Search

OBJECTIVES: The purpose of this study is to determine whether, in patients with atrial fibrillation (AF) undergoing cardiac resynchronization therapy (CRT), atrioventricular junction ablation (AVJA) is associated with a better outcome than treatment with rate-slowing drugs. BACKGROUND: Different trials have demonstrated that CRT is effective in treating heart failure (HF) patients who are in sinus rhythm (SR). No trials have addressed whether CRT confers similar benefits on AF patients, with or without AVJA. METHODS: The clinical outcomes of CRT for patients with permanent AF undergoing CRT combined with either AVJA (n = 443) or rate-slowing drugs (n = 895) were compared with those of SR patients (n = 6,046). RESULTS: Median follow-up was 37 months. Total mortality (6.8 vs. 6.1 per 100 person-years) and cardiac mortality (4.2 vs. 4.0) were similar for patients with AF+AVJA and patients in SR (both p = NS). In contrast, the AF+drugs group had a higher total and cardiac mortality than the SR group and the AF+AVJA group (11.3 and 8.1, respectively; p < 0.001). On multivariable analysis, AF+AVJA had total mortality (hazard ratio [HR]: 0.93, 95% confidence interval [CI]: 0.74 to 1.67) and cardiac mortality (HR: 0.88, 95% CI: 0.66 to 1.17) similar to that of the SR group, independent of known confounders. The AF+drugs group, however, had a higher total mortality (HR: 1.52, 95% CI: 1.26 to 1.82) and cardiac mortality (HR: 1.57, 95% CI: 1.27 to 1.94) than both the SR group and the AF+AVJA group (both p < 0.001). CONCLUSIONS: Long-term survival after CRT among patients with AF+AVJA is similar to that observed among patients in SR. Mortality is higher for AF patients treated with rate-slowing drugs. Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

The purpose of this study is to assess the incremental value of tissue Doppler (TDI) derived displacement curves (TDint) compared to TDI velocity curves (TDvel) for the evaluation of left ventricular (LV) dyssynchrony (LVD). About 25 patients (pts.) with systolic heart failure were studied by TDvel and TDint. Four TDI sample volumes were placed at the basal and four at the mid ventricular myocardium, utilising two imaging planes. LV dyssynchrony (LVD) was defined as an interregional delay of >40 ms corrected for heart rate. 10 pts. had synchronous contraction, 15 pts. LVD as defined by two experts (EC). To determine diagnostic accuracy and intra-observer variability two identical sets of 100 documents (25 pts. × two imaging planes × two modalities) were produced and presented in random order to one trained (TR) and two untrained (UR) readers. The TR more frequently classified documents as unreadable (7.5 vs. 3.5%, P < 0.05) but more often as correct, i.e., consistent with EC (72.0 vs. 57.8%, P < 0.001). 8.7% of the documents were classified as unreadable using TDvel, 1.0% when applying TDint (P < 0.001). The mean value of correct classification of all 3 readers was 54.3% (TDvel only), 70.7% (TDint only), and 77.7% (combining both modalities), (P < 0.001). The kappa value for TR and TDint was 0.68, for TDvel 0.29. For UR, kappa did not differ (TDint: 0.58; TDvel 0.51). TDint is superior to TDvel in accuracy, reproducibility, and applicability for skilled and unskilled investigators when evaluating LVD by TDI. The combined application of TDint and TDvel is optimal.

Background and aims Sleep disordered breathing (SDB), especially Cheyne–Stokes respiration (CSR) is common in patients with chronic heart failure (CHF). Adaptive servoventilation (ASV) was recently introduced to treat CSR in CHF. The aim of this study was to investigate the effects of ASV on CSR and CHF parameters. Methods In 29 male patients (63.9±9 years, NYHA≥II, left ventricular ejection fraction [LV-EF]≤40%), cardiorespiratory polygraphy, cardiopulmonary exercise (CPX) testing, and echocardiography were performed and concentrations of NT-proBNP determined before and after 5.8±3.5 months (median 5.7 months) of ASV (AutoSet CS™2, ResMed) treatment. All patients also received guideline-driven CHF therapy. Results Apnoea–hypopnoea-index was reduced from 37.4±9.4/h to 3.9±4.1/h (p

