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Patients with vetricular tachycardia are usually treated with antiarrhythmic drugs and ablation if the arrhythmia substrate is available for invasive treatment. Despite high efficiency of this treatment there is a significant group of patients who do not benefit from available treatment methods, either because they cannot be applied or do not allow for durable control of the disease. For that reason a novel treatment method, STereotactic Arrhythmia Radioablation (STAR) has been proposed and its safety and efficiency is extensively studied throughout the world. The method is based on irradiation of the arrhythmia substrate identified with electrophysiological examination with high-precision image-guided radiosurgical methods usually used for ablation of malignant tumors. Here we present the protocol of the first Polish study on STAR in patients with intractable ventricular tachycardia (STARVT, NCT04642963), designed to test the safety of the method. Secondary endpoints include measures of the treatment efficiency.

The electrophysiology-guided noninvasive cardiac radioablation, also known as STAR (stereotactic arrhythmia radioablation) is an emerging treatment method for persistent ventricular tachycardia. Since its first application in 2012 in Stanford Cancer Institute, and a year later in University Hospital Ostrava, Czech Republic, the authors from all around the world have published case reports and case series, and several prospective trials were established. In this article, we would like to discuss the available clinical evidence, analyze the potentially clinically relevant differences in methodology, and address some of the unique challenges that come with this treatment method.

Structural, hemodynamic, and morphological cardiac changes following Fontan operation (FO) can contribute to the development of arrhythmias and conduction disorders. Sinus node dysfunction, junction rhythms, tachyarrhythmias, and ventricular arrhythmias (VAs) are some of the commonly reported arrhythmias. Only a few studies have analyzed this condition in adults after FO. This study aimed to determine the type and prevalence of arrhythmias and conduction disorders among patients who underwent FO and were under the medical surveillance of the John Paul II Hospital in Krakow. Data for the study were obtained from 50 FO patients (mean age 24 ± 5.7 years; 28 men (56%)). The median follow-up time was 4 (2–9) years. Each patient received a physical examination, an echocardiographic assessment, and a 24 h electrocardiogram assessment. Bradyarrhythmia was diagnosed in 22 patients (44%), supraventricular tachyarrhythmias in 14 patients (28%), and VAs in 6 patients (12%). Six patients required pacemaker implantation, and three required radiofrequency catheter ablation (6%). Arrythmias is a widespread clinical problem in adults after FO. It can lead to serious haemodynamic impairment, and therefore requires early diagnosis and effective treatment with the use of modern approaches, including electrotherapy methods.

Background: Implantable cardioverter-defibrillator (ICD) therapy has been proven effective in the prevention of sudden cardiac death, but data on outcomes of ICD therapy in the young and otherwise healthy patients with long QT syndrome (LQTS) are limited. Aim: We sought to collect data on appropriate and inappropriate ICD discharges, risk factors, and ICD-related complications. Methods: All LQTS patients implanted with an ICD in 14 centres were investigated. Demographic, clinical, and ICD therapy data were collected. Results: The study included 67 patients (88% female). Median age at ICD implantation was 31 years (12–77 years). ICD indication was based on resuscitated cardiac arrest in 46 patients, syncope in 18 patients, and malignant family history in three patients. During a median follow-up of 48 months, 39 (58%) patients received one or more ICD therapies. Time to first appropriate discharge was up to 55 months. Inappropriate therapies were triggered by fast sinus rhythm, atrial fibrillation, and T-wave oversensing. No predictors of inappropriate shocks were identified. Risk factors for appropriate ICD therapy were: (1) recurrent syncope despite b-blocker treatment before ICD implantation, (2) pacemaker therapy before ICD implantation, (3) single-chamber ICD, and (4) noncompliance to b-blockers. In 38 (57%) patients, at least one complication occurred. Conclusions: ICD therapy is effective in nearly half the patient population; however, the rates of early and late complica­tions are high. Although the number of unnecessary ICD shocks and reimplantation procedures may be lowered by modern programming and increased longevity of newer ICD generators, other adverse events are less likely to be reduced.

Mezczyzne w wieku 23 lat przyjeto do szpitala po reanimacji z powodu migotania komor. Mimo wykonania tomografii komputerowej glowy, echokardiografii i koronarografii z wentrykulografią nie wykryto organicznej przyczyny zatrzymania krązenia. W warunkach podstawowych w badaniu EKG nie uwidoczniono zaburzen przewodzenia i fazy repolaryzacji w odprowadzeniach V1-V3. Wobec braku ajmaliny podjeto probe doustnej prowokacji zespolu Brugadow za pomocą prajmaliny w dawce 40 mg. Godzine po jej podaniu zaobserwowano elektrokardiograficzne cechy zespolu Brugadow typu 1, ktore osiągnely swą definitywną, klasyczną forme po 90 minutach. Pacjentowi wszczepiono kardiowerter-defibrylator. Diagnostyke w kierunku zespolu Brugadow nalezy rozwazyc po zatrzymaniu krązenia rowniez u osob bez choroby organicznej serca z prawidlowym spoczynkowym zapisem EKG.

We discuss a 56‑year‑old man with Fabry disease (FD), a genetic X‑linked glycolipid storage disorder. The patient presented at the Emergency Room in a local hospital due to tachycardia‑associated chest pain, which had occurred occasionally in the past, but on that occasion was long‑lasting (>12h) and distressing. The patient had been diagnosed with FD at the age of 42. He presented a range of symptoms characteristic for the condition, including hypertrophic cardiac myopathy with impaired left ventricular relaxation, angiokeratomas, cornea verticillata, hypohydrosis and acroparesthesia. Residual alpha‑galactosidase A activity at diagnosis was ≈3%. The Enzyme Replacement Therapy (ERT) with the agalsidase alpha was induced. A year later pacemaker implantation was performed due to sick sinus syndrome with symptomatic, severe episodes of bradycardia. The initial diagnosis was tachycardia‑associated chest pain with troponin release in the context of FD left ventricular hypertrophy. However, a decision was made to perform an urgent angiographic evaluation to exclude coronary pathology as a potential factor in the clinical picture. Coronary angiography showed a critical, flow-limiting, stenosis of the left anterior descending artery (LAD) which changed the initial type 2 myocardial infarction (MI) diagnosis to the type 1 MI. Percutaneous stent‑assisted treatment was performed with an optimal angiographic and clinical outcome. However, 5 days later the patient developed a minor left hemispheric ischaemic stroke. In conclusion, the clinical course of a rare pathology such as FD may be importantly complicated by other (more common) pathologies. Physicians, in their diagnostic and therapeutic decision‑making, need to be open to thinking beyond the patient label. JRCD 2018; 3 (7): 246–252

