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An abstract of the study "Influence of LBBB, RBBB, Standard DDD Pacing and Biventricular Pacing on Inter- and Intraventricular Delay in Patients With EF < 35%," by A. Dabrowska-Kugacka and colleagues is presented.

Bone marrow is an exceptionally uncommon site of metastatic dissemination in angiosarcoma (AS) as only single case reports have been published so far. We report a case of a 72-year-old male with epithelioid angiosarcoma of the liver who subsequently developed erythroblastic anemia. The trephine bone marrow biopsy revealed total replacement of the normal hematopoiesis by diffuse infiltrate of AS. This rare complication of the clinical course of this tumor should be taken into account in the pathological diagnosis of patients with AS presenting with hematological abnormalities.

Background: The aim of the study was to assess the relationship between P-wave duration on the surface electrocardiogram (ECG) and echocardiographic parameters of atrial electromechanical delay (EMD), as well as contraction synchrony during different atrial pacing modalities., Methods: In 57 patients with sinus node disease and prolonged sinus P-wave duration treated with multisite atrial pacing (MSAp), the EMD was measured by tissue Doppler in several left and right atrial sites during sinus rhythm, MSAp, and single-site pacing at right atrial appendage (RAAp), Bachmann's bundle (BBp) region, and coronary sinus (CSp) ostium. Regional atrial synchrony was calculated on the basis of EMD., Results: P-wave duration was 141 ± 16, 120 ± 17, 138 ± 17, 144 ± 16, and 160 ± 19 ms during sinus rhythm, MSAp, BBp, CSp, and RAAp, respectively (P < 0.001 RAAp and MSAp vs other). P-wave duration correlated with all atrial EMDs as well as interatrial and intraleft atrial parameters of dyssynchrony. In multivariate analysis, the EMD in lateral left atrial wall was the strongest predictor of P-wave duration (β 0.41; P < 0.001). The relationship between P-wave duration and the atrial EMDs was most prominent during RAAp (all left atrial walls r > 0.51; P < 0.01) and BBp (all atrial walls r > 0.42; P < 0.05), while during sinus rhythm and CSp, only weak correlation between echo and ECG was found. Neither of the tissue Doppler parameters correlated with P-wave duration during MSAp. Interatrial dyssynchrony correlated with P-wave duration during sinus rhythm and RAAp and intraleft atrial dyssynchrony only during sinus rhythm., Conclusions: P-wave duration of the surface ECG is highly correlated with the atrial EMD, the relationship is specific for each pacing modality., (©2010, The Authors. Journal compilation ©2010 Wiley Periodicals, Inc.)

Introduction: High-resolution electrocardiography (ECG-CREM) is a method based on digital electrocardiography. In order to facilitate the interpretation of the Crem records the technique of vectorcardiography was used. In comparison the origin of the ventricular premature complexes (VPCs) could be estimated based on a standard 12-lead electrocardiogram. The aim of the study was to assess the point of origin of the VPCs in ECG-CREM and correlate it with standard electrocardiography (ECG-Stand)., Material and Methods: Our study included 26 patients (16 females, 10 males), aged 51-83 years (avg. 58.1 ±12.3), who presented with recurrent, during at least 6 months' observation, VPCs. The point of origin of VPCs was compared in both methods., Results: The performed analysis of collected ECG-Stand records revealed the presence of arrhythmogenic focal points in six different locations (1, 3, 5, 7, 8, 9). However, we did not affirm their presence in points 2,4,6. They were most commonly located in RVOT zones 8 (30.7%), 9 (23.0%), 5 (23.0%), and most seldom in zones 1, 3, 7 (7.6% each). In the simultaneous record of ECG-CREM with a single VPC it was confirmed that the FPb zone was activated the most frequently (40.0%); the next in relation to frequency were SD and ST (20.0%). Less frequent VPCs have their origin in Crem zones SP, FPa and SB (6.6%)., Conclusions: Electrocardiogram of high signal resolution (ECG-CREM) might be useful in recognition of the origin of ventricular premature complexes from RVOT.

