Left atrial appendage occlusion: Percutaneous and surgical approaches in everyday practice

Prophylactic left atrial appendage occlusion has been suggested as a means of reducing cardioembolism risk in patients with atrial fibrillation. Its clinical benefits have been discussed together with potential endocrine or hemodynamic adverse effects, with conflicting conclusions. We aimed to provide a thorough overview of the current literature and a recommendation for daily clinical decision-making. A comprehensive Medline search through PubMed was conducted to search for relevant articles, which were further filtered using the title and abstract. Sixty-five articles were selected as relevant to the topic. Concomitant left atrial appendage occlusion during cardiac surgery for other reasons is effective in terms of thromboembolism risk reduction in patients with a history of atrial fibrillation and higher CHA2DS2-VASc scores. Surgical occlusion is safe, and epicardial closure techniques are preferred. Thoracoscopic and transcatheter techniques are also feasible, and the individual treatment choice must be tailored to the patient. The concerns about endocrine imbalance or risk of heart failure after occlusion are not supported by evidence. Current evidence is conflicting with regard to hemodynamic consequences of appendage occlusion.

Nonprocedural bleeding after left atrial appendage closure versus direct oral anticoagulants: A subanalysis of the randomized PRAGUE-17 trial

INTRODUCTION

Observational studies have shown low bleeding rates in patients with atrial fibrillation (AF) treated by left atrial appendage closure (LAAC); however, data from randomized studies are lacking. This study compared bleeding events among patients with AF treated by LAAC and nonvitamin K anticoagulants (NOAC).

METHODS

The Prague-17 trial was a prospective, multicenter, randomized trial that compared LAAC to NOAC in high-risk AF patients. The primary endpoint was a composite of a cardioembolic event, cardiovascular death, and major and clinically relevant nonmajor bleeding (CRNMB) defined according to the International Society on Thrombosis and Hemostasis (ISTH).

RESULTS

The trial enrolled 402 patients (201 per arm), and the median follow-up was 3.5 (IQR 2.6-4.2) years. Bleeding occurred in 24 patients (29 events) and 32 patients (40 events) in the LAAC and NOAC groups, respectively. Six of the LAAC bleeding events were procedure/device-related. In the primary intention-to-treat analysis, LAAC was associated with similar rates of ISTH major or CRNMB (sHR 0.75, 95% CI 0.44-1.27, p = 0.28), but with a reduction in nonprocedural major or CRNMB (sHR 0.55, 95% CI 0.31-0.97, p = 0.039). This reduction for nonprocedural bleeding with LAAC was mainly driven by a reduced rate of CRNMB (sHR for major bleeding 0.69, 95% CI 0.34-1.39, p = .30; sHR for CRNMB 0.43, 95% CI 0.18-1.03, p = 0.059). History of bleeding was a predictor of bleeding during follow-up. Gastrointestinal bleeding was the most common bleeding site in both groups.

CONCLUSION

During the 4-year follow-up, LAAC was associated with less nonprocedural bleeding. The reduction is mainly driven by a decrease in CRNMB.

Capture threshold of bipolar and unipolar pacing of left ventricle via coronary sinus branch: longitudinal study

Introduction

The aim of this paper is to first monitor the changes in the capture threshold of endovascularly placed leads for left ventricle pacing, second to compare the pacing configurations, and third to verify the effect of Steroid elution for endovascular leads.

Sample and Method

The study included 202 consecutive single centre patients implanted with the Quartet™ lead (St. Jude Medical). The capture threshold and related lead parameters were tested during implantation, on the day of the patient's discharge, and 3, 9, and 15 months after implantation. The electrical energy corresponding to the threshold values for inducing ventricular contraction was recorded for subgroups of patients with bipolar and pseudo-unipolar pacing vectors and electrodes equipped with and without a slow-eluting steroids. The best setting for the resynchronization effect was generally chosen. Capture threshold was taken as a selection criterion only if there were multiple options with (expected) similar resynchronization effect.