Summary Aim: Cardiac resynchronisation therapy (CRT) has been shown to improve haemodynamics and clinical symptoms in heart failure patients. The present study evaluated the effects of a 4-month CRT on myocardial blood flow (MBF) at rest, after vasodilation and on myocardial oxygen consumption (MVO2). Patients, Methods: We studied 16 patients with idiopathic dilated cardiomyopathy prior to and during CRT performed as biventricular pacing. Resting MBF and MVO2 were determined from an 11C-acetate PET study and vasodilator MBF from a 13N-ammonia study. Results: MBF at rest (0.55 ± 0.10 ml/min/g), after vasodilation (1.20 ± 0.45 ml/min/g), and MVO2 (0.082 ± 0.014/min) did not change by mid-term CRT at a global level (0.57 ± 0.11 ml/min/g; 1.32 ± 0.49 ml/min/g; 0.085 ± 0.018/min), whereas the rate pressure product (RPP) normalised MVO2 decreased from 0.104 ± 0.024 to 0.086 ± 0.018/min (p = 0.02). At baseline, the regional analysis revealed significantly higher values for all parameters in the lateral wall than for those in the other walls. Under CRT the regional differences between the resting parameters equalised and all parameters showed significant lower coefficients of variation. Conclusion: Effects of mid-term CRT on resting MBF, vasodilator MBF and MVO2 occur at a regional level. The resynchronisation is associated with a more homogenous distribution pattern of these parameters among the myocardial walls. Substantial alterations to global MBF at rest, after vasodilation or to MVO2 are not detectable. Regarding the RPP normalised MVO2, there is evidence of improved ventricular efficiency through CRT.

Several studies on the acute effect of cardiac resynchronization in patients with advanced heart failure (HF) and left bundle branch block (LBBB) have shown that left and biventricular stimulation increase pulse pressure and contractility, while patients with a QRS complex 150 ms underwent right, left and biventricular stimulation at different AV delays. Acute response was defined as > or =10% pulse pressure increase. 165 of 188 patients (88%) in sinus rhythm (47 women, mean age 62.5+/-10 years, ejection fraction 23+/-8%, NYHA class 3.1+/-0.3) were regarded acute responders. 10% of 103 patients with dilated cardiomyopathy and 16.5% of 79 patients with coronary artery disease were considered non-responders. 29 patients (81%) with 2 posterolateral veins were acute responders with 10 of them (33%) being responders in only one vein. 54 patients had a higher pulse pressure increase (10.7+/-10.6%) with atrio-left ventricular stimulation, 48 patients with atrio-biventricular stimulation (9.8+/-6.4%). At one-year follow-up, heart failure had significantly (p

Aims Experimental studies indicated unfavourable effects on myocardial energetics and efficiency under asynchronous ventricular stimulation, also shown for left bundle branch block (LBBB) pattern. We noninvasively analyzed the effects on myocardial oxygen consumption (MVO2), perfusion (MBF) and pressure work efficiency by positron emission tomography (PET) before and after resynchronization therapy (CRT) in 31 patients with dilated cardiomyopathy (DCM) and LBBB. Methods 31 patients (19 males, 12 females) with DCM were studied at baseline and 3–4 months follow-up. Baseline characteristics: age 61±7 years; NYHA class 3.0±0.4, ejection fraction 22.1±7.1%, QRS duration 187±19 ms. MVO2 and MBF were measured from 11C-acetate kinetics with PET by a one-compartment model. MVO2 and MBF were normalized to rate pressure product (RPP) to account for different pressure loads and predicted energy demands. Results Global MVO2 assessed from 11C-acetate clearance did not change significantly between baseline and follow-up (0.080±0.015/min vs. 0.082±0.020/min). RPP-normalized MVO2 significantly decreased after CRT (0.072±0.018/min) vs. baseline (0.081±0.017/min; \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P{

Resynchronization of segmental left ventricular mechanics as well as re-coordination of both atrio-ventricular and inter-ventricular contraction are potential mechanisms responsible for the clinical benefit observed in patients with advanced congestive heart failure treated by cardiac resynchronization therapy (CRT). Initially electrical conduction problems, in the majority of cases a left bundle branch block (LBBB), were considered the target for CRT. However, growing experience with CRT in different patient populations including those with only a mild degree of conduction disturbance, and improved cardiac imaging utilizing the tissue Doppler approach have shown the complexity of CRT and the usefulness of sophisticated echocardiographic imaging techniques for therapeutic decision making.

