate ICD interventions recorded in 14 (30%) patients. The causes of these inappropriate ICD shocks were: T-wave oversensing (7 patients), atrial fibrillation with rapid ventricular rhythm (3 patients), lead failure (2 patients), and sinus tachycardia (2 patients). In two patients infections of the ICD pocket requiring removal of the system occurred. Displacement of the lead occurred in one patient. There were no significant differences in the prevalence of complications between the primary and secondary prevention groups or in the number of inappropriate interventions with respect to ICD type., Conclusions: The high rate of appropriate ICD shocks provides proof of high ICD-based SCD prevention efficacy. There is a high rate of complications observed after ICD implantation with inappropriate interventions being the most frequent among them. This indicates that careful programming of the device as well as the use of a programme with T-wave oversensing prevention should be ensured.

We report two patients in whom thrombus formation during radiofrequency catheter ablation was detected by echocardiography. Resolution of thrombus after intravenous use of heparin was observed in both patients. Transesophageal and intracardiac echocardiography may be useful in management of this complication.

A case of a young patient admitted to our hospital due to acute myocardial infarction is presented. Coronary angiography revealed normal coronary arteries. Echocardiography performed immediately after coronary angiography showed the presence of the left atrial myxoma. Three days later the patient underwent urgent surgery with a favourable outcome. The role of echocardiography in detecting atrial myxoma and mechanisms of myocardial infarction caused by this anomaly are discussed.

Acute myocardial infarction complicated by cardiogenic shock in a patient with Leriche syndrome - a case report. A 46-year-old male with atherosclerosis obliterans was admitted to the hospital due to chest pain lasting for two hours and signs of cardiogenic shock. ECG revealed postero-inferior myocardial infarction. The patient was successfully treated with primary angioplasty of RCA. Due to atherosclerosis obliterans angioplasty was performed by transulnar approach. After 22 days of treatment and rehabilitation he was discharged home.

Aims: Conventional ICD algorithms yield approximately 10-30% of spurious interventions. Our aim was to check whether nonlinear dynamics methods might be useful in the verification of ICD interventions., Methods and Results: We extracted 190 consecutive RR files (approximately 2000-9000 RR intervals long) from the ICDs of 70 patients (36 with coronary artery disease, 8 with hypertrophic cardiomyopathy, 19 with dilated cardiomyopathy and 7 with other diseases). The 3D phase space trajectories in delay coordinates, window pattern entropy, and algorithmic complexity of the RR intervals were examined within a 50 beat sliding window. Data were not filtered for arrhythmia and artefacts. Of the 83 recordings with appropriate interventions 79 were correctly recognised in a blind test. Two interventions were not identified in patients with fast atrial fibrillation and two in cases of complex and frequent forms of arrhythmia. There were nine spurious interventions. In all except one case (atrial fibrillation with a fast ventricular response) the analysis by nonlinear methods showed that the intervention was not necessary. All of the 98 control recordings were correctly identified in the blind test., Conclusions: The results show that nonlinear dynamics methods may be used to supplement the existing ICD detection algorithms to enhance the detection success rate.

Implantation of an automatic cardioverter-defibrillator (ICD) in children may be challenging due to the increased risk of periprocedural and long-term complications. ICD was implanted in two boys with hypertrophic cardiomyopathy, aged 6 and 9 years, with of a body weight of 20 and 25 kg, respectively. In one patient an ICD was implanted due to a history of ventricular fibrillation whereas the second patient underwent prophylactic ICD implantation due to a family history of sudden cardiac death. No short- or mid-term complications were recorded. Difficulties and risks of ICD implantation in children are discussed.