Results and Discussion

The measurements showed that the ratio of threshold energies of UNI vs. BI was 5× higher (p < 0.001) at implantation. At the end of the follow-up, it dropped to 2.6 (p = 0.012). The steroid effect in BI vectors was caused by a double capture threshold in the NSE group compared to the SE group (p < 0.001), increased by approximately 2.5 times (p < 0.001). The study concludes that after a larger initial increase in the capture threshold, the leads showed a gradual increase in the entire set. As a result, the bipolar threshold energies increase, and the pseudo-unipolar energies decrease. Since bipolar vectors require a significantly lower pacing energy, battery life of the implanted device would improve. When evaluating the steroid elution of bipolar vectors, we observe a significant positive effect of a gradual increase of the threshold energy.

Left Atrial Appendage Closure versus Non-Warfarin Oral Anticoagulation in Atrial Fibrillation: 4-Year Outcomes of PRAGUE-17

BACKGROUND

The PRAGUE-17 trial demonstrated that left atrial appendage closure (LAAC) was non-inferior to non-warfarin oral anticoagulants (NOAC) for preventing major neurological, cardiovascular or bleeding events in high-risk patients with atrial fibrillation (AF).

OBJECTIVE

To assess the pre-specified long-term (4-year) outcomes in PRAGUE-17.

METHODS

PRAGUE-17 was a randomized non-inferiority trial comparing percutaneous LAAC (Watchman or Amulet) with NOACs (95% apixaban) in non-valvular AF patients with a history of cardioembolism, clinically-relevant bleeding, or both CHA₂DS₂-VASc > 3 and HASBLED > 2. The primary endpoint was a composite of cardioembolic events (stroke, transient ischemic attack, or systemic embolism), cardiovascular death, clinically-relevant bleeding, or procedure/device-related complications (LAAC group only). The primary analysis was modified intention-to-treat (mITT).

RESULTS

We randomized 402 AF patients (201 per group, age 73.3±7.0 years, 65.7% male, CHA₂DS₂-VASc 4.7+1.5, HASBLED 3.1+0.9). After 3.5 years median follow-up (1,354 patients-years), LAAC was non-inferior to NOAC for the primary endpoint by mITT (subdistribution hazard ratio[sHR] 0.81, 95% CI 0.56-1.18; p=0.27; p for non-inferiority=0.006). For the components of the composite endpoint, the corresponding sHRs (and 95% CIs) were 0.68 (0.39-1.20; p=0.19) for cardiovascular death, 1.14 (0.56-2.30; p=0.72) for all-stroke/TIA, 0.75 (0.44-1.27; p=0.28) for clinically-relevant bleeding, and 0.55 (0.31-0.97; p=0.039) for non-procedural clinically-relevant bleeding. The primary endpoint outcomes were similar in the per-protocol [sHR 0.80 (95% CI 0.54-1.18), p=0.25] and on-treatment [sHR 0.82 (95% CI 0.56-1.20), p=0.30] analyses.

CONCLUSION

In long-term follow-up of PRAGUE-17, LAAC remains non-inferior to NOACs for preventing major cardiovascular, neurological or bleeding events. Furthermore, non-procedural bleeding was significantly reduced with LAAC.

Ablation strategies for different types of atrial fibrillation in Europe: results of the ESC-EORP EHRA Atrial Fibrillation Ablation Long-Term registry

AIMS

The ESC EORP EHRA Atrial Fibrillation (AF) Ablation Long-Term registry was designed to assess management and outcomes of AF catheter ablation procedures in Europe. To investigate the current ablation approaches and their outcomes for patients with paroxymal AF (PAF) and non-PAF in Europe.

