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Aims Identification of patients with congestive heart failure at risk of sudden death remains problematic and few data are available on the prognostic implications of QT dispersion. We sought to assess the predictive value of QT dispersion for arrhythmic events in heart failure secondary to dilated cardiomyopathy or ischaemic heart disease. Methods and Results Twelve-lead ECGs calculated for QT dispersion, 24h Holter ECGs and signal-averaged ECGs were prospectively recorded in 205 heart failure patients in sinus rhythm. The 86 patients with ischaemic heart disease and the 119 with dilated cardiomyopathy were not significantly different as regards NYHA grades (51 vs 49% in grades III–IV), cardiothoracic ratio (57±7 vs 57±6%) and ejection fraction (28±8 vs 29±9%). The mean QT dispersion (66±29 vs 65±27ms), the frequency of non-sustained ventricular tachycardia (37 vs 38%) and ventricular late potentials (41 vs 40%) were not significantly different in patients with ischaemic or dilated cardiomyop-athy. QT dispersion was not significantly related to other arrhythmogenic markers. During follow-up (24±16 months), 66 patients died, 22 of them died suddenly and seven presented a spontaneous sustained ventricular tachycardia. In patients with dilated cardiomyopathy, in multivariate analysis, only a QT dispersion >80ms was an independent predictor of sudden death (RR: 4·9, 95% CI 1·4–16·8,P<0·02) and arrhythmic events (RR: 4·5, 95% CI 1·5–13·5,P<0·01). In patients with ischaemic heart disease, no studied parameter was found significantly related to sudden death or arrhythmic events. Conclusion: In congestive heart failure, abnormal QT dispersion can identify patients with dilated cardiomyopathy who are at high risk of arrhythmic events. [ABSTRACT FROM PUBLISHER]

The authors report the initial experience of an electrophysiological laboratory starting ablation for atrial fibrillation, a promising technique which is not yet widely practiced because of the risks related to the procedure. The incidence of severe complications (tamponade, pulmonary vein stenosis, ischaemic events) did not appear to be different in the first 100 procedures compared with the next 100 procedures: 3% in the two groups. The selection of patients, strict perioperative management and the initial support by confirmed operators seem to be the factors which minimise the complications rate of the procedure.

Aims: Analysis of heart rate variability is a noninvasive tool that allows to study autonomic control of the heart. Several studies have shown disturbed heart rate variability in patients with chronic heart failure (CHF). We sought to assess the prognostic value of time domain measures of heart rate variability in CHF., Methods and Results: We prospectively enrolled 190 patients with CHF in sinus rhythm, mean age 61+/-12 years, 109 (57.4 %) in NYHA class II and 81 (42.6 %) in class III or IV, mean cardiothoracic ratio 57.6+/-6.4 % and mean left ventricular ejection fraction 28.2+/-8.8 %, 85 (45 %) with ischemic and 105 (55 %) with idiopathic dilated cardiomyopathy. Time domain measures of heart rate variability were obtained from 24 h Holter ECG recordings. During follow-up (22+/-18 months), 55 patients died. In multivariate analysis, independent predictors for all-cause mortality were: ischemic heart disease, cardiothoracic ratio > or =60 % and standard deviation of all normal RR intervals <67 ms (RR=2.5, 95 % CI 1.5--4.2)., Conclusions: Depressed heart rate variability has independent prognostic value in patients with CHF.

Objective: This is a report of endovascular treatment of a case of type B thoracoabdominal aortic dissection in a patient with progressive dyspnea, dorsolumbar pain, and expanding aortic diameter over a 1-year period., Methods: Pretreatment imaging evaluation showed that the false lumen supplied only the celiac trunk. Endovascular treatment combined (1) embolization of the first segment of the celiac trunk to avoid distal back-flow into the false lumen and (2) stent grafting to occlude the initial entry tear., Results: The treatment resulted in technical and clinical success. The patient remains asymptomatic 12 months after treatment., Conclusion: Stent grafting offers an interesting therapeutic alternative to exclude the initial entry tear in aortic dissection and may be combined with other endovascular procedures.