Background: It has been proposed that multisite atrial pacing (MSAp) restores atrial electrical activation and prevents atrial fibrillation recurrence; however, single-site Bachmann's bundle pacing (BBp) has also been reported as providing effective atrial resynchronization. Coronary sinus pacing (CSp) leads to reversed impulse propagation within the atria., Methods and Results: Acute echocardiographic examination was performed in 15 healthy subjects, and in 25 patients with sinus node dysfunction and recurrent atrial fibrillation during MSAp (atrial leads in the BB area and CS ostium), and single-site BBp and CSp. Regional atrial synchrony was assessed by tissue Doppler echocardiography. Pacing mode had no effect on stroke volume. CSp resulted in right atrial filling diminution, shortened mechanical atrioventricular delay in the right heart and diminished right ventricular inflow. The magnitude of reversion of the physiological right-to-left atrial contraction sequence was most prominent during CSp (15+/-11, 12+/-23, 3+/-21, 42+/-23 ms; control, MSAp, BBp, CSp respectively, P<0.0001). BBp provided the best atrial contraction synchrony, and had a comparable effect on global cardiac function to MSAp., Conclusions: Single-site BBp provides comparable hemodynamics to MSAp and is sufficient to restore atrial contraction synchrony. Single-site CSp induced echocardiographic pacemaker syndrome in the right heart.

Background: Multisite atrial pacing (MAP) was introduced to improve atrial electrical synchrony and prevent recurrence of atrial fibrillation (AF)., Methods and Results: In the present study there were 57 patients with sinus node disease, AF recurrence and prolonged P-wave on ECG with 2 MAP modalities. In all patients 1 lead was implanted in the coronary sinus (CS) ostium area. In the right atrial appendage (RAA)+CS group (28 patients) the other atrial lead was in the RAA, and in the BB+CS group (29 patients) in the Bachmann's bundle (BB) region. Tissue Doppler was used to register the electromechanical delay (EMD) in the atrial walls and estimate the atrial contraction synchrony. Cardiac output and myocardial performance index did not differ during the 2 MAP modalities. During BB+CS, in comparison with RAA+CS pacing, the peak of the mitral atrial wave occurred earlier (P<0.01), the usual right-left atrial contraction sequence was reversed more frequently (P<0.004), all atrial EMDs except for the lateral left atrium (LA) were shorter (P<0.05), and LA synchrony was greater (P<0.001)., Conclusions: In patients treated with MAP, implanting 1 of the atrial leads in the BB area instead of the RAA has no influence on global cardiac hemodynamics, but does result in earlier LA contraction, and reversal of the typical right-left atrial contraction sequence, as well as providing greater LA contraction synchrony.

Background: Optimal right ventricular (RV) pacing site in patients referred for permanent cardiac pacing remains controversial. A prospective randomized trial was done to compare long-term effect of permanent RV apex (RVA) vs RV outflow tract (RVOT) pacing on the all-cause and cardiovascular mortality., Methods and Results: A total of 122 consecutive patients (70 men, 69 +/-11 years), with standard pacing indications were randomized to RVA (66 patients) or RVOT (56 patients) ventricular lead placement. After the 10-year follow-up period the mortality data were summarized on the basis of an intention-to-treat analysis. During the long-term follow-up, 31 patients from the RVA group died vs 24 patients in the RVOT group (hazard ratio (HR), 0.96; 95% confidence interval (CI), 0.57-1.65; P=0.89). There were 10 cardiovascular deaths in the RVA and 12 in the RVOT group (HR, 1.04; 95%CI, 0.45-2.41; P=0.93). There were no differences in the all-cause or cardiovascular mortality between the pacing sites after adjustment for age, gender, arterial hypertension, atrial fibrillation, New York Heart Association class and left ventricular end-diastolic diameter., Conclusions: The RVOT provides no additional benefit in terms of long-term survival over RVA pacing.