In patients with systolic heart failure the assessment of peak oxygen consumption during cardiopulmonary exercise (CPX) testing provides an objective measure of functional capacity and important prognostic information. Several studies in pacemaker therapy and in cardiac resynchronization therapy (CRT) have used peak oxygen uptake as an endpoint. This article reviews the impact of CPX testing on patient selection for CRT.

BACKGROUND AND INTRODUCTION Cardiac resynchronization therapy (CRT) is a promising non-pharmacological treatment option for patients (pts) with severe severe heart failure (CHF), systolic left ventricular (LV) dysfunction, and ventricular conduction abnormalities (VCA). Pt selection for CRT, however, is still controversial. Tissue Doppler echocardiography (TDE) can be used to analyze regional wall motion with high temporal resolution. PATIENTS AND METHODS In 33 CHF pts with VCA (QRS width > or =140 ms) and 20 normal probands, left and right ventricular (RV) filling and emptying were analyzed by flow and tissue Doppler to assess regional (anterior, lateral, inferior, and septal) asynchrony within the LV as well as asynchrony between the RVand LV. All time measurements were corrected for a heart rate of 60 bpm. Results Maximum interventricular and segmental intraventricular delay was 30 ms in the normals. LV asynchrony, defined as a regional delay of > or =40 ms, was found in 29/33 (88%) of the CHF pts, in 4 cases there was synchronous LV contraction despite VCA. In the pts with LV asynchrony, 22 (67%) showed the maximum delay in the lateral wall, 7 (21%) in the septum. Inter- and intra-ventricular asynchrony correlated weakly. CONCLUSIONS In many CHF pts with VCA, there is a delay both between the two ventricles, and among different LV regions. Predominantly but not exclusively, the LV lateral wall shows the maximum intra-LV delay. Some CHF pts, however, seem to have a synchronous LV contraction despite VCA. TDE thus adds important information for pt selection with respect to CRT.

Our experience with 121 coronary vein (CV) leads in 116 patients shows that CV leads are the leads of choice for pacing the left ventricle (LV). The information gained from pre-operative venous angiography permits individual selection of the most appropriate lead model for each case. The use of steerable electrophysiology catheters facilitates guide catheter cannulation of the coronary sinus (CS) when the anatomy is difficult and reduces the risk of complications. By selecting the CV lead model most suitable for each individual patient, we achieved successful implantation in 99.1% of patients. In this day and age, epicardial electrodes should be restricted to cases with CS anomalies which make CS cannulation impossible, and to LV lead implantation during heart surgery.

Hardware-related complications in implantable cardioverter/defibrillators (ICD) are still a common problem. Identifying underlying reasons becomes more and more difficult as the complexity of ICD systems increases. We report a patient with a dual chamber ICD (DDD-ICD) who suffered multiple complications. These included: ventricular oversensing causing inappropriate shocks and episodes of asystole; an insulation defect resulting in ineffective shocks as a consequence of a short circuit between the active can device and a defective high voltage cable; and device dysfunction requiring several hospitalizations and operative system revisions.

To the Editor: Sleep-disordered breathing (SDB) is associated with an increasing mortality 1, 2. The prevalence of SDB, in particular central sleep apnoea and Cheyne–Stokes respiration, is remarkably high in heart failure patients 3. Therefore, screening for SDB in heart failure patients is an emerging clinical problem. Waiting times for in-hospital polysomnography (PSG), which still represents the gold standard for SDB diagnosis, are increasing. Consequently, cardiorespiratory polygraphy (PG) devices for the diagnosis of SDB have been introduced. Two studies of PG devices have previously been published in the European Respiratory Journal . Dingli et al. 4 compared data of PSG with those obtained with a portable PG device (Embletta: Medcare, Reykjavik, Iceland) to detect obstructive sleep apnoea. Using simultaneous measurements they found a close agreement in …