Background: Patients with aortic stenosis (AS) may develop heart failure even in the absence of severe valve stenosis. Our aim was to assess the contribution of systemic arterial properties and the global left ventricular afterload to graded heart failure symptoms in AS. Methods: We retrospectively reviewed medical records of 157 consecutive subjects (mean age, 71±10 years; 79 women and 78 men) hospitalized owing to moderate-to-severe degenerative AS. Exclusion criteria included more than mild aortic insufficiency or disease of another valve, atrial fibrillation, coronary artery disease, severe respiratory disease or anemia. Heart failure symptoms were graded by NYHA class at admission. Systemic arterial compliance (SAC) and valvulo-arterial impedance (Zva) were derived from routine echocardiography and blood pressure. Results: Sixty-one patients were asymptomatic, 49 presented mild (NYHA II) and 47 moderate-to-severe (NYHA III-IV) heart failure symptoms. Mild symptoms were associated with lower SAC and transvalvular gradients, while more severe exercise intolerance coincided with older age, lower systolic blood pressure, smaller aortic valve area and depressed ejection fraction. By multiple ordinal logistic regression, the severity of heart failure symptoms was related to older age, depressed ejection fraction and lower SAC. Each decrease in SAC by 0.1 ml/m² per mmHg was associated with an increased adjusted odds ratio (OR) of a patient being in one higher category of heart failure symptoms graded as no symptoms, mild exercise intolerance and advanced exercise intolerance (OR: 1.16 [95% CI, 1.01-1.35], P=0.045). Conclusions: Depressed SAC may enhance exercise intolerance irrespective of stenosis severity or left ventricular systolic function in moderate-to-severe AS. This finding supports the importance of non-valvular factors for symptomatic status in AS.

Background A percutaneous intravascular cardioverter-defibrillator (PICD) has been developed with a right ventricular (RV) single-coil lead and titanium electrodes in the superior vena cava (SVC)–brachiocephalic vein (BCV) region and the inferior vena cava (IVC). Objective To compare defibrillation thresholds (DFTs) of the PICD with those of a conventional ICD in humans. Methods Ten patients with ischemic cardiomyopathy and ejection fraction ≤35% were randomized to initial testing with either PICD or conventional ICD. A standard dual-coil lead was positioned in the RV apex. If randomized to PICD, the device was placed into the vasculature such that 1 titanium electrode was positioned in the SVC-BCV region and the second in the IVC. For PICD DFTs, the RV coil of the conventional ICD lead was connected to the PICD mandrel [shock vector: RV (+) to SVC-BCV (−) + IVC (−)]. When testing the conventional ICD, a subcutaneous pocket was formed in the left pectoralis region and the ICD was connected to the lead system and positioned in the pocket [shock vector: RV (+) to SVC (−) + active can (−)]. Each device was removed before testing with the other. A step-down binary search protocol determined the DFT, with the initial shock being 9 J. Results The mean PICD DFT was 7.6 ± 3.3 J, and the conventional ICD system demonstrated a mean DFT of 9.5 ± 4.7 J (N = 10; paired t test, P = .28). Conclusion The intravascular defibrillator has DFTs similar to those of commercially available ICDs.

Objectives The purpose of the study was to determine the efficacy and safety of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach. Background Embolic stroke is the most devastating consequence of atrial fibrillation. Exclusion of the LAA is believed to decrease the risk of embolic stroke. Methods Eighty-nine patients with atrial fibrillation were enrolled to undergo percutaneous ligation of the LAA with the LARIAT device. The catheter-based LARIAT device consists of a snare with a pre-tied suture that is guided epicardially over the LAA. LAA closure was confirmed with transesophageal echocardiography (TEE) and contrast fluoroscopy immediately, then with TEE at 1 day, 30 days, 90 days, and 1 year post-LAA ligation. Results Eighty-five (96%) of 89 patients underwent successful LAA ligation. Eighty-one of 85 patients had complete closure immediately. Three of 85 patients had a ≤2-mm residual LAA leak by TEE color Doppler evaluation. One of 85 patients had a ≤3-mm jet by TEE. There were no complications due to the device. There were 3 access-related complications (during pericardial access, n = 2; and transseptal catheterization, n = 1). Adverse events included severe pericarditis post-operatively (n = 2), late pericardial effusion (n = 1), unexplained sudden death (n = 2), and late strokes thought to be non-embolic (n = 2). At 1 month (81 of 85) and 3 months (77 of 81) post-ligation, 95% of the patients had complete LAA closure by TEE. Of the patients undergoing 1-year TEE (n = 65), there was 98% complete LAA closure, including the patients with previous leaks. Conclusions LAA closure with the LARIAT device can be performed effectively with acceptably low access complications and periprocedural adverse events in this observational study.

Atrial fibrillation (AF) is leading cardiac arrhythmia with important clinical implications. Its diagnosis is usually made on the basis on 12-lead ECG or 24-hour Holter monitoring. More and more clinical evidence supports diagnostic use of cardiac event recorders and cardiovascular implantable electronic devices (CIED). Treatment options in patients with atrial fibrillation are extensive and are based on chosen rhythm and/or rate control strategy. The use and selected contraindications to AF related pharmacotherapy, including anticoagulants are shown. Nonpharmacological treatments, comorbidities and risk factors control remain mainstay in the treatment of patients with AF. Electrical cardioversion consists important choice in rhythm control strategy. Much progress has been made in the field of catheter ablation and cardiac surgery methods. Left atrial appendage occlusion/closure may be beneficial in patients with AF. CIED are used with clinical benefits in both, rhythm and rate control. Pacemakers, implantable cardioverter-defibrillators and cardiac resynchronization therapy devices with different pacing modes have guaranteed place in the treatment of patients with AF. On the other hand, the concepts of permanent leadless cardiac pacing, atrial dyssynchrony syndrome treatment and His-bundle or para-Hisian pacing have been proposed. This review summarizes and discusses current and novel treatment options in patients with atrial fibrillation.

Brugada syndrome is an autosomal dominant genetic disease with variable expression characterized by abnormal electrocardiographic findings – right bundle branch block and ST-segment elevation in the anterior precordial leads, without evidence of structural heart disease. Individuals affected by the disease have an increased risk of ventricular tachyarrhythmias and sudden cardiac death (SCD). We present a case of a 33-year old man who was admitted to cardiology department after sudden cardiac arrest due to ventricular fibrillation. Evaluation for a structural heart disease was negative and routine tests did not reveal the cause of cardiac arrest. Retrospective evaluation of the patient electrocardiograms showed changes consistent with Brugada type 2 pattern that were variable over time. Performed pharmacological challenge with sodium channel blocker – ajmaline – provided an ambiguous result. Nevertheless, the patient was qualified for an implantable cardioverter defibrillator implantation as a secondary SCD prophylaxis. He underwent the procedure without complications and was discharged home in good general condition without symptoms.