METHODS AND RESULTS

Data from index ablations were collected in 27 European countries at 104 centres in a prospective fashion. Pre-procedural, procedural, and 1-year follow-up data were captured on a web-based electronic case record form. Data on the ablation procedure were available for 3446 patients. Of these, 2513 patients and 933 patients underwent pulmonary vein isolation (PVI) or PVI plus (PVIplus) additional ablation, respectively. The ablation strategy was limited to PVI in 81% and 56% of patients in the PAF and non-PAF group, respectively (P < 0.001). In the non-PAF group, left atrial linear ablation and ablation of complex fragmented atrial electrograms were more commonly performed. Arrhythmias recurrence after PVI was 29% and 39% in the PAF and non-PAF group, respectively (P < 0.001) and 42% after PVIplus in both groups. Atrial fibrillation related hospital admissions were more common in the PVIplus group (20% vs. 14%). A very low procedural complication rate was observed. No relevant differences were observed with regard to repeat ablation (PVI 9% and PVIplus 11%).

CONCLUSION

In patients with PAF and non-PAF, the ablation strategies of PVI and PVIplus led to similar arrhythmia-free survival rates after 1 year. A considerable hospital readmission rate was noted.

Midterm outcomes of mini-invasive surgical and hybrid ablation of atrial fibrillation

BACKGROUND

We evaluated the feasibility and effectiveness of thoracoscopic and a staged surgical and transcatheter ablation technique to treat stand-alone atrial fibrillation (AF).

METHODS

. Between 2009 and 2016, a cohort of 65 patients underwent bilateral totally thoracoscopic ablation of symptomatic paroxysmal AF (n=30; 46%), persistent AF (n=18; 28%) or long-standing persistent AF (n=17; 26%) followed by catheter ablation in case of AF recurrence. Surgical box lesion procedure included bilateral pulmonary vein and left atrial posterior wall ablation using irrigated bipolar radiofrequency with documentation of conduction block.

RESULTS

There were no intra- or peri-operative ablation-related complications. There was no operative mortality, no myocardial infarction, and no stroke. Skin-to-skin procedure time was 120.5 ± 22.0 min and the postoperative average length of stay was 8.1 ± 3.0 days. At discharge, 60 patients (92%) were in sinus rhythm. Median follow-up time was 866 days (IQR, 612-1185 days). One-year success rate after surgical procedure was 78% (off antiarrhythmic drugs). Eleven patients (17%) underwent catheter re-ablation. Sixty (92%) patients were free of atrial fibrillation after hybrid ablation (on demand) at 1 year follow up after the last ablation. The success at 24-months was achieved in 96% (paroxysmal) and 78% (persistent) patients. At the last follow-up control, 69% patients discontinued oral anticoagulant therapy.

CONCLUSIONS

. Combination of mini-invasive surgical and endocardial treatment (two-stage hybrid procedure) is a safe and effective method for the treatment of isolated (lone) AF. This procedure provided good midterm outcomes.

Interventional left atrial appendage closure vs novel anticoagulation agents in patients with atrial fibrillation indicated for long-term anticoagulation (PRAGUE-17 study)

Atrial fibrillation (AF), with a prevalence of 1% to 2%, is the most common cardiac arrhythmia. Without antithrombotic treatment, the annual risk of a cardioembolic event is 5% to 6%. The source of a cardioembolic event is a thrombus, which is usually formed in the left atrial appendage (LAA). Prevention of cardioembolic events involves treatment with anticoagulant drugs: either vitamin K antagonists or, recently, novel oral anticoagulants (NOAC). The other (nonpharmacologic) option for the prevention of a cardioembolic event involves interventional occlusion of the LAA.

OBJECTIVE

To determine whether percutaneous LAA occlusion is noninferior to treatment with NOAC in AF patients indicated for long-term systemic anticoagulation.