Mitral regurgitation (MR) can be found in a sizeable percentage of patients with chronic congestive heart failure (CHF) and systolic left ventricular (LV) dysfunction despite a structurally normal valve. This functional or secondary regurgitation results from a dysbalance between closing and opening forces on the mitral leaflets due to reduced LV contractility, geometric distortion of the subvalvular apparatus, and global dilatation of the left ventricle and the mitral annulus. MR in LV dysfunction has a negative impact on both symptoms and prognosis. Surgical correction of secondary MR remained controversial although it was found to be technically feasible and to provide symptomatic benefit in some (mostly) mono-center series. Cardiac resynchronization therapy (CRT) was also found to improve secondary mitral regurgitation. However, the prediction in which patient significant secondary MR will improve with CRT is largely unresolved. The following paper reviews the available data concerning the two major interventional options for significant secondary MR in patients with CHF and systolic LV dysfunction, i.e. mitral valve surgery vs. CRT, and describes our institutional approach to this problem.

The prevalence of sleep-disordered breathing (SDB) in patients with chronic heart failure seems to be remarkably high, but existing studies are based on small cohorts of patients who were not receiving guideline-based drug treatment for heart failure. The aim of this study was to investigate the prevalence of SDB in patients with ischemic (ICM) or non-ischemic (DCM) cardiomyopathy.A total of 647 consecutive patients (130 females, 517 males; mean age 63.23 10.4 years) in stable, symptomatic chronic heart failure (NYHA class at least II) and with impaired systolic left ventricular function (ejection fractionor = 40%) were screened by cardiorespiratory polygraphy for the presence and type of SDB. Sleep apnea was classified as obstructive (OSA) or central (CSA) according to the majority of events, and as ICM or DCM according to the results of current left heart catheterization. SDB was defined according to the apnea-hypopnea index (AHI) as: no SDB:or = 5/h, mild: 6 -14/h, moderate: 15-29/h, and severeor = 30/h.Prevalence of SDB was 70% among DCM and 82% among ICM patients (p0.05). Central sleep apnea was found in 32% of DCM and 46% of ICM patients, obstructive sleep apnea in 38% of DCM and 36% of ICM patients. Moderate (15.7% vs. 9.9%, p0.05) and severe central sleep apnea (24.4% vs. 15.5%, p0.05) was documented more often in ICM than DCM patients. Severity of obstructive sleep apnea was similar in ICM and DCM patients. ICM patients were older than DCM patients (66.4 11 years vs. 66.0 9.0 years, p0.01) and in general presented with a greater impairment of cardiopulmonary function.There is a high prevalence of SDB in patients in chronic heart failure. Central sleep apnea can be documented particularly in ICM patients and seems to be a marker for the severity of heart failure. Because of their prognostic implications, risk stratification and identification of patients eligible for specific SDB treatment, screening for such disorders should be part of every heart failure work-up.

Background: Securing transvenous left ventricular (LV) pacing leads without an active fixation mechanism in proximal coronary vein (CV) segments is usually challenging and frequently impossible. We investigated how active fixation leads can be safely implanted in this location, how to avoid perforating the free wall of the CV, and how to recognize and respond to perforations. Materials and Methods: In five patients with no alternative to LV pacing from proximal CV segments, 4 Fr SelectSecure (Medtronic, Minneapolis, MN, USA) leads, which have a fixed helix, were implanted through a modified 6 Fr guide catheter with a pre-shaped tip (Launcher, Medtronic). Results: Active fixation leads were successfully implanted in proximal CVs in five patients. There were no complications. Acute and chronic pacing thresholds were comparable to those of conventional CV leads. The pre-shaped guide catheter tip remains in close proximity to the myocardial aspect of the CV, directing the lead helix toward a safe implantation site. Conclusions: If only proximal CV pacing sites are available, 4 Fr SelectSecure leads can be safely implanted through a modified Launcher guide catheter, avoiding more invasive implantation techniques. Other than venous stenting or implantation of leads with retractable tines, SelectSecure leads are expected to remain extractable.