A recent experimental study suggested that proton pump inhibitors (PPI), widely used to prevent gastroduodenal complications of dual antiplatelet therapy, may increase the accumulation of the endogenous nitric oxide synthesis antagonist asymmetric dimethylarginine (ADMA), an adverse outcome predictor. Our aim was to assess the effect of PPI usage on circulating ADMA in coronary artery disease (CAD). Plasma ADMA levels were compared according to PPI use for ≥1 month prior to admission in 128 previously described non-diabetic men with stable CAD who were free of heart failure or other coexistent diseases. Patients on PPI tended to be older and with insignificantly lower estimated glomerular filtration rate (GFR). PPI use was not associated with any effect on plasma ADMA (0.51 ± 0.11 (SD) vs. 0.50 ± 0.10 µmol/L for those with PPI (n = 53) and without PPI (n = 75), respectively; p = 0.7). Additionally, plasma ADMA did not differ between PPI users and non-users stratified by a history of current smoking, CAD severity or extent. The adjustment for patients’ age and GFR did not substantially change the results. Thus, PPI usage does not appear to affect circulating ADMA in non-diabetic men with stable CAD. Whether novel mechanisms of adverse PPI effects on the vasculature can be translated into clinical conditions, requires further studies.

We present a complication of the infected pacing system extraction by lobular pneumonia in a 73-year-old female patient. The pacing system involved DDD pacemaker, atrial and ventricular endocardial leads implanted 12 year beforehand. The defect of the atrial lead emerged during the pacemaker replacement 4 years ago. The diagnosis of the injury cause and its reparation were not undertaken at that time. An interruption of the atrial lead which resulted in the formation of a loop inside the cardiac chamber was found when purulant pacemaker pocket infection had been diagnosed. The patient was referred for the pacing system extraction after preoperative specific antibiotic treatment. After a long-lasting, difficult, two-step leads extraction procedure, pneumonia developed. An echocardiogram revealed enlargement of the right atrium and ventricle, with elevated pulmonary artery pressure up to 40 mmHg. An atypical chest X-ray with the presence of a large pleural liquid volume led to the work-up of hemorrhagic complications and postponed the antithrombotic therapy. With the delay of 1.5 month the pulmonary scintigraphy showed features of pulmonary embolism. The embolism was most likely caused by a vegetation mobilized from the endocardial lead and/or endocardium during the extraction maneuvers. Before the surgery, the vegetations attached to the leads or to the endocardium had not been visualized. Anticoagulant therapy with antivitamins K was successful, which resulted in the pulmonary pressure normalization. The patient has remained in a good condition for the next 3 months of follow-up.

Only several world-leading centers have summarized outcomes of invasive therapy of ventricular arrhythmia.The aim of the work is to compare the effectiveness of RF ablation of ventricular arrhythmia.183 patients (111 males, mean age 50 ± 17) underwent RF ablation of ventricular ecopic beats (VEB). Retrospective analysis of procedural protocols, in- and outpatient medical records was performed. RF ablation was done using electroanatomical CARTO system, Pacemapping or both methods (CARTO + Pacemapping).Long-term ablation effectiveness was as follows: CARTO - success rate assessed during the ablation procedure was 84,4%; during post operation period follow-up 70,3%, and in long term followup 71,1%; Pacemaping-success rate assessed during the ablation procedure was 91,7%; during post operation period follow-up 83,3%, and in long term follow-up 75,0%; CARTO + Pacemaping - success rate assessed during the ablation procedure was 85,4%; during post operation period follow-up 70,8%, and in long term follow-up 77,1%. Mean amount of VEBs per day before ablation was 18750 ± 12560 (2435 to 50000) and after ablation 575 ± 428 (0 to 1550), p0.001. Best results were achieved in cases where both mapping techniques were used in combination. Among clinical parameters affecting long-term ablation effectiveness, only hypertension was found to significantly decrease long-term effectiveness of VEB ablation. Only ablation temperature and energy affected long-term therapy effect significantly (p0,0014; HR=0,84). After the ablation, there was improvement of the left-ventricular end-diastolic diameter and ejection fraction.Long-term success of ventricular extrasystoly ablation in combined method (CARTO+Pacemapping) was slightly higher compared in CARTO technique and in Pacemapping technique. Classic RF ablation is effective and safe, therefore it can be considered as first-line therapy. In ablation, precise localization of arrhythmic focus is the most important factor. Ablation temperature and energy were significantly correlated to long-term ablation effectiveness. After ventricular extrasystoly ablation, left ventricle ejection fraction increased and left ventricle end-diastolic diameter decreased. Hypertension significantly decreased long-term effectiveness of ventricular extrasystoly ablation.

Przedstawiono trudności w interpretacji rytmu z szerokimi zespolami QRS u 25-letniej pacjentki z preekscytacją komor oraz okresowo wystepującym przyspieszonym rytmem z szerokimi zespolami QRS (94/min), spelniającym w elektrokardiogramie (EKG) morfologiczne kryteria rytmu komorowego, bez poprzedzających zalamkow P. Wstepne trudności w interpretacji EKG wyjaśnilo wykonane badanie elektrofizjologiczne, w ktorym wykazano nadkomorowe pochodzenie rytmu przewodzonego do komor przez droge dodatkową. Wykonanie ablacji prądem o czestotliwości radiowej drogi dodatkowej odslonilo okresowo wystepujący rytm dolno-przedsionkowy pochodzący z okolic mieśniowki zatoki wiencowej. Bliskie sąsiedztwo rytmu przedsionkowego i drogi dodatkowej skutkowalo natychmiastowym przewodzeniem do komor, doskonale imitując rytm komorowy. Opisany przypadek zwraca uwage na potrzebe uwzglednienia rytmu pozazatokowego z preekcytacją komor w toku diagnostyki rytmu z szerokimi zespolami QRS.

A 56-year-old woman, previously healthy, was hospitalized after an episode of ventricular tachycardia in the course of infection. In view of the fulminant course of heart failure the patient was connected to an extracorporeal membrane oxygenation (ECMO) system. After 3 weeks of treatment with ECMO the patient received a heart transplant. A histopathological examination of the tissues of the explanted heart revealed giant cell myocarditis. The patient was treated with immunosuppression based on induction therapy followed by a standard regimen with steroids. Currently, the patient remains in good general condition with an left ventricular ejection fraction of 60%.

