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Anderson-Fabry disease (AFD) is an X-linked inherited lysosomal disease caused by a defect in the gene encoding lysosomal enzyme α-galactosidase A (GLA). Atrio-ventricular (AV) nodal conduction defects and sinus node dysfunction are common complications of the disease. It is not fully elucidated how frequently AFD is responsible for acquired AV block or sinus node dysfunction and if some AFD patients could manifest primarily with spontaneous bradycardia in general population. The purpose of study was to evaluate the prevalence of AFD in male patients with implanted permanent pacemaker (PM).The prospective multicentric screening in consecutive male patients between 35 and 65 years with implanted PM for acquired third- or second- degree type 2 AV block or symptomatic second- degree type 1 AV block or sinus node dysfunction was performed.A total of 484 patients (mean age 54 ± 12 years at time of PM implantation) were enrolled to the screening in 12 local sites in Czech Republic. Out of all patients, negative result was found in 481 (99%) subjects. In 3 cases, a GLA variant was found, classified as benign: p.Asp313Tyr, p.D313Y). Pathogenic GLA variants (classical or non-classical form) or variants of unclear significance were not detected.The prevalence of pathogenic variants causing AFD in a general population sample with implanted permanent PM for AV conduction defects or sinus node dysfunction seems to be low. Our findings do not advocate a routine screening for AFD in all adult males with clinically significant bradycardia.

Autoři originalniho textu European Heart Rhythm Society (EHRA): H. Burri, C. Starck, A. Auricchio, et al.Celosvětový narůst poctu implantovaných zařizeni zvysuje potřebu skoleni a výcviku v oblasti implantace kardiostimulatorů a implantabilnich kardioverterů-defibrilatorů. I když existuji mezinarodni doporuceni pro indikovani a programovani těchto zařizeni, zatim nebylo dosaženo konsenzu ohledně techniky implantace. Tento dokument je výsledkem systematicke reserse a přehledů literatury a konsenzu mezinarodni pracovni skupiny. Jeho cilem je vyplnit tuto mezeru vypracovani standardů pro implantaci uvedených zařizeni.

Uvod: Kardioinhibicni mechanismy jsou castou a větsinou prognosticky benigni přicinou synkop. Jejich caste rekurence vsak významně snižuji kvalitu života a mohou mit za nasledek i važne urazy. Farmakologicka i režimova nefarmakologicka lecba je větsinou neuspěsna.

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

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

The current AF definition requires recording in classical ECG or Holter ECG at least a 30-s episode of AF. According to the current definition, the presence of frequent shorter episodes of fast atrial arrhythmia or episodes of arrhythmia identified with widely used screening tools requires subsequent steps to establish a definite diagnosis of AF. The use of different clinical risk scores can help to refine target populations better. Due to the unpredictable and highly variable nature of AF episodes, a monitoring time lasting 2 weeks or longer is preferable to maximize the possibility of identifying subjects with AF. Several capabilities are currently available for AF search/screening, including devices based on plethysmographic pulse assessment, belts and vests for long-term ECG monitoring, modern Holter capabilities, and ILRs. Decision-making regarding using particular of them should depend on proof of efficacy based on published data, patient characteristics, and purpose of monitoring (screening/search). Additionally, all subjects with CIED with the possibility of atrial sensing should be carefully evaluated to identify AHREs. In large-scale screening projects, ML and AI could provide the appropriate interpretation of large databases containing the results of a giant number of participants. From the patient perspective, participation in screening has positive but also negative aspects. Therefore, each patient should be able to accept or refuse to participate in a screening programme, being fully aware of the potential benefits or hurdles of the screening. As the first step of shared decision-making, identifying a patient’s values, goals, and preferences is mandatory.