Objectives: Investigation of which atrial pacing modality provides atrial synchrony and the most physiological atrial contraction pattern in patients with brady-tachycardia syndrome., Methods: Fifteen healthy subjects and 57 patients with sinus node dysfunction, atrial fibrillation recurrences, and prolonged P-wave on the electrocardiogram treated with multisite atrial (MSA) pacing were studied. One atrial lead was implanted in the coronary sinus (CS) ostium area, the other at the right atrial appendage (RAA): RAA+CS group (28 patients), or Bachmann's bundle (BB) region: BB+CS group (29). Sinus rhythm (SR) and CS, RAA, BB, RAA+CS, and BB+CS pacing modalities were evaluated. Electromechanical delay (EMD) in atrial walls was assessed by tissue Doppler echocardiography. Interatrial (DeltainterA), intra-right (DeltaRA), and intra-left (DeltaLA) atrial dyssynchrony were calculated., Results: During SR, in the study group versus controls, important DeltainterA: 55 +/- 23 versus 22 +/- 11 ms (P < 0.01) and DeltaLA: 47 +/- 21 versus 21 +/- 6 ms (P < 0.001) were present. Single-site BB and both MSA pacing modes restored DeltainterA and DeltaLA (DeltainterA: 24 +/- 16, 20 +/- 13 and 14 +/- 9 ms, DeltaLA: 28 +/- 18, 28 +/- 13 and 20 +/- 10 ms during BB, RAA+CS and BB+CS pacing, respectively). CS pacing prolonged lateral RA EMD, while RAA pacing LA walls EMD, which resulted in DeltainterA persistence. CS pacing induced DeltaRA (50 +/- 23 vs 16 +/- 8 ms, P < 0.0001 vs controls). Atrial contraction sequence during BB pacing resembled that observed in controls., Conclusions: (1) Single-site BB and both MSA pacing modes restored atrial synchrony. (2) Single-site RAA and CS ostium pacing retained interatrial dyssynchrony; moreover, CS pacing created RA dyssynchrony. (3) Single-site BB pacing provided physiological atrial contraction sequence.

Background: Echocardiographic examination is essential for clinical assessment of patients after cardiac resynchronisation therapy (CRT)., Aim: To assess the benefit of CRT in patients with end-stage heart failure at long-term follow-up., Methods: 28 patients with end-stage heart failure, NYHA class >or= III (>or= II in patients with indications for implantable cardioverter defibrillator and echocardiographic signs of ventricular mechanical systolic dyssynchrony), left ventricular ejection fraction (LVEF) <35%, QRS duration >120 ms and left bundle branch block morphology received a biventricular device. Standard colour Doppler echocardiography examination was performed at baseline, and then every 6 months, up to 2 years. Parameters of systolic and diastolic LV function, mitral insufficiency and right ventricular (RV) pressure were evaluated., Results: Following CRT, a statistically significant improvement of LV dimensions (p<0.05), and LVEF (p<0.001) was recorded. CRT also resulted in a mitral regurgitation decrement (p<0.01). Interventricular mechanical delay was shortened (p=0.0005). After 2 years, non-significant worsening of LV dimensions was observed. At long-term follow-up CRT did not result in LV volume, left atrium, RV dimension or RV pressure reduction., Conclusions: CRT is associated with reverse remodelling of the LV at mid-term follow-up.

Background: Cardiac resynchronisation therapy (CRT) has been shown to be effective in the treatment of patients with end-stage heart failure (HF). However, long-term results of CRT have not yet been validated., Aim: To assess the sustained benefit of CRT in patients with end-stage HF at long-term follow-up. In addition, predictors of response to CRT were analysed., Methods: Twenty-eight patients with end-stage HF, NYHA class >or=III (>or=II in patients with indications for ICD and echocardiographic signs of ventricular mechanical systolic dyssynchrony), left ventricular ejection fraction <35%, QRS duration >120 ms and left bundle branch block morphology received a biventricular device (BiV). In 27 patients LV pacing was achieved via the coronary sinus tributaries and in 1 patient an endocardial LV lead was introduced transseptally. Ten patients received an ICD-CRT device. The control group consisted of 29 patients fulfilling the criteria for ICD-CRT implantation in whom the CRT system was not implanted for various reasons. At baseline, 3 months after implantation, and then every 6 months the following parameters were evaluated: NYHA class, quality of life (QoL) score, QRS duration on surface ECG, and 6-minute walking distance. The need for hospitalisation assessed one year before and one year after implantation was compared. Follow-up was obtained up to 2 years., Results: The NYHA class and 6-minute walking test were significantly improved in the CRT group after 3 months and continued to improve gradually until 24 months of follow-up. The QoL improvement at 6 months was sustained over 2 years. Hospitalisation rate due to worsening of HF decreased. One-year and two-year survival were significantly better in the CRT group than in the control group (94 and 87 vs. 80 and 73% respectively). The only predictor of clinical improvement after CRT implantation was baseline NYHA class., Conclusion: Clinical improvements with CRT are progressive and sustained over 2 years of follow-up.