STUDY DESIGN

The trial will be a prospective, multicenter, randomized noninferiority trial comparing 2 treatment strategies in moderate to high-risk AF patients (ie, patients with history of significant bleeding, or history of cardiovascular event(s), or a with CHA₂DS₂VASc ≥3 and HAS-BLED score ≥2). Patients will be randomized into a percutaneous LAA occlusion (group A) or a NOAC treatment (group B) in a 1:1 ratio; the randomization was done using Web-based randomization software. A total of 396 study participants (198 patients in each group) will be enrolled in the study. The primary end point will be the occurrence of any of the following events within 24months after randomization: stroke or transient ischemic attack (any type), systemic cardioembolic event, clinically significant bleeding, cardiovascular death, or a significant periprocedural or device-related complications.

CONCLUSION

The PRAGUE-17 trial will determine if LAA occlusion is noninferior to treatment with NOAC in moderate- to high-risk AF patients.

Cardiac resynchronization therapy in clinical responders: right ventricular echocardiographic changes at mid-term follow-up

OBJECTIVE

The objective of this study was to assess the mid-term effects of cardiac resynchronization therapy on systolic function and remodelling of the right ventricle in clinical responders and non-responders.

METHODS

A biventricular system was implanted between July 2005 and May 2008 in 58 patients with heart failure NYHA class II-IV. At baseline, three and 15 months after implantation, the following parameters were determined: NYHA class, quality of life, six-minute walk test, echocardiography including assessment of right ventricular systolic function by tricuspid annular plane systolic excursion and by pulsed tissue Doppler imaging (myocardial peak systolic velocity was measured at the tricuspid annulus). We also assessed the presence of ventricular dyssynchrony.

RESULTS

There were no significant changes after three months of cardiac resynchronization therapy on right ventricular systolic function and remodelling in responders and non-responders. Among responders, we found a statistically significant improvement of right ventricular systolic function and also a significant decrease in the size of the right ventricle after 15 months of therapy (systolic excursion before therapy 17.8 +/- 4.0 mm vs. 19.4 +/- 3.7 mm, P < 0.05, after therapy; peak systolic velocity initially 11.9 +/- 2.9 cm/s vs 12.7 +/- 3.2 cm/s; right ventricle size before therapy 29.3 +/- 5.0 mm vs. 27.8 +/- 4.2 mm, P < 0.05, after therapy. These changes were not observed in non-responders.

CONCLUSIONS

Fifteen months after cardiac resynchronization therapy, we found a statistically significant improvement of right ventricular systolic function and a significant reduction of right ventricular size in responders to cardiac resynchronization therapy.

Echocardiographic changes after cardiac resynchronisation therapy

BACKGROUND AND AIM

The aim of this prospective study was to evaluate echocardiographic changes in clinical responders and nonresponders after 3 and 15 months of cardiac resynchronisation therapy (CRT).

METHODS

Fifty eight patients in whom a biventricular system was implanted between 2005 and 2008 were followed up at 3 and at 15 months. Clinical and echocardiography parameters including intra- and interventricular dyssynchrony were assessed at baseline and after 3 and 15 months of CRT. Every patient in whom quality of life, New York Heart Association (NYHA) class and/or 6-minute walk test (6MWT) improved (improvement of ≥ 1 NYHA class, 6MWT by more than 10%), and who was neither in hospital for heart failure nor died for cardiac reasons, was categorised as a clinical responder.