Aim of this prospective study was to assess quality of life (QoL), left ventricular (LV) function and exercise performance in two groups of patients (pts) with atrial fibrillation (Af) treated with: radiofrequency catheter ablation (RFA) and antiarrhythmic drugs (AA). Between 1996 and 2000 - 74 patients, 28 women, with drug refractory Af were enrolled by clinical indications for two modes of therapy: RFA and AA. RFA group consisted of 38 pts, 63.7 +/- 11.5 years old: 28 pts with RF AV Node ablation and pacemaker implantation (PI) and 10 pts with AV Node modification or right atrial isthmus RF ablation due to Af conversion to atrial flutter (Aflu) during medical therapy. AA group consisted of 36 pts, aged 59.7 +/- 13.8 years. Patients from RFA group suffered significantly more serious diseases than pts from AA group. No significant (sign.) differences between two groups were found in age, gender, arrhythmia history and number of AA taken. Pts were analyzed before entry, after 3 and 12 months of follow-up (3 mo. FU, 12 mo. FU) with following indices: LV function (Echo: EF & FS), exercise performance (treadmill test), QoL questionnaires, number of hospital admissions connected to arrhythmia or procedures (RFA & PI), number of AA drugs taken in RFA group. RFA group: Two deaths occurred due to end stage respiratory insufficiency (COPD), one pt required reposition of pacemaker lead. AA group: 3 pts required RFA due to uncontrolled Af/Aflu (AV Node ablation with PI - 1 pt, right atrial isthmus ablation - 2 pts). Analysis of two patients groups: LV function: Sign. improvement (EF & FS) in both groups in 12 mo. FU; Exercise performance: no sign. changes in 3 and 12 mo. FU. QoL: Arrhythmia scale: 3 mo. FU sign. reduction in both groups; 12 mo. FU reduction in RFA group only; Anxiety scale: 3 and 12 mo. FU sign. reduction of anxiety level in RFA group; Exercise and activity scales: 3 and 12 mo. FU sign. improvement in RFA group. During 3 and 12 mo. FU sign. less pts from RFA group required hospital admission versus pts from AA group. Sign. reduction in AA was noted in RFA group. Patients with symptomatic Af treated with RFA benefit from this kind of therapy more than patients treated with AA. Quality of life improvement visible in short term observation in patients from RFA group is still present after one year observation. Improvement in LV function is observed after one year in both groups of pts with Af.

In clinical practice there is a major problem with angina, which is resistant to medical therapy with hemodynamically acting agents. In that group of patients it is necessary to consider the indications for coronary angiography and percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafts (CABG). But some of these patients, especially those who had previous CABG or PTCA, coronary diabetic patients and elderly patients do not qualify for revascularization procedures. In patients with recurrent angina the beneficial effect of trimetazidine, a metabolic agent, that shifts cardiac energy metabolism from fatty acid oxidation to glucose oxidation was demonstrated. In the TRIMPOL II analysis of subgroup of post-revascularized patients with recurrent angina was demonstrated the improvement in exercise treadmill test parameters and clinical symptoms in a group treated with trimetazidine added to preexisting monotherapy with metoprolol in comparison with placebo plus metoprolol. The time to 1 mm ST-segment depression was increased with trimetazidine by 80s and was significantly greater than that recorded in the placebo group (465+/-143.8s vs 385.1+/-144.6s, P<0.01). The time to onset of angina was significantly greater for the group treated with trimetazidine in comparison with placebo (508.1+/-132.4 vs 433.6+/-164s, P=0.031). The total duration of exercise was significantly greater than that recorded for patients with placebo plus metoprolol (524.4+/-131.5 vs 466.9+/-144.8, P=0.048). A similarly significant observation was made regarding workload (10.1+/-2.4 vs 9+/-2.4 METs, P=0.035). The maximum ST-segment depression at peak exercise was significantly smaller in the trimetazidine group than in placebo group (1.4+/-0.8 vs 1.8+/-0.7 mm, P<0.01). The mean number of angina attacks per week was 1.7+/-2.3 for patients in the trimetazidine treated group, as compared with 3.1+/-2.9 for patients receiving placebo (P<0.01). The rate-pressure product at peak of exercise remained unchanged. The results suggest the rationale for metabolic therapy in post-revascularized patients with recurrent angina. Because no influence on heart rhythm, blood pressure, blood glucose level and excellent tolerability, trimetazidine may be also especially recommended for elderly and coronary diabetic patients, especially those with impaired left ventricular function.