Background: Benefits of cardiac resynchronisation therapy (CRT) for survival in selected congestive heart failure (CHF) patients have been acknowledged by the 2005 ESC guidelines., Aim: To analyse mortality in CRT pacing only (CRT-P) patients during at least one-year follow-up., Methods: This was a prospective, multi-site, at least one-year observational study on mortality and mode of death in patients who received CRT-P due to commonly accepted indications. One-year follow-up data (or earlier death) were available for 105 patients (19 females, 86 males) aged 60.6+/-9.8 years (35-78). Baseline NYHA class was 3.2+/-0.4 (3-4). Coronary artery disease (CAD) was the underlying aetiology of CHF in 57 (54%) patients and 48 (46%) patients had CHF due to non-coronary factors., Results: Mean follow-up duration was 730 days (360-1780), median 625. There were 21 (20%) deaths: 5 (24%) sudden cardiac deaths (SCD), 13 (62%) deaths due to heart failure (HFD) and 3 (14%) other deaths. Thirteen (62%) patients died within the first year of observation. All SCD occurred in this period. Mean time to death was 303+/-277 days (19-960) to HFD - 339+/-313 days (19-960) and to SCD - 208+/-127 days (31-343). There were no significant differences between survivors and non-survivors with respect to left ventricular ejection fraction (LVEF) (25+/-10 vs. 20+/-8%), 6-minute walk test (6 min WT) (276+/-166 vs. 285+/-163 m) and LV diastolic diameter (LVEDD) (71+/-9 vs. 78+/-10 mm) (all NS). The SCD and HFD patients had similar age (62.0+/-5.4 vs. 56.6+/-13.2 years), gender (80 vs. 83% males), NYHA class (3.1+/-0.2 vs. 3.5+/-0.3), LVEF (22+/-9 vs. 17+/-5%), LVEDD (86+/-10 vs. 79+/-9 mm), 6 min WT (270+/-142 vs. 292+/-188 m) (NS). In 4 patients from the SCD group CHF was of non-coronary aetiology and only in 1 patient from the HFD group (p=0.003). The values of LVEF, LVEDD and NYHA class in HFD patients who died during the first year after implantation, compared with those who died later, were similar., Conclusions: Sudden cardiac death probability in the studied CRT-P population was the highest during the first year after implantation. Afterwards, the risk of HFD started to increase. Thus, in all patients eligible for CRT prophylactic defibrillation function should be considered.

Background: An increased defibrillation threshold (DFT) may limit the efficacy of an implantable cardioverter-defibrillator (ICD) in termination of life-threatening ventricular arrhythmias. A search for methods of decreasing DFT has been ongoing since the introduction of ICD into clinical practice., Aim: To assess the effects of various shock polarities on DFT., Methods: The study group consisted of 19 patients (8 females and 11 males, mean age 52+/-17 years) who received devices (Biotronik, Germany) with a single-coil defibrillation lead. In all patients the value of DFT was assessed using a normal shock polarity as well as using a reversed polarity shock, starting from the energy lower than that measured during normal DFT testing. The impedance of the defibrillation system using two different polarities was also measured. The effects of demographic and clinical parameters on defibrillation parameters were also examined., Results: When using normal shock polarity, the mean DFT value was 12+/-5 J (range 3.1-20 J) and impedance was 64+/-12 Omega. When shock polarity was reversed, the mean DFT value was 9.2+/-5.0 J (range 2-20 J) and impedance was 67+/-11 Omega. In 11 (58%) patients the polarity change caused a marked (by 37%) decrease in the mean DFT value - from 11.5+/-5.1 J to 7.2+/-3.8 J. In 5 patients DFT reduction was > or = 5 J. There was no relationship between demographic or clinical parameters and defibrillation efficacy using the two tested shock polarities., Conclusions: The reversal of shock polarity reduces DFT in more than half of patients. In patients with a high DFT the use of reversed polarity of defibrillating impulse may reduce DFT, which widens the safety margin and makes implantation of additional leads unnecessary. Because clinical parameters have no value in predicting the effects of polarity changes on DFT, the efficacy of reversed polarity shock has to be assessed individually in each patient.