RESULTS

In the responders' group, we found a significant improvement of right ventricular systolic function and a decrease in the size of the right ventricle (RV) only after 15 months (tricuspid annular plane systolic excursion [TAPSE] 17.8 ± 4.0 mm to 19.4 ± 3.7 mm, p 〈 0.05, RV diameter 29.3 ± 5.0 mm to 27.8 ± 4.2 mm, p 〈 0.05). Significant improvement of other monitored parameters occurred 3 months after CRT implantation: left ventricle (LV) end-diastolic diameter 70.5 ± 7.8 mm to 66.1 ± 8.3 mm, p 〈 0.001, LV ejection fraction 22.0 ± 5.4% to 27.1 ± 9.8%, p 〈 0.05, pulmonary artery pressure (peak gradient of tricuspid regurgitation) 37.1 ± 14.8 mm Hg to 27.6 ± 8.9 mm Hg, p 〈 0.001, tricuspid regurgitation (grade) 1.9 ± 0.9 to 1.5 ± 0.6, p 〈 0.05, mitral regurgitation (grade) 2.6 ± 0.9 to 2.2 ± 0.9, p 〈 0.001, LV dP/dt max (peak positive rate of pressure rise [slope of mitral regurgitant jet]) 482.4 ± 155.4 mm Hg/s to 981.2 ± 654.5 mm Hg/s, p 〈 0.001, velocity time integral (VTI) in LV outflow tract (LVOT) 14.1 ± 4.3 cm to 16.7 ± 4.1 cm, p 〈 0.001. In the group of nonresponders, only 2 parameters improved significantly: LV dP/dt max 561.2 ± 347.9 mm Hg/s to 1024.5 ± 745.3 mm Hg/s, p 〈 0.001, and LVOT VTI 14.5 ± 3.0 cm to 16.3 ± 2.9 cm, p 〈 0.001. Other echocardiographic parameters did not show any important changes, and no changes occurred between 3 and 15 months. On the contrary, after 15 months we saw significant progression of tricuspid regurgitation in nonresponders. In multivariate analysis, combination of baseline delay between time to peak systolic velocity in ejection phase at basal septal and basal lateral segments (Ts-lateral-septal delay) and serum creatinine was a strong predictor of clinical CRT response (area under curve was 0.80, percentage of correct decision was 82%).

CONCLUSIONS

In the group of responders, significant changes of most monitored echocardiographic parameters were observed 3 months after CRT implantation. The only parameters which changed significantly after 15 months, but not previously, were the systolic function of the RV and the decrease in the RV size. In the group of nonresponders, these changes were not observed.

Thoracoscopic left ventricular lead implantation

OBJECTIVE

Cardiac resynchronization therapy is a therapeutic option in patients with chronic heart failure. Epicardial lead implantation for biventricular pacing is usually the method of second choice after failed coronary sinus cannulation. The present study describes an initial experience with minimally invasive surgical lead implantation using thoracoscopy.

METHODS

Since August 2008, a total of 17 patients (mean age 69.6 + 11.1 years) with congestive heart failure, NYHA functional class 3.1 +/- 0.4, and depressed ejection function (24.8% +/- 5.7%) were referred for surgery because of failed left ventricular lead implantation through the coronary sinus. Under single-lung ventilation and video-assisted thoracoscopy, epimyocardial steroid-eluting screw-in leads were implanted on the left ventricular free wall.

RESULTS

There were no in-hospital deaths or major co-morbidities. The mean skin-to-skin operating time was 115.9 +/- 32.1 min, and the post-operative average length of stay was 8.4 +/- 2.5 days. Intraoperative acute threshold capture of the left ventricular lead was 0.88 +/- 0.54 V/0.5 ms, and the value of lead impedance was 434.7 +/- 110.8 Omega. Extension to a small thoracotomy was necessary in 1 patient to stop epicardial vein bleeding.

CONCLUSION

Minimally invasive left ventricular lead implantation is a safe procedure with excellent acute threshold capture.

[Long-term outcome of catheter ablation therapy of supraventricular tachyarrhythmias]

AIM

The aim of the article is presentation of our results and experiences with radiofrequency catheter ablation (CA) in the therapy of supraventricular tachyarrhythmias.

PATIENTS AND METHODS

From 1996 to 2009, 1 485 patients underwent CA (total procedure number - 1 627). The group consist of 772 patients with paroxysmal atrioventricular nodal reentry tachycardia (AVNRT): 484 women, mean age 50.3 +/- 16.4 years; 312 patients with atrioventricular reentry tachycardia (AVRT): 145 women, mean age 40.1 +/- 14.9 years; 391 patients with typical atrial flutter (AF): 96 women, mean age 61.6 +/- 11 years; and 64 patients with atrial tachycardia (AT): 35 women, mean age 53.6 +/- 14.2 years, focal AT 33, macroreentrant AT 31. CA was performed for more than one type of arrhythmia in 54 patients.

