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As catheter ablation became the standard therapy for atrial fibrillation (AF), the number of AF procedures has risen exponentially. Therefore, workflow optimization is crucial in order to meet the rising demands for EP interventions. Recently, instead of standard groin compression we have started using the "Z stitch" for introducers’ removal. This novel method does not necessitate protamine administration and often lengthy manual compression. Purpose We aim to demonstrate utilization of "Z stitch" for groin access closure in cryoballoon (CB) ablation and its impact on EP lab workflow. Methods We have analyzed all patients having undergone CB ablation utilizing the "Z stitch" (Z group) and the last 50 consecutive CB patients who received standard groin compression (non-Z group). Procedures were performed under conscious sedation. Both femoral veins were punctured and a single introducer was placed in each vein. A single transeptal puncture was preformed guided by intracardial ultrasound and a 28 mm cryoballoon was used. A single 180 seconds freeze strategy was employed. In the past, protamine was slowly administered after ablation and at least 15 minute manual groin compression was applied until no visual bleeding could be detected. Elastic bandage was placed around both groins. Later on, the "Z stitch" was used around both introducers without the need for protamine administration, manual compression and bandage placement (Picture). The stitches were removed next morning. Results A total of 100 consecutive patients (79% male, 61.2 ± 10.6 years old) were evaluated, 50 in both groups. There was no difference in the mean procedure duration ("skin to skin") between two groups. However, a total lab time was significantly longer in non- Z group. There was no differences in complication rates, which consisted solely of phrenic nerve palsy and groin complications. There was no AV fistula or pseudoaneurysms detected in our cohort (Table). Conclusion Utilization of Z stitches for introduces’ removal seems safe and effective way to achieve hemostasis after cryoballoon ablation. It abolishes the need for protamine administration which can cause serious advert events. Manual compression is no longer required. Consequently, EP lab workflow is improved, since the total lab time utilization per patient is significantly shortened. Results non-Z group Z group p Procedure duration (min) 69.4 ± 20.4 73.4 ± 24.8 0.380 Lab time (min) 129.9 ± 35.3 109.1 ± 30.6 0.002 Complications (N) 5 (2 hematoma) 4 (2 hematoma) NS

The third-generation cryoballoon has been designed with a 40% shortened tip length compared with the former second- generation CB device. Ideally, a shorter tip could result with an improved visualization of real-time (RT) recordings in the pulmonary vein (PV) due to a more proximal positioning of the inner lumen mapping catheter. Beside the high incidence of RT recordings, for the first time, we observed dual fascicle electrograms with different isolation time for each fascicle, when using the new device. Purpose We sought to analyze the rate of visualization of RT recordings and dual fascicle electrograms in our first series of patients with the third generation cryoballoon device. Methods All consecutive patients having undergone CB ablation using the third generation technology were analyzed. Procedures were performed under conscious sedation. A single transeptal puncture was preformed guided by intracardial ultrasound and a 28 mm cryoballoon was used. A single 180 seconds freeze strategy was employed. Results A total of 80 consecutive patients (77.5% male, 60.3 ± 10.8 years) were evaluated. Real-time recordings were detected in 275 of 320 PVs (85.9%). Specifically, RT recordings could be visualized in 68 left superior PVs (85%), 69 left inferior PVs (86.2%), 73 right superior PVs (91.2%), and 65 right inferior PVs (81.2%). Furthermore, in 14 of 320 PVs (4.3%) two different fascicles electrograms were detected. A distinctive isolation time for each fascicle could be observed both in sinus rhythm and in atrial fibrillation (Picture). Most commonly, dual fascicles were observed in left superior PV (7.5%) and right inferior PV (6.3%). In the rest of the veins this phenomenon was not so frequent. In 2.5% of right superior PV and in only 1.2% of left inferior PV dual fascicles could be observed. Conclusion The rate of visualization of RT recordings is significantly high during third generation CB ablation. Real-time recordings can be visualized in 85.9% of veins with this novel cryoballoon. Furthermore, for the first time, isolation of two different fascicles during a single cryoballoon lesion could be observed. Other that more proximal mapping catheter position, there is second possible explanation for the visualization of dual fascicles with this novel balloon. Shorter tip could result with poorer cryoballoon stability and weaker contact with the atrium wall, hence non- uniform freezing and isolation of different fascicles in different times.

Point-by-point catheter ablation using radiofrequency energy (RF) is still the most prevalent technique for achieving pulmonary vein isolation (PVI), but recently single shot devices have been developed with the aim of reducing the complexity of the procedure. The aim of our study was to examine the introduction of AF ablation procedure to a new electrophysiology lab, comparing the two different modern approaches - the second generation cryoballoon (CB) and contact sensing RF catheters with advanced 3D electroanatomic mapping system

Ovaj sažetak prikazuje usporedbu pristupa postavljanju elektrode za lijeku klijetku u sklopu resinkronizacijske terapije. Ehokardiografski se pratilo remodeliranje klijetke u bolesnika kod kojih je elektroda postavljena transvenski i u bolesnika kod kojih je postavljena minitorakotomijom.

Cytochrome P450 enzyme debrisoquine 4-hydroxylase, responsible for the metabolism of different classes of drugs and other chemical substances, exhibits genetic polymorphism with great interindividual and interethnic differences in metabolic capacity. The activity of enzyme ranges from very expressed, rapid, to total absence of activity. Up to 7% of Caucasians may demonstrate ultrarapid metabolism--UEM of debrisoquine and other drugs, substrates of debrisoquin hydroxylase, due to inheritance of multiplicate functional CYP2D6 gene, causing an increased amount of enzyme to be expressed. Identification of subjects with ultrarapid metabolism is of potential clinical value for optimization of therapy and avoidance of therapeutic failure due to inadequate dosage. In our study we wanted to determine the prevalence of UEM genotype in Croatian population applying long-PCR method. We found a 4% prevalence of ultrarapid metabolizers with multiplicated CYP2D6 gene.