Arrhythmogenic right ventricular dysplasia is a genetic disease, in which pathologic fibrofatty tissue occurs mainly in the right ventricle of the heart. Changes in heart muscle predispose to arrhythmias such as ventricular tachycardia or ventricular fibrillation, so these patients are candidates for implantation of implantable cardioverter-defibrillator. Furthermore, depending on the indication, RF-ablation is performed, which, due to changes in morphology of the heart muscle, are often difficult and of uncertain efficacy. In this paper we present a case of a patient with implanted cardioverter-defibrillator for primary prevention of sudden cardiac death. Initially, the patient experienced only complications related to the possession of the device, but due to the significant progression of the disease and symptoms, the device turned out to be necessary. In addition, the patient underwent complex electrophysiology procedures to control recurrent episodes of ventricular tachycardia. Treatment of cardiac arrhythmias in arrhythmogenic right ventricular dysplasia is problematic both because of the inability to predict the course of disease in asymptomatic patients, as well as due to the difficulty of carrying out effective ablation of arrhythmia foci in morphologically altered myocardium.

Background The arrhythmic role of the left atrial appendage (LAA) has been implicated in the maintenance of persistent atrial fibrillation. LAA isolation with catheter ablation has been successful but is limited by the risk of tamponade and electromechanical dissociation with the potential for LAA thrombus formation. Objective To assess whether LAA ligation results in LAA electrical isolation. Methods A total of 68 patients with contraindication or intolerance to oral anticoagulation therapy underwent LAA ligation with the LARIAT suture delivery device. Patients had unipolar [n = 30(44%)] or bipolar [n = 38(56%)] voltage measurements pre- and post-LAA ligation. Results All 68 patients underwent successful LAA ligation. There was a statistically significant reduction in the mean LAA voltage from pre-ligation (unipolar pre-ligation voltage 1.1 ± 0.53 mV; bipolar pre-ligation voltage 4.7 ± 2.83 mV) to post-ligation (unipolar post-ligation voltage 0.3 ± 0.38 mV; bipolar post-ligation voltage 0.6 ± 0.27 mV). Ninety-four percent of the patients had a reduction in the LAA voltage after the closure of the snare, with 10 of 30 (33%) of the patients having complete elimination of LAA voltage with the initial tightening of the suture. Pacing from the LAA after the closure of the snare resulted in lack of capture of the left atrium in 28 of 31 patients. Conclusions The snare closure of the LAA using the LARIAT device produces an acute reduction in the LAA voltage and inhibits the capture of the left atrium during LAA pacing. Future studies are needed to determine whether LAA ligation affects atrial fibrillation burden.

Introduction A percutaneously placed implantable intravascular defibrillator (PICD) has been developed with a right ventricular (RV) single-coil lead and titanium electrodes in the superior vena cava (SVC) and the inferior vena cava (IVC). This study evaluated implant techniques, device stability, and anchor histology of the PICD over 9 months in a canine model. Methods Twenty-four hounds (wt = 30–55 kg) were anesthetized and a custom sheath introduced into the right femoral vein. The PICD was advanced over a wire and positioned with the titanium electrodes (cathodes) in the SVC and the IVC. A nitinol anchor secured the device in the jugular. The RV lead was positioned in the RV apex and screwed into place. The catheters, wires, and sheath were removed with an average implant time of 14 minutes. In one group of animals (n = 13), serial venograms were performed at 7 days, 14 days, and 28 days. In a second group (n = 6) and third group (n = 5), venograms were also performed at 90 days and 270 days, respectively. Six canines were sacrificed and anchor histologic examination done at 90 days. Results All implants were successful with no surgical complications observed. Devices (N = 24) remained appropriately positioned with no anchor migration. Histology at 90 days showed 98% endothelialization of the anchor. Venograms revealed patent IVC and jugular veins in all animals at every time point examined. Conclusions The PICD can be rapidly and chronically implanted in animals. Long-term intravascular defibrillator placement is feasible in a canine model.

Increased heart rate at rest (HR) is a risk factor of sudden cardiac death (SCD) and cardiovascular mortality.Retrospective assessment of increased HR influence on mortality and ventricular tachycardia followed by adequate ICD intervention.350 patients (52 female, 298 male), mean age 65.1+/-10.1 years (22-89 years) with ICD without resynchronization function implanted between 2008 and 2010 were examined. ECGs at rest were used to determine HR. In case of atrial fibrillation, mean value of 2 shortest and longest RR intervals was calculated to determine HR.During the mean observation period of 387+/-300 days, 73 patients (66 male, 7 female), mean age 63.7+/-12.2 years (22-89) had an arrhythmial/intervention, and 46 patients (9 male, 37 feamle), mean age 68.8+/-10.3 years (43-86) died. To optimize sensitivity and specificity of HR, cut off point was established using ROC curve (79/min). Number of patients with HR79/min was significantly higher (64.7% vs 19,1%, p0.022) in the group of patients with arrhyth-mialintervention vs no arrhythmial/intervention, and in dead vs alive patients (73.9% vs 19.5%, p0,001). Kaplan-Meier univariate analysis proved, that HRor =79/min was an important factor increasing probability of survival (p0.001) and arrhythmial/intervention free live (p0.012). HR79/ min particularly predisposed to fast ventricular arrhythmias and interventions - CV (p0.092). In Cox multivariate analysis, HRor =79/min was a protective factor only in death risk (HR=0.2362, 95%CI=0.1094-0.5099, p0.0002).An important factor increasing probability of survival without ventricular arrhythmia or death was a mean heart rate below 79/min. The cycle length of the baseline rhythm determine the arrhythmia cycle length.