RESULTS

Acute ablation success was achieved in 98.7% of patients with AVNRT, 94.6% of patients with AVRT, 97.7% of patients with AF, and 81.3% of patients with AT. Serious procedure complications occurred in 22 patients (1.4%). The recurrence rate was 1.8-12.5%. 88 patients underwent successful reablation procedure. Long-term ablation success was achieved in 89-99% of patients depending on the different type of arrhythmia. During the long-term follow-up (mean 73 +/- 38 months) died 23 patients, the most common cause of death was malignancy (9 patients).

CONCLUSION

Our long-term experience and good results documented high success rate and safety of radiofrequency catheter ablation in the therapy of patients with supraventricular tachyarrhythmias.

[Improvement of quality of life after ablation of longstanding persistent versus paroxysmal atrial fibrillation: results of 2-year follow-up]

AIMS

The purpose of the study was to assess quality of life and socio-economic parameters in patients after ablation of paroxysmal versus longstanding persistent atrial fibrillation (AF).

METHODS

The study included 89 patients with paroxysmal AF and 56 patients with longstanding persistent AF who underwent ablation within 1 year, and were afterwards prospectively followed up for 2 years. Quality of life was evaluated by the EQ-5D questionnaire before and every 6 months after ablation.

RESULTS

Objective, respectively subjective quality of life at baseline was lower in patients with longstanding persistent AF (67 +/- 16 vs 71 +/- 10; p = 0.01, resp. 64 +/- 12 vs 67 +/- 16; p = 0.07); however, after 2 years, it exceeded that of the patients with paroxysmal AF (80 +/- 17 vs 75 +/- 18; p = 0.03; resp. 73 +/- 13 vs 70 +/- 17; p = 0.18). The baseline-2 year difference in improvement was higher in patients with longstanding persistent AF in both objective (p = 0.001) and subjective component (p = 0.05). Both groups displayed significant decrease in the days of hospitalization, and the days of working incapacity.

CONCLUSION

Patients with longstanding persistent AF exhibit worse baseline quality of life than the patients with paroxysmal AF, and higher quality of life improvement after ablation.

Hemostatic changes before and during electrophysiologic study and radiofrequency catheter ablation

We sought to investigate specific hemostasis activation markers during electrophysiologic study (EPS) with consequent radiofrequency catheter ablation (RFA). Sixty patients were studied prospectively during routine EPS with RFA for paroxysmal supraventricular tachycardia. Blood samples were drawn before the insertion of venous sheaths (T0), at the end of EPS (T1), and 30 min after completion of RFA (T2). To study coagulation and fibrinolytic and platelet activity, we measured concentrations of thrombin-antithrombin III (TAT), D-dimers (DD), plasminogen activator inhibitor type 1 (PAI-1), tissue-type plasminogen activator (t-PA), and circulating platelet aggregates. The results are expressed as median and show 95% confidence levels. Levels of DD increased from 0.24 mg/L at T0 to 0.37 mg/L at T1 (P < 0.001) and to 0.59 mg/L at T2 (P < 0.001). TAT levels increased from 5.29 μg/L at T0 to 35.80 μg/L at T1 (P < 0.001) and decreased to 26.30 μg/L at T2 (P < 0.001). PAI-1 concentration decreased from 30.10 μg/L at T0 to 26.4 μg/L at T1 (P < 0.001). t-PA at T2 increased to 5.10 μg/L from 4.75 μg/L at T1 (P = 0.001). No other differences between corresponding medians were statistically significant (P > 0.05). We found that concentrations of DD at T2 versus T1 depended on the number of radiofrequency energy applications (r (S) = 0.387; P = 0.002). Marked platelet activation was observed from the start of the procedure, without changes during the procedure.