Restricted outdoor activity during COVID-19 related lockdown may accelerate heart failure (HF) progression and thereby increase cardiac arrhythmias. We analyzed the impact of March/April 2020 lockdown on physical activity and arrhythmia burden in HF patients treated with cardiac resynchronization therapy (CRT) devices with daily, automatic remote monitoring (RM) function.The study cohort included 405 HF patients enrolled in Observation of Clinical Routine Care for Heart Failure Patients Implanted with BIOTRONIK CRT Devices (BIO|STREAM.HF) registry in 16 countries, who had left ventricular ejection fraction (LVEF) ≤40% (mean 28.2 ± 6.6%) and NYHA class II/III/IV (47.9%/49.6%/2.5%) before CRT pacemaker/defibrillator implantation. The analyzed RM data comprised physical activity detected by accelerometer, mean heart rate and nocturnal rate, PP variability, percentage of biventricular pacing, atrial high rate episode (AHRE) burden, ventricular extrasystoles and tachyarrhythmias, defibrillator shocks, and number of implant interrogations (i.e., follow-ups). Intraindividual differences in RM parameters before (4-week period) versus during (4-week period) lockdown were tested for statistical significance and independent predictors were identified.There was a significant relative change in activity (mean -6.5%, p .001), AHRE burden (+17%, p = .013), and follow-up rate (-75%, p .001) during lockdown, with no significant changes in other RM parameters. Activity decreased by ≥8 min/day in 46.5% of patients; predictors were higher LVEF, lower NYHA class, no defibrillator indication, and more activity before lockdown. AHRE burden increased by ≥17 min/day in 4.7% of patients; predictors were history of atrial fibrillation, higher LVEF, higher body mass index, and activity decrease during lockdown.Unfavorable changes in physical activity, AHRE burden, and follow-up rate were observed during lockdown, but not in ventricular arrhythmia.

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

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

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

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

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

Introduction. The medicine management is considered an important area of health care, which is ensured by various healthcare professionals including nurses. Nurses gain the competence of medicines administration immediately after graduation. This competence can be applied to any area of healthcare. Even in specialized settings such as intensive care units, any additional qualification e.g. specialized education is not required. On the contrary, appropriate education is considered an important factor that could help to reduce the risk of adverse events related to medication management. Aim. The aim of this study was to analyse the students’ knowledge in this field at the end of nursing studies at bachelor level (n = 67) and specialized intensive care nursing studies at master level (n = 42). Methodology. Knowledge was assessed using a written test, which was related to the management of medicinal products administered commonly at intensive care units by qualified nurses as well as nurse specialists without distinction. From the point of view of the formal competencies of healthcare professionals, the questions were divided into three categories. Results. The mean success rate on the test was 53.4%. The highest range of knowledge was demonstrated by already qualified students at the end of specialised studies with prior work experience in ICU, the lowest by students just before graduation. The highest rating was achieved by all students in the activity-oriented category for which the responsibility lies primarily with the medical doctor, but nurses were expected to have this knowledge and participate at related activities on the basis of a physician’s order. This knowledge included also the area of clinical pharmacology. On the other hand, the lowest score was achieved by all groups of students in the category of activities that are not treated by the physician’s order, and the use of diverse knowledge from different areas was usually necessary. Conclusions. Clinical practice has an irreplaceable role for nurses in the process of qualifying education as well as lifelong learning. The extent of nursing education in medicine management, the manner of nursing training, as well as the proportion of nursing specialists in the nursing team at specialised workplaces, deserves much greater attention in terms of ensuring safe care in this area. Shifting some competencies and duties in medicine management, especially related to intravenous (IV) therapy, to less qualified healthcare professionals appears to be highly controversial and risky.

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

Uvod: Srdecni resynchronizacni lecba (SRL) je v soucasne době považovana za ucinnou a bezpecnou lecebnou metodu u pacientů s pokrocilým srdecnim selhanim. V připadě selhani endovazalniho zavedeni levokomorove (LK) elektrody je alternativou kardiochirurgicka implantace.Cile: Cilem prace bylo zhodnotit elektricke parametry kardiochirurgicky implantovaných LK elektrod a porovnat je s transvenozně implantovanými elektrodami, identifikovat přiciny selhani endovazalni implantace, srovnat klinický a echokardiografický resynchronizacni ucinek a porovnat bezpecnost obou přistupů.Metody a výsledky: U pacientů s indikaci k SRL byla LK elektroda implantovana buď endovazalně (skupina endo) nebo v připadě selhani endovazalniho přistupu, nebo jako soucast jineho kardiochirurgickeho výkonu byla elektroda implantovana epikardialně (skupina epi). Studie byla koncipovana jako studie připadů a kontrol. V každe skupině bylo zařazeno 92 pacientů (26 žen, 66 mužů) průměrneho věku 69 let (epi) a 68 let (endo). Levokomorova stimulace byla při třilete kontrole ucinna u 98,1 % pacientů ve skupině epi, resp. u 96,6 % pacientů ve skupině endo (p = NS). Stimulacni prah byl mezi oběma skupinami srovnatelný při propustěni a při třilete kontrole. Při jednoměsicni kontrole byl prah signifikantně vyssi v epi skupině (1,62 V vs. 1,06 V, p < 0,001), podobně jako při jedno- a dvoulete kontrole (1,57 V vs. 1,09 V a 1,54 V vs. 1,21 V, p < 0,001). Energetický výdej pro LK stimulaci byl u pacientů v epi skupině ve vsech casových okamžicich signifikantně vyssi. Celkova proceduralni uspěsnost endovazalni implantace cinila 94,6 %. Klinicka odpověď na SRL byla zaznamenana u 71,4 % pacientů v epi a u 68,1 % pacientů v endo skupině (p = NS). Průměrný narůst ejekcni frakce LK v absolutnich hodnotach byl v obou skupinach srovnatelný (6,0 % vs. 7,2 %, p = NS). V epi skupině byla zaznamenana signifikantně vyssi jedno- i třileta mortalita (19,0 % vs. 5,5 %, resp. 21,7 % vs. 6,5 %, p < 0,001).Zavěr: Ve střednědobem sledovani jsou epikardialni elektrody schopne ucinne LK stimulace. Energeticka narocnost epikardialni LK stimulace je vyssi. Resynchronizacni ucinek je u pacientů s epikardialni a endokardialni LK elektrodou podobný, ale mortalita pacientů s epikardialni LK elektrodou se zda být významně vyssi.