There are few studies on the immediate and long term efficacy of ablation of ventricular ectopic beat (VEB) using different mapping systems arrhythmia. The aim of the study was to evaluate the efficacy of intraoperative, immediate and late outcome of RF ablation ventricular arrhythmias and a comparison of methods for identification and ablation of arrhythmia substrate.In 88 patients, average age 50,8+/-17,8 years old (16 to 90) with performed RF ablation of VEB from the left ventricular and (or) right ventricular. We retrospectively evaluated surgical reports and clinical records. The number of applications, energy, temperature, duration of application, impedance, radiation exposure to X-ray and the presence of obesity, myocardial infarction were evaluated. RF ablation was performed using the method of Carto or Carto and Pace mapping stimulation or Pace mapping stimulation alone. Patients were divided into 3 groups: group A - long result was positive after ablation, group B - treatment was ineffective, group C - ad hoc and postoperative result were positive but long result was negative.The observation time was 30+/-11 months (3-48). An ad hoc positive end point of VEB ablation was 86%, postoperative 74%, and a distant 60%, respectively. There was 13% ineffective treatments. Carto system was used in 53 patients. In 6 (11%, group B) treatment was ineffective, the remaining 47 patients achieved complete success in 31 (58%, group A) cases, while temporary success in 16 (30%, group C) cases. The relationship between the average temperature of 57 Celcius degree during ablation (HR = 1.148, regression = 0.138, p0.039) and the effectiveness of treatment was found. No statistical significance between the assessment of the effectiveness of ablation of arrhythmias and the location of the substrate were found but there was no statistical difference between the analyzed parameters and the technical and clinical effectiveness of ablation in the method of localization of arrythmia. The highest percentage of ablation failures in follow-up concerned the technique Carto alone (34%), the most effective was combined techniques adding Pace mapping plus Carto (76% succes rate long after ablation).To find substrate of arrhythmia to ablate operator should be guided by stimulation mapping and electroanatomical map in order to achieve distant effect of operation. The only significant parameter correlating with the distant ablation efficacy was the mean temperature of the ablation. While using Carto to ablate arrythmia most important role is played by the precise location of the arrhythmia substrate rather than increasing the temperature during ablation.

The purpose of the study was to determine the efficacy and safety of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach.Embolic stroke is the most devastating consequence of atrial fibrillation. Exclusion of the LAA is believed to decrease the risk of embolic stroke.Eighty-nine patients with atrial fibrillation were enrolled to undergo percutaneous ligation of the LAA with the LARIAT device. The catheter-based LARIAT device consists of a snare with a pre-tied suture that is guided epicardially over the LAA. LAA closure was confirmed with transesophageal echocardiography (TEE) and contrast fluoroscopy immediately, then with TEE at 1 day, 30 days, 90 days, and 1 year post-LAA ligation.Eighty-five (96%) of 89 patients underwent successful LAA ligation. Eighty-one of 85 patients had complete closure immediately. Three of 85 patients had a ≤ 2-mm residual LAA leak by TEE color Doppler evaluation. One of 85 patients had a ≤ 3-mm jet by TEE. There were no complications due to the device. There were 3 access-related complications (during pericardial access, n = 2; and transseptal catheterization, n = 1). Adverse events included severe pericarditis post-operatively (n = 2), late pericardial effusion (n = 1), unexplained sudden death (n = 2), and late strokes thought to be non-embolic (n = 2). At 1 month (81 of 85) and 3 months (77 of 81) post-ligation, 95% of the patients had complete LAA closure by TEE. Of the patients undergoing 1-year TEE (n = 65), there was 98% complete LAA closure, including the patients with previous leaks.LAA closure with the LARIAT device can be performed effectively with acceptably low access complications and periprocedural adverse events in this observational study.

The Ex-Maze III procedure is a recently developed surgical method for ablation of atrial fibrillation (AF). The procedure uses epicardial approach and can be performed on the beating heart.To evaluate the efficacy and safety of Ex-Maze III ablation in patients undergoing mitral valve (MV) surgery.The study group consisted of 20 consecutive patients (8 males, mean age 67 years) who underwent MV surgery and had concomitant AF. Eighteen patients were diagnosed with long-standing permanent AF and 2 patients with paroxysmal AF. The mean duration of AF was 9.5 years prior to surgery. All the patients underwent the Ex-Maze III procedure on the beating heart immediately before the MV surgery (MV replacement in 17 patients and MV repair in 3 patients). The patients were followed 1, 3, 6 and 12 months after procedure with ECG and 24-h ambulatory ECG monitoring (at 12 months).There were no serious complications in the study group. All the patients were in AF immediately after the procedure and underwent electrical or pharmacological cardioversion (4 and 16 patients, respectively). The proportion of patients remaining in sinus rhythm was 15 (75%) patients at 1 month, 16 (80%) patients at 3 months, 17 (85%) patients at 6 months and 12 months after procedure.The Ex-Maze III procedure for ablation of AF on the beating heart is safe and effective in patients with AF undergoing concomitant MV surgery. In order to better evaluate the outcomes of the procedure a prospective randomised multicentre study is needed.

INTRODUCTION Atrial fibrillation (AF) is a common arrhythmia affecting approximately 1% to 2% of the general population. OBJECTIVES The aim of the study was to evaluate the efficacy and safety of thoracoscopic ablation in patients with AF. PATIENTS AND METHODS A total of 25 patients aged from 42 to 77 years (mean 56.4 years) with persistent or long-standing persistent AF were scheduled for the procedure. Thoracoscopic epicardial ablation of the right atrium, pulmonary veins, and left atrium was performed on the beating heart using the Cox MAZE III-based diagram, via 3 ports and 2 cm incision below the xiphoid. Exit block was always assessed. Patients were prospectively followed for 12 months after the procedure. 24-hour electrocardiography (Holter monitoring) was used to confirm the results. RESULTS Conduction block across ablation lines was achieved in 21 patients (84%). At 1 month of follow-up, the sinus rhythm (SR) was observed in 18 of 20 patients. At 3 months, the SR was observed in 19 patients (76%). Two patients had atrial flutter, while 3 still experienced AF. At 6 months, the SR was observed in 21 patients (84%); 2 patients still had AF, 1 patient atrial flutter, and 1 patient had a pacemaker implanted. Results of follow-up at 1 year did not differ from those at 6 months. No changes in the size of the left atrium and left ventricular ejection fraction, no deaths, stroke, transient ischemic attack, or infectious complications were observed. CONCLUSIONS The efficacy of epicardial thoracoscopic ablation of the left and right atrium was high, reaching 84% during 1-year follow-up. No serious complications were observed in the postoperative period (except for the need for pacemaker implantation in 1 patient).

Cardiac resynchronization therapy (CRT) is an acknowledged treatment for advanced heart failure in acquired dilated cardiomyopathy, resistant to pharmacotherapy. Although there are no therapeutic standards regarding heart failure originating from congenital heart defects with systemic right ventricle, a number of CRT implantations by transvenous approach in congenitally corrected transposition of the great arteries (CCTGA) have been reported since 2001, even though none of them expressly referred to a case concomitant with dextrocardia and situs inversus anomaly. We present a 57 year-old patient with dextrocardia and CCTGA, who underwent surgical closure of interatrial and interventricular septal defects at the age of 19, and in whom a VVI pacemaker was subsequently implanted at age 36. A three-lead CRT system was implanted by transvenous approach. Imaging techniques, including multi-slice computed tomography, targeted to pacing system and unusual anatomical relationships were applied. Within a 20-month follow-up, a significant improvement of functional NYHA class, systemic right ventricle ejection fraction and exercise capability were observed. Entirely transvenous CRT system implantation is feasible in patients with dextrocardia and CCTGA, and has substantial potential for long-term benefits.