Background: Implantable cardioverter-defibrillators (ICD) have been increasingly used in adult patients for the prevention of sudden cardiac death (SCD). The usefulness and feasibility of ICD implantation in children have been less well established., Aim: To analyse indications, results and safety of ICD therapy in children., Methods: ICDs were implanted in seven children, aged from 6 to 17 years. All patients underwent cardiological evaluation which included analysis of medical history, physical examination, chest X-ray, standard ECG, 24-hour Holter ECG monitoring and echocardiography., Results: In five children devices were implanted due to aborted sudden death (ventricular fibrillation) whereas in the remaining two - as a primary prevention of SCD. Three children had hypertrophic cardiomyopathy, one - dilated cardiomyopathy, one - mitral valve prolapse and QT prolongation, one - congenital long QT syndrome and the remaining patient - idiopathic ventricular tachycardia. Single-chamber devices were implanted in six children, and dual-chamber system - in one patient. In all patients endocardial leads were implanted and ICD pocket was formed under the greater pectoral muscle. During follow-up ranging between four months to 5.4 years, four children developed ventricular fibrillation or ventricular tachycardia which were terminated by appropriate ICD discharges., Conclusions: 1. ICD implantation in children is effective in the prevention of SCD. 2. In our population, the most frequent indications for device implantation were life-threatening ventricular arrhythmias occurring in patients with cardiomyopathy. 3. Cardiac arrest due to ventricular fibrillation may occur in children without a history of aborted SCD. 4. ICD implantation in children is feasible and safe.

Unlabelled: A prospective collection of clinical (history), electrocardiography (ECG), exercise electrocardiography (EE), dobutamine stress echocardiography (SE) and catheterization data was performed in 551 patients with chest pain regarded as definite or probable stable angina pectoris. All patients (65% male) without prior history of myocardial infarction undergone clinical evaluation: chest pain classification according to Diamond, ECG, EE (regarded as positive on the basis of > or = 1 mm ST-depression), SE (ischemia was defined as new or worsening wall motion abnormalities using a 16-segment model) and coronary angiography (CA):CAD was defined as > or = 50% narrowing of at least one major vessel. Sensitivity and specificity of ECG, EE, SE was calculated: and results are as follows respectively: 23% and 87%, 93% and 21%, 85% and 69%. On the basis of these results with implication of probability analysis two algorithms were developed by computer program. They incorporated pretest variables: age, gender, chest pain classification, ECG and results of one or two non-invasive tests: EE and (or) SE. The sensitivity and specificity of the algorithm is 96% and 44%., Conclusions: 1. Chest pain characteristics remains an effective tool for estimating probability of CAD. 2. The diagnostic value of resting electrocardiography in stable CAD is low. 3. SE has comparably sensitivity but significantly higher specificity than EE. 4. We demonstrated that when the likelihood of CAD is high on the basis of initial evaluation, diagnostic non-invasive testing is not indicated before CA. 5. When the probability is intermediate or low, implementation of first choice test should be different in women (SE) and men (EE).

Unlabelled: The aim of the study was to develop simple algorithm for non-invasive estimating probability of the presence of CAD to optimize indications for cardiac catheterization. A prospective collection of clinical, electrocardiography (ECG), exercise electrocardiography (EE), dobutamine stress echocardiography (SE) and catheterization data was performed. All patients (n = 551, 65% male) complaining of chest pain, without prior history of myocardial infarction undergone EE (regarded as positive on the basis of > or = 1 mm ST-depression) SE (ischemia was defined as new or worsening wall motion abnormalities using a 16-segment model) and coronary angiography (CA): CAD was defined as > or = 50% narrowing of at least one major vessel. Two algorithms were developed with the use of probability analysis by computer program which employs Bayes' theory. They incorporated pretest variables: (age, gender, chest pain classification according to Diamond), ECG and results of one or two non-invasive test: EE and (or) SE. The studied population was divided into 3 groups on the basis of pretest likelihood of CAD: 1. low (< 10%), 2. intermediate (10-70%, in man divided into intermediate--low.: 10-29% and intermediate--high: 30-70%) and 3. high (> 70%)., Results: The prevalence of CAD in studied population was 61%. The sensitivity of the algorithm is 96% and specificity was 44%. Sensitivity and specificity of EE and SE was respectively: 93%, 21% and 85%, 69%)., Conclusions: 1. An algorithm derived in our study is simple and may be useful in decision making that relates to CA. 2. We showed that when the likelihood of CAD is high on the basis of initial evaluation, diagnostic non-invasive testing is not indicated before CA, when the probability is intermediate or low, implementation of first choice test should be different in women (SE) and men (EE).