Half of all deaths occurring in patients with heart failure are sudden deaths probably related to a malignant ventricular arrhythmia. The pathophysiological mechanisms of these arrhythmias are unclear, but left ventricular function, hypokalaemia accentuated by diuretics and treatments altering inotropism play a definite role. Because of the diversity of aetiologies generating heart failure, the multiplicity of fatal arrhythmias and the multifactorial origin of these arrhythmias, there is no formal marker for the risk of sudden death in patients with heart failure, at the present time. In addition to the NYHA classification and detection of episodes of syncope, assessment of these patients must be as complete as possible, at least including repeated evaluation of the ejection fraction, Holter ECG monitoring and detection of delayed ventricular potentials.

Sudden death accounts for about 35% of the mortality of cardiac failure and its incidence does not decrease with the use of angiotensin converting enzyme inhibitors. Non-sustained ventricular tachycardia on Holter monitoring, late ventricular potentials and tachycardia induced by programmed ventricular stimulation have no formal predictive value of sudden death, underlining the varied character of the mechanisms underlying sudden death during cardiac failure. Sustained ventricular tachycardia degenerating to ventricular fibrillation is only one of the rhythmic factors implicated together with inaugural ventricular fibrillation, bradyarrhythmias and electromechanical dissociation. The underlying cardiac disease plays a role in the initiation of the fatal arrhythmia. In coronary artery disease, recurrent acute ischaemia is the principal trigger factor in patients who often have triple vessel disease. This explains the fact that classic markers of arrhythmia in the post-infarction period, which are only the reflection of the arrhythmogenic substrate of ventricular tachycardia, usually due to reentry around the fibrous scar of the infarct, are not valid in patients with progressive ischaemic cardiomyopathy. The most effective antiarrhythmic treatment in this type of patient is the prevention of ischaemia, when possible. In primary dilated cardiomyopathy, the mechanism underlying sudden death could be different at each stage. In NYHA Stages I and II, ventricular tachyarrhythmias could play a major part in unexpected sudden death in patients whose stable haemodynamic status suggested a more prolonged survival. The value of an implantable defibrillator would seem to be proved in this group of patients, at least in secondary prevention. In Stages III and IV, ventricular arrhythmias only indicate the degree of ventricular dysfunction and sudden death may follow bradyarrhythmias and electromechanical dissociation due to the precarious haemodynamic status.

Objective: Hypertensive left ventricular hypertrophy (LVH) is associated with increased risk of arrhythmias and mortality. However, no clinical study demonstrated a significant relation between ventricular arrhythmias and mortality in systemic hypertension., Design and Methods: To evaluate the prognostic value of arrhythmogenic markers in systemic hypertension, we included between 1987 and 1993. 214 hypertensive patients, 59.1 +/- 12.8 years old, without symptomatic coronary disease, myocardial infarction, systolic dysfunction, electrolyte disturbances or antiarrhythmic therapy. At inclusion, an ECG, a 24 h Holter ECG (204 patients) with Lown classification of ventricular arrhythmias, an echocardiography (reliable in 187 patients) with left ventricular mass index and ejection fraction calculation, a SAECG (125 patients, enrolled after 1988) with ventricular late potentials (LP) were recorded. QT interval dispersion (QTd) was calculated on 12 leads standard ECG and LVH was appreciated., Results: At baseline echocardiographic LVH was recorded in 63 patients (33.7%) with normal ejection fraction (75 +/- 7.4%). Non-sustained ventricular tachycardia (Lown IVb) was found in 33 pts (16.2%) and LP in 27 patients (21.6%). After a mean follow up of 42.4 +/- 26.8 months, all-cause mortality was 11.2% (24 patients); 17 patients died of cardiac causes (7.9%); of these 9 patients (4.2%) died suddenly. In univariate analysis, age, strain pattern of LVH, advanced Lown classes and abnormal QT dispersion (> 80 ms) were significantly related to global, cardiac and sudden death (p < or = 0.01). Left ventricular mass index was closely related to cardiac mortality (p = 0.002). LP failed to predict mortality. In multivariate analysis, only Lown class IVb was an independent predictor of global and cardiac mortality, increasing the risk of global death 2.6 fold [1.2-6.0] (CI 95%) and the risk of cardiac death 3.5 fold [1.2-9.7] (CI 95%)., Conclusions: In hypertensive patients the presence of non-sustained ventricular tachycardia on 24 h Holter has a prognostic value.