Background Atrial fibrillation is associated with an increased risk of embolic events. The left atrial appendage (LAA) is believed to be an incubator for thrombus formation. LAA exclusion has been advocated to potentially reduce embolic events arising from the LAA. Objective The aim of the study was to determine the feasibility of a closed-chest surgical suture ligation of the LAA in man. Methods Thirteen patients undergoing either mitral valve surgery (n = 2) or electrophysiological study and radiofrequency catheter ablation for atrial fibrillation (n = 11) underwent ligation of the LAA with the LARIAT snare device. In patients having an ablation procedure, pericardial access was obtained prior to the patients undergoing radiofrequency catheter ablation. After transseptal catheterization, endocardial and epicaridal magnet-tipped guide wires were positioned under fluoroscopic guidance to stabilize the LAA. Transesophageal echocardiography (TEE) was used as guidance for positioning a marker balloon at the ostium of the LAA. An over-the-wire approach was used to guide the LARIAT snare device over the LAA to allow closure and suture ligation of the LAA. TEE and contrast fluoroscopy were used to confirm acute closure of the LAA. Results Both mitral valve replacement (MVR) patients had complete closure of the LAA determined by visual inspection. Ten of 11 patients having ablation underwent a successful closed-chest LAA ligation procedure with TEE and contrast fluoroscopy verification of closure of the LAA. Only one of 11 procedures was terminated owing to the lack of echocardiography guidance of the snare over the marker balloon. One patient with pectus excavatum did have ligation of his LAA; however, a thorascopic procedure was required to remove the snare from the LAA owing to compression of the LARIAT by the concave sternum. There were no other significant complications. Conclusions Catheter-based surgical suture ligation of the LAA is feasible in humans. This novel catheter approach may be appropriate for patients with atrial fibrillation who are ineligible for anticoagulation therapy. Further investigation is needed to demonstrate the long-term safety and efficacy of LAA closure.

Although the short-term results after radiofrequency (RF) catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT), accessorry pathway (AP), atrioventricular junction (AVJ) and common atrial flutter (Aflu) have been widely reported, there is insufficient data on long-term outcome.To evaluate the long-term efficacy of RF ablation of cardiac arrhythmias in a single center.The study population consisted of 349 consecutive patients (mean age 49.5 years) who underwent RF ablation of AP (136 patients), AVNRT (105 patients), AVJ (86 patients) or Aflu (15 patients). In 4 patients two AP and in 3 patients AP and AVNRT were ablated during the same session. The patients were subsequently followed-up for an average of 44.3 months (12-76 months).Ablation was successful in 341 patients (97.7%). Major complications occurred in 8 patients (2.3%) and included av block (6 patients), ventricular fibrillation (1 patient) and cardiac tamponade (1 patient). Tachycardia recurrences were observed in 21 patients (6.2%) after successful ablation. All the recurrences occurred within 10 months (mean 2.3 months) after ablation. The recurrence rate was 5.8% (6 patients) in the AVNRT group, 9.2% (12 patients) in the AP group, 1.2% in the AVJ group (1 patient) and 13% (2 patients) in the Aflu group. The differences between groups were insignifficant.(1) The immediate success rate of RF ablation of AVNRT, AP, AVJ or Aflu was high and there was a low incidence of complications. (2) The recurrence rate during long-term observation is low. (3). All the recurrences occurred within 10 months after successful ablation.

The aim of the study was to clinical analyse patients with cardioverter-defibrillator (ICD) treated in Cracow Department of Electrocardiology IK CMUJ between 1997-2004.Data from 199 patients, aged 10 to 82, mean 56.9 year, in whom 198 implantations (31 of dual-chamber) and replacements were analyzed.(1) Number of ICD implantation as primary prevention is insufficient in this Dept. (2) Simultaneous presence of pacemaker and ICD is acceptable. (3) Careful sudden cardiac death risk stratification, even in non-classic indicative diseases should be undertaken. (4) Subcutaneous ICD implantation, even in slim people can be done without danger of skin erosion and parameters deterioration. 5. Devices implanted in the past presented longevity shorter than expected. (6) Cooperation with house-officers and pathologists is insufficient.

Active-fixation pacemaker leads seem to have advantages over passive-fixation ones, such as the possibility of pacing at various sites, low dislodgement rate, and they are easier to extract. Unexpectedly their popularity in European countries is not high.The comparative estimation of acute electrical parameters between high-impedance fractal passive-fixation and traditional active-fixation leads. Second aim of the study was the evaluation of commonly used active- and passive-fixation leads in order to find the best solution for ambulatory implantation.35 patients received passive-fixation Biotronik Synox SX60BP pacemaker leads and 35 patients received active-fixation Biotronik YP60BP pacemaker leads. Intraoperative measurement of pacing threshold, impedance, R amplitude, and slew-rate were performed.The pacing threshold was statistically significant lower (p = 0.1) in passive-fixation "tined-tip" SX60BP group (0.45 vs. 0.63). In 3 active-fixation cases "exit block" with ineffective pacing occured in early post-operative period.Active-fixation YP60BP electrodes should not be used for ambulatory implantation course.

The purpose of the present study was to evaluate the effects of RF ablation on parameters of left ventricular (LV) function and exercise capacity in patients with AVRT.The study population consisted of 24 subjects (10M, 14F), mean age 38.1+/-8.9 years. Subjects over 50 years of age, with concomitant cardiovascular disease and EF50% were excluded from the study. The following examinations were performed in all patients at baseline and at six months after the procedure: 1) physical examination, 2) standard ECG recording, 3) 24hr Holter monitoring, 4) transthoracic ECHO, 5) treadmill exercise test using the modified Bruce protocol to evaluate exercise duration, peak heart rate and workload achieved.After RF ablation NYHA functional class improved in the whole population. The left ventricular dimensions (LVESD, LVEDD), left ventricular ejection fraction (LVEF), fractional shortening (FS) in AVRT group remained unchanged. Parameters of LV diastolic function significantly improved, whereas systolic pulmonary venous flow S and pulmonary venous atrial reversal flow AR were significantly reduced (p0.005, p0.001, respectively). All dimensions of the left atrium significantly decreased after the procedure (p0.001). In all patients parameters of exercise capacity were increased after the procedure.In patients with AVRT RF ablation did not affect significantly left ventricular dimensions and systolic function. Elimination of AVRT resulted in improved NYHA functionalclass, diastolic LV function, exercise capacity and reduction of left atrial size.