The purpose of this study was to evaluate the efficacy of sublingual nitroglycerin (NTG) during treatment with oral sustained-release isosorbide dinitrate (ISDN) in two doses: 80 mg and 120 mg. In a double-blind crossover design study 38 men with stable angina initially received either an oral placebo (OP) or ISDN. All patients received either NTG 0.5 mg or sublingual placebo (SLP) 2.5 h after OP ingestion, but only NTG 2.5 h after ISDN. The same pattern was used in the first ingestion and in long-term OP or ISDN therapy for 7 days (OP and ISDN every 6 h, and ISDN once daily). The efficacy of NTG was evaluated by analyzing walking time to ischaemia (WTI) during exercise tests performed 5 minutes after NTG or SLP administration, and the efficacy of ISDN 2 h and 6 h after oral ingestion. In the first ingestion NTG significantly improved WTI ( p < 0.0001) by 42.7% after OP, by 46.5% after 80 mg ISDN and by 52.1% after 120 mg. After long-term OP therapy NTG prolonged WTI ( p < 0.01) by 15.6%, during once-daily ISDN treatment, an 80 mg dose prolonged WTI by 22.8% and a dose of 120 mg by 36.5%. However, NTG did not improve WTI in q.i.d. therapy. Six hours after the first 80 mg ISDN ingestion WTI improved ( p < 0.0001) by 66.0%, and after 120 mg by 58.4%. Following once-daily therapy ISDN prolonged WTI ( p < 0.0001) by 27.2% after an 80 mg dose and by 36.2% after a dose of 120 mg. No improvement was observed in q.i.d. treatment. Thus, severe tolerance to ISDN abolishes the anti-ischaemic effects of NTG, and appropriate regimens of ISDN have considerable anti-anginal effects during chronic administration.

Unlabelled: The relation of stress dobutamine echocardiography test results to angiographic features was assessed in 551 patients with chest pain regarded as definite or probable stable angina pectoris. The indications for catheterization in each patient were determined at the discretion of the attending physician. All patients underwent diagnostic coronary angiography (clinically important coronary artery disease was defined as > 50 per cent narrowing of the diameter of at least one major vessel or > or = 50 per cent of the left main coronary artery) and stress dobutamine echocardiography (DSE): Ischemia was defined as new or worsening wall motion abnormalities using a 16-segment model. Sensitivity and specificity of DSE was calculated: 85% and 69% respectively for the entire group, 79% and 71% in women, 87% and 66% in men and compared with diagnostic value of the electrocardiographic exercise test (EE) in the same population. Sensitivity and specificity of the EE was respectively: 93% and 21% for the entire group, 91% and 16% in women, 94% and 27% in men., Conclusions: 1. DSE has comparable sensitivity but significantly higher specificity than EE. 2. Variables determining false positive result of DSE are as follows: mean maximal heart rate, reached % of the target heart rate and wall motion abnormalities present in single segment. 3. Variables determining false negative results are: sex (male) and one vessel disease. 4. Treatment with beta-adrenolytic agents increases incidence of nondiagnostic results of DSE.

Radiofrequency catheter ablation (RFA) in structurally normal heart ventricular arrhythmias has been found to be promising direction of develop. Authors presented the case of successful RFA of symptomatic ventricular tachycardia originating from right ventricle outflow tract (RVOT). Arrhythmogenic locus was localised basing on ECG pattern, analyze of endocardial potentials and pace mapping method. In two-year follow up she was free of symptoms and ventricular arrhythmia, no medication needed. RFA is an effective and safe therapy in ventricular tachycardia in structurally normal heart.