Východiska: Osetřovatelska pece u pacienta s poruchou vědomi zahrnuje různe cinnosti. Některe z nich mohou být spojeny s použitim některých lecivých připravků s mistnim ucinkem. Tradicni pojeti role sestry při podavani lecivých připravků v Ceske republice je vazano na předchozi ordinaci lekaře. Ackoli se zda, že realna praxe se může významně lisit, tento stav zatim nebyl zcela analyzovan.Cil: Cilem teto studie bylo popsat realnou praxi při podavani lecivých připravků s lokalnim ucinkem během poskytovani zakladni osetřovatelske pece na pracovistich intenzivni pece.Metodika: Kvalitativni studie se zucastnilo 25 vseobecných sester. Výzkumný vzorek byl vybran ucelově, přicemž kriteriem výběru byla jejich kvalifikace a praxe na pracovisti intenzivni pece. Sběr dat probihal formou hloubkových rozhovorů.Výsledky: Analýzou dat bylo identifikovano 5 hlavnich kategorii popisujici tuto praxi: 1) indikace připravků, 2) výběr prostředků, 3) interval použiti, 4) specifika použiti a zachazeni s připravky, 5) dokumentace. Jako hlavni oblasti osetřovatelske pece v ramci, ktere dochazi k podavani těchto lecivých připravků, byly uvaděny pece o oci, pece o dutinu ustni, a pece o kůži. Konkretni lecive připravky k zevnimu použiti použivane během osetřovatelske pece nebyly indikovany pouze lekařem. Faktory majici vliv na výběr konkretnich prostředků sestrou v realne praxi byly znacně různorode. Znalosti a zkusenosti sestry zaroveň ovlivňovaly frekvenci podani nebo použiti těchto připravků a modifikovaly způsob jejich aplikace. Zavěr: Rozsah teto praxe, stejně jako jeji vztah ke kvalitě poskytovane pece bude potřeba dale ověřit.

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

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

Introduction. Although the incidence of cardiac arrest in children is much lower than in adults, the condition is still considered a major health problem with a very low chance for survival. As in adults, the timely provision of cardiopulmonary resuscitation (CPR) in children is crucial. Current guidelines for CPR in children were published along with the guidelines for CPR in adults in 2015. As in previous years, they are based on consensus provided by International Liaison Committee on Resuscitation (ILCOR). Guidelines of particular ILCOR member councils may vary and reflect regional characteristic such as different access to health care, education methods or willingness of population to provide emergency assistance. Moreover, the conditions requiring CPR in children are characterized not only by different incidence, but also by aetiology or techniques used for different age groups. Therefore, emphasis is put on simplicity and feasibility as well as on consistency with adult guidelines to improve retention of the paediatric sequences. Nurses may be first rescuers not only in health care facilities. Better understanding of CPR guidelines might help them to improve their ability to detect conditions requiring CRP and also initiate and provide effective emergency care. Aim. The aim of this study is to compare different approaches to paediatric CPR, in particular to basic life support (BLS), used in current guidelines of different ILCOR member councils. Results and conclusions. General algorithm for adult CPR may be followed for victims of all age, but in case of children, slightly different approach might have much more favourable outcome.