In patients with drug refractory atrial fibrillation radiofrequency (RF), ablation of the atrioventricular (AV) junction and pacemaker implantation is an alternative procedure. The aim of this study was to assess the left ventricular systolic function, exercise tolerance and quality of life (QOL) in patients who underwent RF AV junction ablation and permanent pacemaker implantation.24 patients (14 male, 10 female, 64.8 +/- 11.0 years) underwent RF ablation. The duration of symptoms was 4 +/- 1.9 years prior to ablation. Post ablation, the selected pacing mode was DDDR for the 4 patients with paroxysmal AF and VVIR for the 20 patients with chronic AF. The underlying heart disease was coronary artery disease (17 CAD), arterial hypertension (15 AH) and heart failure (9 HF). Prior to the ablation and after 6 months follow-up--an ECHO, exercise tolerance (the six minute walk -M6) and QOL assessment (the questionnaire of SF-36, functional symptomatology scale, DASI scale) were performed. The NYHA class was also evaluated.The patients showed a significant improvement in NYHA class (p0.005), in QOL (SF-36, p0.0025; symptomatic score, p0.025; DASI, p0.01) and in the M6 (p0.01). We did not find significant changes in left ventricular performance. The significant correlation was observed between the SF-36 and functional symptomatology (r = 0.71) and DASI (r = 0.53). We divided our patients into two groups: Group A (patients with the higher NYHA class, p0.025) with significant improvement QOL and Group B with insignificant improvement of QOL. Post ablation in group A we--observed significant improvement in NYHA class and M6 (p0.01).1. In patients with drug refractory atrial fibrillation, RF AV junction ablation and permanent pacemaker implantation significantly improve the QOL, M6 and NYHA class. 2. Significant improvement of QOL as well as in M6 can be expected after RF ablation with pacemaker implantation, especially in patients with more advanced hart failure (higher NYHA class).

We present a 59 year old patient with advanced heart failure who underwent lead extraction. The lead was implanted 11 years ago, and 2 years later looped spontaneously following its fracture. The transvenous extraction process through inferior vena cava was complicated by knotting of the inactive lead over the active ventricular lead. The patient was pacemaker-dependent. Finally, the old lead was successfuly explanted. The active intact lead was used to create resynchronisation system.

A 61-year-old patient with a 20-year history of permanent pacemaker implantation and half--a-year cardiac resynchronization therapy using a left ventricular lead placed via surgical approach was admitted for extraction of an old coiled right ventricular lead, which triggered ventricular arrhythmia and created a risk of pulmonary embolism. The lead was extracted via the left femoral vein in two stages: untying a loop on the lead using a pig-tail catheter and Dotter basket followed by traction and dissection of adhesions using a Byrd dilator sheath. Dissection of the old lead from the active right ventricular one posed special technical problems.

Transcutaneous RF catheter ablation of the atrioventricular junction (AVJ) in pts with ventricular pacemaker (VVIR) implantated is an accepted treatment for drug-intolerant or drug refractory atrial fibrillation. The ventricular arrhythmias and sudden cardiac death may be associated with increased of QT dispersion (QTD), mainly in pts with reduced LV function (low ejection fraction - EF) after AVJ ablation. The present study evaluates the dynamic of the changes of QTD in response to a sudden pacing rate drop from 80/min to 40/min in follow up 1 day, 3, 6 and 9 months after ablation (1d, 3m, 6m, 9m).The 12-lead ECGs were recorded on 22 pts (mean age 72.6+/-5.4 yrs) (10 with low EF (50%) - group A, 12 with normal EF (or =50%) - group B) on the 1 day, 3, 6 and 9 months following AVJ ablation during a sudden drop in ventricular pacing rate from 80 to 40 beats/min. The maximum QT interval (QTM), minimum QT interval (QTm), and QTD were measured on the last 5 beats prior to the rate drop (QTM-80, QTm-80, QTD-80) and on the first 5 beats after the rate drop (QTM-40, QTm-40, QTD-40). These QT parameters were compared. The echocardiographical studies were performed on the 1d, 3m, 6m and 9m following AVJ ablation.In response to a sudden paced heart rates drop from 80 to 40 beats/min, the DeltaQTM (QTM-40 - QTM-80) increased during follow-up in both groups, while the DeltaQTm (QTm-40-QTm-80) increased in group B(23.3+/-25.7 in 1d, 27,5+/-20.1ms in 9m; p0.001), but not in group A (1+/-16.6 in 1d, 5+/-25.1ms in 9m). Consequently, the AQTD (QTD-40 - QTD-80) increased significantly in group A at 6 months (29+/-31.1ms; p0.05) but not in group B (9.2+/-17.3msl. The negative correlation between QTD-40, QTD-80 and EF was observed in group A.Following AVJ ablation, QTD increased during a sudden rate drop in pts with reduced LV function, but not in pts with EFor = 50%. The significant correlation between QTD and paced rate was found in pts with LV dysfunction. The increased QTD in response to a sudden heart rate drop in pts with low EF was due to a failure of the expected prolongation of the QTm.

During implantation of a DDD pacemaker the following difficulties may be encountered: venous anomalies (the absence of vessels of adequate calibre or difficulty in subclavian vein puncture), arrhythmias during implantation (episodes of atrial flutter/fibrillation while the atrial leads are being positioned), lack of mechanical stability of the electrode in the heart chamber and inability to achieve an acceptable pacing and sensing threshold during implantation. The purpose of the study was to analyse retrospectively the reasons for DDD pacemaker failure in patients operated on between 1993 and 2005.We reviewed retrospectively all implantation data from 1988 to 2005 to identify patients with primary failure of DDD pacemaker implantation. Further analysis included patients who had received a DDD pacemaker between 1993 and 2005, when this type of pacemaker made up between 9 and 40% of all pacemaker implantations. We implanted 7469 pacemakers, including 1958 (26.2%) dual-chamber pacemakers, in 783 patients with atrioventricular block (AVB), 392 with sick sinus syndrome (SSS), 450 with AVB +/- SSS and 333 with tachy-brady syndrome (TBS). The mean age of the patients was 65.5 +/- 17.3 years. DDD pacing was unsuccessful in 108 (1.4%) patients, including 32 with AVB, 22 with SSS, 16 with SSS +/- AVB and 38 with TBS. The mean age of these patients was 78.5 +/- 19.4 years.The reasons for failed implantation were venous anomalies in 12%, an arrhythmia episode in 27.8%, a high pacing threshold in the atrium in 17.6%, low atrial potential amplitude in 25.9% and lack of mechanical stability of the electrode in 16.7% of patients. The difficulties were encountered in elderly patients (p0.01), most frequently in patients with SSS and TBS (71). Between 2004 and 2005 venous anomalies and a high pacing threshold were the main causes of failure.Currently the main difficulties encountered during pacemaker implantation are venous anomalies and a high pacing threshold. Arrhythmia episodes, low atrial potential amplitude and lack of mechanical stability are of minor importance. Elderly patients with sick sinus syndrome and tachy-brady syndrome have the highest failure rate. (Cardiol J 2007; 14: 155-159).