The experience of 579 patients with left ventricular pacing specific characteristics of various leads and lead types for left ventricular stimulation are reported. After describing the advantages of coronary vein (CV) leads versus epicardial lead usage for left ventricular stimulation, commercially available CV leads are introduced and discussed. Since there is no universally applicable CV lead, the individual optimal lead choice and the sequelae of erroneous lead choice are described in typical clinical examples.

Cardiac resynchronization therapy (CRT) has been shown to improve haemodynamics and clinical symptoms in heart failure patients. The present study evaluated the effects of a 4-month CRT on myocardial blood flow (MBF) at rest, after vasodilation and on myocardial oxygen consumption (MVO(2)).We studied 16 patients with idiopathic dilated cardiomyopathy prior to and during CRT performed as biventricular pacing. Resting MBF and MVO(2) were determined from an (11)C-acetate PET study and vasodilator MBF from a (13)N-ammonia study.MBF at rest (0.55 +/- 0.10 ml/min/g), after vasodilation (1.20 +/- 0.45 ml/min/g), and MVO2 (0.082 +/- 0.014/min) did not change by mid-term CRT at a global level (0.57 +/- 0.11 ml/min/g; 1.32 +/- 0.49 ml/min/g; 0.085 +/- 0.018/min), whereas the rate pressure product (RPP) normalised MVO(2) decreased from 0.104 +/- 0.024 to 0.086 +/- 0.018/min (p = 0.02). At baseline, the regional analysis revealed significantly higher values for all parameters in the lateral wall than for those in the other walls. Under CRT the regional differences between the resting parameters equalized and all parameters showed significant lower coefficients of variation.Effects of mid-term CRT on resting MBF, vasodilator MBF and MVO(2) occur at a regional level. The resynchronization is associated with a more homogenous distribution pattern of these parameters among the myocardial walls. Substantial alterations to global MBF at rest, after vasodilation or to MVO(2) are not detectable. Regarding the RPP normalised MVO(2), there is evidence of improved ventricular efficiency through CRT.

Several studies on the acute effect of cardiac resynchronization in patients with advanced heart failure (HF) and left bundle branch block (LBBB) have shown that left and biventricular stimulation increase pulse pressure and contractility, while patients with a QRS complex150 ms may deteriorate during stimulation. Patients with LBBB, severe HF and a QRS width150 ms underwent right, left and biventricular stimulation at different AV delays. Acute response was defined asor =10% pulse pressure increase. 165 of 188 patients (88%) in sinus rhythm (47 women, mean age 62.5+/-10 years, ejection fraction 23+/-8%, NYHA class 3.1+/-0.3) were regarded acute responders. 10% of 103 patients with dilated cardiomyopathy and 16.5% of 79 patients with coronary artery disease were considered non-responders. 29 patients (81%) with 2 posterolateral veins were acute responders with 10 of them (33%) being responders in only one vein. 54 patients had a higher pulse pressure increase (10.7+/-10.6%) with atrio-left ventricular stimulation, 48 patients with atrio-biventricular stimulation (9.8+/-6.4%). At one-year follow-up, heart failure had significantly (p0.0001) improved from NYHA class 3.1+/-0.4 to 2.1+/-0.7, VO(2)peak from 12.7+/-2.8 to 15.9+/-3.6 ml/min/kg. Left ventricular enddiastolic diameter being an indicator of reverse remodeling decreased from 80.5+/-10.5 to 73.3+/-13 (p0.0001). Hemodynamic testing before CRT allows for the identification of acute non-responders as well as the best mode and site of stimulation and the optimal atrioventricular delay in responders.

OBJECTIVES Retrospective analysis of five cases of coronary vein balloon angioplasty performed to allow insertion of left ventricular pacing leads. BACKGROUND Coronary vein stenoses or an insufficient vessel caliber can preclude transvenous placement of coronary vein leads. METHODS We compared our total patient population (n = 218), in whom we implanted coronary vein leads, to those five patients who required coronary vein angioplasty to allow lead placement. Standard over-the-wire coronary artery balloon angioplasty catheters were used to dilate the vessel to 2.5 mm (n = 3) or 3.5 mm (n = 2). RESULTS Transvenous lead placement succeeds in >99% of patients. Four cases of target vein stenoses and one case of a vein of insufficient caliber were successfully treated by balloon angioplasty. There were no complications. CONCLUSIONS Coronary vein angioplasty is an effective and safe technique to permit transvenous left ventricular pacing lead insertion in cases of target vein stenoses or insufficient target vein caliber.