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

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

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

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

Uvod: Fibrilace sini (FS) je jednou z nejcastějsich supraventrikularnich arytmii. Jeji výskyt v běžne populaci za poslednich dvacet let výrazně vzrostl. Problematika vnimani osetřovatelske pece dosud nebyla podrobně zkoumana.Cile a metody: Cilem tohoto výzkumu bylo posoudit, jak je vnimano pecovatelske chovani sestrami a pacienty u radiofrekvencni katetrove ablace (RFA) pro FS. Výzkum byl realizovan pomoci kvantitativni metody za použiti standardizovaneho dotazniku CBI-24 (Caring Behaviors Inventory).Výsledky: Výzkumný vzorek studie tvořily dva soubory: pacienti s FS podstupujici RFA (n = 264) a kardiologicke sestry (n = 92). Výzkum probihal v letech 2012-2014. Na zakladě celkoveho hodnoceni vnimani pecovatelskeho chovani v poskytovane osetřovatelske peci z pohledu pacientů a sester nebyly zjistěny statisticky významne rozdily (p = 0,15). Při vyhodnoceni jednotlivých dimenzi, tzn. "jistoty", "znalosti a dovednosti", "respektovani" a "propojenosti", bylo patrne, že statisticky signifikantni rozdil mezi sestrami a pacienty byl ve vnimani v dimenzi "znalosti a dovednosti" (p = 0,04) a v dimenzi "propojenost" (p = 0,003), jelikož pacienti lepe hodnotili osetřovatelskou peci oproti sestram.Zavěr: Pacienti po RFA FS hodnotili celkově pecovatelske chovani lepe než sestry. Sestrami byla lepe vnimana technicka zdatnost než humanistický přistup k pacientům. Pacienti u sester lepe hodnotili oblasti zaměřene na výkon než vytvořeni pocitu jistoty a bezpeci pro pacienty. Jako dalsi problematicke jevy byly identifikovany oblast komunikace a edukace.

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

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

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

Echocardiography is a basic examination in cardiology used to assess the anatomy and function of the heart. An echocardiography nurse is a health care specialist who is able to use echocardiographic equipment to obtain images of the heart. Standards for echocardiography personnel vary widely between countries. In the Czech Republic, there is no training program for nurses to carry out echocardiograms and the work is done almost exclusively by physicians. In many other countries, including the United Kingdom and the USA, specialist nurses carry out and report echocardiograms independently. In this article, we compare requirements for echocardiography nurses in different countries.

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

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

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

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

Introduction Radiofrequency catheter ablation (RFA) has recently become a routine part of atrial fibrillation (AF) treatment. The goal of our study was to determine whether the implementation of RFA of AF under general anesthesia (GA), compared to analgosedation (AS), will affect important characteristics of the ablation procedure, comfort of the patient and whether there is any clinical impact on the complication rate and the overall success of the procedure. Methods 50 patients with AF were randomized in a ratio of 1 : 1 into two groups for RFA in AS and in GA. Procedural characteristics, arrhythmia-free survival for the time of 12 months and subjective evaluation of pain tolerability of the procedure were monitored. Results Overall procedural times were comparable in GA and AS groups (111.2 ± 16.3 min vs 104.8 ± 25 min, p = NS). Time needed for preparation of patients was significantly longer in the GA group, while time needed for electrical disconnection of all pulmonary veins (PVs) was significantly shortened. Electrical isolation of the ipsilateral PVs after the last RF application was achieved in 94 % of lesions in GA and in 78 % of lesions in AS, respectively (p = 0.02). Shorter time of RF energy application to achieve electrical isolation of PVs was needed in the group of GA than in the group of AS (1 386 ± 387 s vs 1 745 ± 463 s, p = 0.005). Subjective discomfort evaluation of the procedure was more favorable in patients in the GA group. 88 % of patients in the GA group vs 68 % patients in AS (p = 0.1) had stable sinus rhythm off antiarrhythmic treatment during the 12 month period following the index procedure. While in the GA group all 3 patients with AF recurrence were willing to undergo another procedure in the GA, in the AS group only one patient out of 8 patients with AF recurrences underwent reablation. Conclusion RFA of AF performed under GA provided improved tolerance and positive perception of the procedure, higher final treatment success and improved quality of life.Key words: general anesthesia - paroxysmal atrial fibrillation - pulmonary vein isolation - radiofrequency catheter ablation.

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

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