Pacemaker dependency (PD) can be defined as the risk of serious injury or death from sudden pacemaker failure, an event more dangerous than progressive rate decrease. The aim of this study was to evaluate the incidence of PD during long-term follow-up after pacing system implantation.The study included 3638 patients (mean age 65.3 +/- 10.2 years). Indications for pacing were sick sinus syndrome (SSS) in 1315 patients, atrioventricular block (AVB) in 1482, AVB and SSS in 478 and atrial fibrillation (AF) with bradycardia in 363 patients. The mean follow-up was 4.8 +/- 1.8 years. Pacemaker dependency was defined as the absence of an intrinsic rhythm of 30 beats/min during back-up pacing and after switching off the pacemaker. If any significant symptoms of bradycardia developed or if the underlying rhythm did not appear (asystole5 s) the pacing was restarted. Pacemaker dependency was observed in 76 (2.1%) of the 3638 patients . In this subgroup pacing indications were SSS in 8 (0.6%) of 1315 patients, AVB in 52 (3.5%) of 1482, SSS and AVB in 15 (3.1%) of 478 and AF with bradycardia in 1 (0.3%) of 363. Patients with AVB had a significantly higher incidence of PD than patients with SSS or AF (p0.001, p0.005, respectively). A total of 139 patients suffered from myocardial infarction and 106 patients had a temporary pacing prior to pacemaker implantation. The majority of these patients were pacemaker dependent (p0.001).In our study PD occurred very rarely, being found in 2.1% of all patients. Patients with AVB have a significantly higher incidence of PD than patients with SSS or AF. Temporary pacing prior to pacemaker implantation and previous myocardial infarction indicate patients at risk of PD development. (Cardiol J 2007; 14: 83-86).

Complete atrioventricular block, second-degree Mobitz type II and first-degree atrioventricular block with right bundle branch block were observed consecutively following successful radiofrequency ablation in close proximity to the sinus node. This resulted in the modification and disappearance of the inappropriate sinus tachycardia that had previously been present. Neither tachycardia nor conduction disturbances have been recorded in the 9-year follow-up, implying that ventricular pacing standby should also be considered in high atrial ablation cases. (Cardiol J 2007; 14: 504-507).

THE AIM OF THE STUDY was to analyze left ventricular systolic function and dimensions, paced QT dispersion (QTD), exercise tolerance (six minute walk test- M6) and quality of life (QOL) after RFAVJ in a 6-month (6m) and a 24-month (24m) follow-up.RFAVJ was performed in 30 pts (18 men and 12 women) aged from 43 to 81 years (mean age 69.8+/-11.3). AF was first diagnosed from 2 to 9 (mean 5+/-2.1) years prior to ablation. All patients received VVIR pacemakers. Pacing rate was programmed at 80 bpm. Prior to RFAVJ all patients underwent: transthoracic echocardiography (ECHO) to assess the left ventricular ejection fraction (EF), ventricular end-diastolic and end-systolic dimension (LVDD, RVDD, LVSD, respectively) and left atrial dimension; QOL assessment based on self-evaluation using: a questionnaire of the SF-36, Manolis, DASI scale. M6 on flat surface. These examinations were repeated at 6m and 24m after ablation. The maximum QT interval (QTM), minimum QT interval (QTm) and QTD were measured from the 12-lead ECG after RFAVJ on the first day (1d) and at 6m, 24m following RFAVJ.SF total increased from 73.4 to 96.3 (p0.0025) in 6m, and to 113.8 (ns) in 24m, symptomatic score from 15.7 to 20.8 (p0.025) in 6m, and to 22.4 (ns) in 24m, DASI from 39.3 to 46.1 (p0.01) in 6m and decreased to 23.9 (p0.001) in 24m. Any significant changes in EF and the remaining ECHO parameters in 6m were observed. At 24 m we found significant decreased in EF (p0.01) and increased in LVSD (p0.05). Parameters of the M6 significantly improved. A significant correlation was observed between the SF-36 and functional symptomatology and DASI in 6m. The mean QTm, QTM and QTD were unchanged.1. In pts with drug refractory AF, RFAVJ and VVIR significantly improve QOL and M6. 2. At long term follow up a significant decrease in EF and increase in LVSD were demonstrated. 3. No significant changes in the paced QT and QTD were observed.

The treatment of ventricular arrhythmias and the prevention of sudden cardiac death should be focused on the optimal therapy of primary cardiac disease. Antiarrhythmic drugs and non-pharmacological therapies (radiofrequency ablation, surgery, cardiac pacing, cardioversion and defibrillation) play also an important role. Despite the recognition that the goal should be to prevent the arrhythmia, implanted cardioverter-defibrillators (ICDs) became the major form of therapy used.

The case of 65-year-old male patient who underwent DDD pacemaker implantation due to symptomatic tachy-brady syndrome with first degree AV block is presented. During the procedure a paroxysmal atrial fibrillation occured and the presence of persistent left superior vena cava (PLSVC) was diagnosed. The "straight" passive fixation leads were introduced through the PLSVC and placed in the right atrium and ventricle, using curved stylets. Atrial lead implantation during atrial fibrillation is discussed. At three month, a follow-up revealed normal DDD pacemaker function.

Primary treatment of ventricular tachyarrhythmias (VTs) is performed in order to influence the outcome of the underlying cardiac disease. In the hierarchy of therapy of VTs, prevention of the arrhythmia by preventing formation (i.e, infarction) of destruction of the substrate by surgical or catheter ablation should be the highest goal. Termination of VTs by drugs or antitachycardia pacing or slowing of the arrhythmia to hemodynamic tolerance would be a second option, and rescue by cardioversion or defibrillation with an implantable cardioverter-defibrillator (ICD) should be the last goal. Despite the recognition that the goal should be to prevent the arrhythmia, ICDs have become the major form of therapy used.