Aims In patients with implantable cardioverterdefibrillators (ICD), the goals of lowering the defibrillation threshold (DFT) can be achieved by means of higher defibrillation safety margins, more rapid charging of capacitors, improved battery longevity, implying smaller devices. Whether an increase in the electrically active surface of ICD leads by fractal coating results in decreased DFTs is unknown. Methods and Results In this prospective randomized cross-over study the defibrillation efficacy of a novel right ventricular endocardial defibrillation electrode fractally coated with iridium was compared with an uncoated but otherwise identical electrode in 30 patients undergoing ICD implantation. In each patient, DFT testing was performed twice according to a binary search protocol introducing the two different electrodes in a random order. The mean DFT was 8·44·1 J with the fractally coated lead and 9·63·6 J using the uncoated lead. The improvement of 1·2 J was statistically not significant (P=0·11). No differences were observed between the patients with an improved DFT (n=12) and those with an unchanged or worsened DFT (n=18) concerning age, underlying cardiac disease, NYHA class, or left ventricular ejection fraction, respectively. Conclusion Increasing the electrical surface of defibrillation leads by fractal coating does not lead to a substantial clinically relevant reduction in defibrillation thresholds. Defibrillation impedance is not influenced by the increased electrical surface of the defibrillation lead. (Europace 2000; 2: 154–159)

Background In the major trials of cardiac resynchronization therapy (CRT), the survival benefit of the therapy, relative to control subjects, increases with QRS duration. In the non-CRT heart failure population, however, a wide QRS duration is associated with a shorter survival. Relative survival benefit from a therapy, however, is not synonymous with a longer absolute survival. We sought to determine whether baseline QRS duration relates to the absolute survival after CRT. Methods and Results In this prospective, longitudinal, observational study, 3,319 consecutive patients undergoing CRT (QRS 120-149 ms 26%, QRS 150-199 ms 58%, and QRS ≥200 ms 16%) were assessed in relation to mortality over 10 years. Overall mortality rates (per 100 patient-years) were 9.2%, 9.3%, and 13.3% in the 3 groups, respectively (all P P P P P = .017) and cardiac mortality (HR 1.59 [95% CI 1.14-2.24], P = .007). Conclusions At long-term follow-up, absolute overall and cardiac survival after CRT is similar in patients with a preimplant QRS duration of 120 to 149 ms and 150 to 199 ms but markedly shorter in patients with a QRS ≥200 ms.

Cardiac allograft vasculopathy (CAV) has become one of the primary obstacles to long-term survival of patients after heart transplantation. The low sensitivity of currently available noninvasive tests still remains a problem in the early diagnosis of the disease. To assess the feasibility, safety, and usefulness of dobutamine stress echocardiography as a noninvasive predictor of cardiac allograft vasculopathy, we examined 20 patients (3 female) 3-35 months after orthotopic heart transplantation. All patients underwent coronary angiography within 2 weeks of dobutamine stress echocardiography.89% of the segments examined could be evaluated for wall motion abnormalities. Under increasing doses of dobutamine (5 to max. 30 micrograms/kg/min), heart rate increased from 88 +/- 13 bpm to 141 +/- 16 bpm. and systolic blood pressure from 139 +2- 14 mm Hg to 154 +/- 28 mm Hg. Two of 4 patients with angiographically detected CAV developed new wall motion abnormalities under dobutamine; their wall motion score increased from 1.23 +/- 0.22 to 1.31 +/- 0.24. In the other patients without CAV, the wall motion score remained almost unchanged (1.01 +/- 0.3 to 1.02 +/- 0.4). Dobutamine was well tolerated, and there were no serious complications. Thus, dobutamine stress echocardiography seems to be feasible and safe in patients after heart transplantation. Our results suggest that it might be useful for the detection of cardiac allograft vasculopathy. The final determination of its clinical usefulness in the diagnosis of cardiac allograft vasculopathy needs further extensive investigations.