Background: Cardioversion of atrial fibrillation (AF) carries the risk of thromboembolic complications and, therefore, anticoagulation therapy is routinely administered before and after this procedure. In patients with permanent AF who undergo implantation of cardioverter-defibrillator (ICD), anticoagulants are usually withdrawn during the perioperative period. However, in some patients sinus rhythm may be restored during defibrillation threshold (DFT) testing which potentially may increase the risk of thromboembolic complications., Aim: To assess the frequency of sinus rhythm restoration during ICD implantation in patients with permanent AF and the rate of both thromboembolic events and local bleeding complications which may occur due to temporary withdrawal of anticoagulation therapy and its re-initiation early after the procedure., Methods: Permanent AF was present in 23 (12%) of 193 patients selected for ICD implantation. All patients received prolonged oral anticoagulation according to the generally accepted standards. Anticoagulation therapy was stopped few days before the procedure and replaced by low molecular weight heparin which was administered up to 24 hours before ICD implantation and re-initiated 12-24 hours afterwards., Results: During DFT testing sinus rhythm was restored in 5 (21.7%) patients with AF. Clinical and DFT characteristics were similar in those who were converted to sinus rhythm and those who remained in AF. No thromboembolic events were noted in either group. Local haematoma at the site of ICD implantation occurred in two (8%) patients., Conclusions: Sinus rhythm was restored in 21.7% of patients with permanent AF who underwent ICD implantation. Temporary withdrawal of anticoagulation therapy did not increase the risk of thromboembolic complications, however, its early re-initiation after implantation resulted in an increase in local bleeding complication rate.

The aim of the work was an individual assessment of the effect on coronary reserve exerted by the widely used drug from the group of nitrates--isosorbide dinitrate (ISDN) in conventional and slow-release (SR) presentations, in various doses. The patients--38 males with stable coronary disease were given orally, by randomised double blind method, conventional isosorbide dinitrate (ISDN) in 10 and 20 mg doses, and slow-release isosorbide dinitrate in 20 mg SR, 40 mg SR, 80 mg SR and 120 mg SR doses, or placebo for the first time and for 7 days: four times daily, three times daily (with a 12-hour break), twice daily (with an 18-hour break) and once daily. In each of the therapeutic methods, walking times were analysed during exercise test six hours following drug administration, that is total time (TT), time to angina (TA) and time to ischaemia (TI). A prolongation by > or = 20% of walking times after ISDN administration as compared to placebo in > 50% of patients was accepted as significant improvement. Six hours after the first administration, a significant improvement of TT, TA and TI as compared to placebo was observed in the case of ISDN 20 mg, 40 mg SR, 80 mg SR and 120 mg SR. After administration of the drugs four times daily no significant improvement was observed after any dose. After administration of the drugs thrice daily, significant improvement was found in the case of TA (80 mg SR) and TI (20 mg SR, 40 mg SR and 120 mg SR), after twice daily administration--in the case of TI (40 mg SR and 80 mg SR) and after once daily administration--in the case of TT (80 mg SR), TA (120 mg SR) and TI (40 mg SR, 80 mg SR and 120 mg SR). In > 50% of patients, the coronary activity of ISDN in higher doses persists for six hours in the case of the first time administration; continuous therapy leads to tolerance development and intermittent therapy makes possible to avoid it. Tolerance does not depend on patients' sensitivity to nitrates.

Prognostic value of exercise test in evaluation of cardiac events were examined in 326 pts after coronary artery bypass grafting (CABG). During 6 years follow up 18 (5.5%) cardiac deaths and 23 (7.1%) myocardial infarctions were observed. Chest pains persisted in 116 pts (35.6%) and 37 (11.3%) pts needed hospital treatment. Coronary and bypass angiography were performed in 25 pts (7.7%) followed by PTCA in 8 pts (2.5%) and CABG in 5 (1.5%) pts. Exercise duration and maximal work capacity in exercise tests were significantly lower in pts with cardiac events. Reasons of exercise termination: ST segment depression, heart rate and blood pressure values were not different in pts with and without cardiac events and didn't have prognostic value. Patients with cardiac events had significantly reduced left ventricle function. The value of ejection fraction influenced significantly relative risk of cardiac death (p < 0.05).