Unlabelled: Safety of patients treated with an implanted cardioverter-defibrillator (ICD) depends on defibrillator threshold (DFT). In patients with frequent ICD interventions the high DFT influences battery life-time. The aim of the study was to compare DFT in abdominally placed ICD with an active and passive can and dual-coil endocardial leads., Material and Methods: The study involved 9 patients (4 F and 5 M, mean age 56 +/- 19 years) with previously implanted in abdominal position ICD with passive can and dual-coil defibrillation lead. In all patients DFT was measured using active and passive can ICD at the time of planed generator replacement., Results: Compared to the passive can, the abdominal active can ICD lowered DFT in 6 patients (66%), in 1 patients the DFT increased, whereas in 2 patients we observed no change in DFT. The mean DFT measured with the passive can ICD was 11.6 +/- 5.2J (5.1-20J) and with the active can was 9,3 +/- 4,5J (3-18J). The mean defibrillation resistance was 64 +/- 11W (48-84W) and 55 +/- 8W (47-70W) in passive and active can respectively. Active can ICD decreased the DFT by 20% (p = 0.049) and the defibrillation resistance by 23% (p = 0.012)., Conclusions: An abdominally positioned active can ICD with dual coil defibrillation leads allowed to lower DFT and defibrillation resistance in a majority of patients. It seems useful to replace previously implanted passive can ICDs with an active ones particularly in patients with high DFT.

Introduction: In patients treated with permanent pacing, the electrode is typically placed in the right ventricular apex (RVA). Published data indicate that such electrode placement leads to an unfavourable ventricular depolarization pattern, while right ventricular outflow tract (RVOT) pacing seems to be more physiological., Aim: To compare long-term effects of RVOT versus RVA pacing on clinical status, left ventricular (LV) function, and the degree of atrioventricular valve regurgitation., Methods: Patients with indications for permanent pacing, admitted to hospital between 1996 and 1997, were randomised to receive RVA or RVOT pacing. In 2004 during a final control visit in 27 patients clinical status, echocardiographic parameters and QRS complex duration as well as NT-proBNP level were measured. Analysed parameters were compared between groups and in the case of data available during the perioperative period also their evolution in time was assessed., Results: Out of 27 patients 14 were randomised to the RVA group and 13 to the RVOT group. No significant differences between groups were observed before the procedure with respect to age, gender, comorbidities or echocardiographic parameters. Mean duration of pacing did not differ significantly between the groups (89+/-9 months in RVA group vs 93+/-6 months in RVOT group, NS). In the RVA group significant LV ejection fraction decrease was observed (from 56+/-11% to 47+/-8%, p <0.05); in the RVOT group LV ejection fraction did not change (54+/-7% and 53+/-9%; NS). Progression of tricuspid valve regurgitation was also observed in the RVA group but not in the RVOT group. During the final visit NT-proBNP level was significantly higher in the RVA group: 1034+/-852 pg/ml vs 429+/-430 pg/ml (p <0.05)., Conclusions: In patients with normal LV function permanent RVA pacing leads to LV systolic and diastolic function deterioration. RVOT pacing can reduce the unfavourable effect and can slow down cardiac remodelling caused by permanent RV pacing. Clinical and echocardiographic benefits observed in the RVOT group after 7 years of pacing are reflected by lower NT-proBNP levels in this group of patients.