Ventricular arrhythmias are a frequent finding in patients with heart failure, and heart failure is a major underlying condition which is correlated to sudden death. Therefore, both sudden death and death from progression of heart failure strongly overlap. Besides long-term ECG recording, newer diagnostic techniques have been developed. The prognostic significance of the signal-averaged ECG in patients with advanced left ventricular dysfunction in the presence of coronary artery disease has been demonstrated; however, in patients with dilated cardiomyopathy, signal-averaging for detection of late potentials has not yet been clearly established as a useful diagnostic tool. Furthermore, heart period variability has been shown to correlate to overall mortality but not to a specific mechanism. Finally, programmed ventricular stimulation, though useful in patients with left ventricular dysfunction and/or heart failure in the setting of coronary artery disease, is of questionable significance in patients with dilated cardiomyopathy. With increasing degrees of left ventricular dysfunction, the efficacy of antiarrhythmic drugs decreases. On the other hand, with increasing degrees of heart failure, antiarrhythmic drugs demonstrate a greater negative inotropic effect, more frequent proarrhythmic effects, and more frequent bradyarrhythmias. Currently, several ongoing amiodarone trials are assessing different approaches of antiarrhythmic treatment in patients with heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Accelerated graft coronary atherosclerosis disease is the main reason for long-term mortality and morbidity of heart transplant recipients. The aim of this in vivo study was to evaluate coronary atherosclerotic vessel abnormalities and endothelial function using angiography, intravascular ultrasound, and intracoronary acetylcholine infusion. Fourteen patients (11 male, 3 female; mean age 49.3 years) were examined early after heart transplantation (mean interval after transplantation: 11 weeks) because of coronary artery disease (n = 8), idiopathic dilatative cardiomyopathy (n = 7), mitral valve replacement (n: 1) or left atrial filiae of a leiomyosarcoma (n = 1). Mean age of the donor hearts (female n = 8) was 29 years; 3 patients received double- and 14 patients triple-immunosuppression. All patients underwent biplane ventriculography and coronary angiography; a total of 120 coronary segments (main stem 21, left anterior descending artery 85, circumflex artery 14) was examined by intravascular ultrasound (20 MHz, 3.5 F catheters). In 13 patients, acetylcholine was infused into the proximal left anterior descending artery (0.15 microgram/min to 150.0 micrograms/min) to evaluate vasomotion within this segment. Ventriculography demonstrated regional wall abnormalities in 2 patients, angiography revealed 9 noncritical stenotic segments in 5 patients. Intravascular ultrasound detected 52 cross-sectional areas with a three-layer appearance indicating intimal thickening. Mean circumferential expansion of intimal proliferation was 192 degrees and mean intimal thickness was 0.35 mm. Only 5 segments of the sonographically pathological cross-sectional areas showed angiographic evidence of atherosclerotic lesions. After intracoronary infusion at a lower dose (0.15 and 1.5 micrograms/min) of acetylcholine, vasoconstriction was observed in 2 patients, at a dose of 15.0 and 150.0 micrograms/min in 10 patients. This response to acetylcholine did not depend on the intravascular or angiographical extent of atherosclerotic vessel abnormalities. In heart transplant recipients, coronary artery abnormalities can already be depicted at an early stage using intravascular ultrasound. The majority of patients show coronary vasoconstriction following infusion of acetylcholine at a higher dose. Further investigation is necessary to clarify whether the depicted vessel wall abnormalities can already be interpreted as newly developed graft atherosclerosis and whether abnormal vasomotion after acetylcholine is indicative of endothelial dysfunction.

To the Editors: In a recent editorial in the European Respiratory Journal , K.A. Franklin criticised the screening of heart failure patients for sleep-disordered breathing (SDB) 1. The major concern was that, to date, no beneficial effect on overall prognosis has been shown for any therapeutic option, e.g. nocturnal oxygen, continuous positive airway pressure (CPAP) or adaptive servoventilation (ASV). The Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure (CANPAP) trial was the first study to assess the effect of CPAP therapy …