High-sensitivity troponin T as a marker of myocardial injury after radiofrequency catheter ablation

Background

The aim of our study was to monitor radiofrequency catheter ablation-induced myocardial damage by measuring high-sensitivity cardiac troponin T (hs-cTnT).

Methods

Serum concentrations of hs-cTnT (Elecsys 2010 system, Roche) were measured in 73 healthy blood donors and serially in 27 patients who had samples taken both before and 24 h after radiofrequency ablation (RFA) for atrioventricular nodal re-entry tachycardia (AVNRT), atrial fibrillation (AF) or right atrial flutter (AFL).

Results

Significant increases of hs-cTnT were seen in patients after RFA (AVNRT: P = 0.0115, AF: P = 0.0011, AFL: P = 0.0009). Postprocedural serum hs-cTnT correlated with the number of radiofrequency applications and with the duration of RFA procedure. Spearman's coefficient of rank correlation ( r) were as follows: hs-cTnT versus RFA duration: r = 0.771 ( P < 0.001); hs-cTnT versus number of pulses: r = 0.708 ( P < 0.001). Patients with the diagnosis of AVNRT had lower serum hs-cTnT concentration after RFA compared with AFL ( P < 0.0001) and AF ( P < 0.0001) patients.

Conclusions

Our data indicate that RFA causes a significant increase of serum hs-cTnT concentration that could be used to monitor myocardial injury.

Longterm remission of left posterior fascicular ventricular tachycardia due to mechanical trauma

We present a case of a 28 year old woman with paroxysmal left posterior fascicular ventricular tachycardia (LPFVT). Ventricular tachycardia was not inducible after completing of left ventricle 3D reconstruction. Even though catheter ablation was not performed, no LPFVT recurrence has been documented during 60 months follow-up. We surmise that we caused mechanical trauma during the mapping of the posterior fascicle that damaged arrhythmogenic structures and subsequently led to long term remission of the left posterior fascicular ventricular tachycardia.

Bland-White-Garland syndrome in adults: sudden cardiac death as a first symptom and long-term follow-up after successful resuscitation and surgery

Two cases (a 23-year-old man and a 33 year-old-woman) with Bland-White-Garland (BWG) syndrome (an anomalous origin of the left coronary artery from the pulmonary artery) are presented. Their first symptom was survived sudden cardiac death. Both patients underwent surgical repair. One patient received an implantable defibrillator because of serious structural changes in the left ventricle and symptomatic non-sustained ventricular tachycardia; the second patient is free of therapy. During long-term follow-up (10.5 and 4.5 years, respectively), ventricular tachyarrhythmias did not recur. Both cases show good long-term prognosis in resuscitated adult patients after surgical repair for BWG syndrome regardless of the presence of structural changes.

Cavotricuspid Isthmus Catheter Ablation Across an Inferior Vena Cava Filter

Patients who suffer from recurrent thromboembolic events often receive an inferior vena cava (IVC) filter. There are few data available regarding treatment of this patient population with catheterization interventions, especially catheter ablation. We report a case of cavotricuspid isthmus catheter ablation across an IVC filter.

[Can we cure atrial flutter with radiofrequency ablation in an hour?]

BACKGROUND

Radiofrequency ablation of common atrial flutter requires the creation of a complete transmural ablation line across cavotricuspid region to achieve bidirectional conduction block. Irrigated tip catheters facilitate rapid achievement of this block by creation larger and deeper lesions. The EASTHER registry was organized to collect data about the efficacy of the procedure in small and middle volume centres in Central and Eastern Europe, all using THERMOCOOL catheter technology.

METHODS

Easther is a prospective registry (April 2002-February 2003). 133 consecutive patients (81.1% male, age 59.0 +/- 10.4 years, range 30-81 years) with common atrial flutter were enrolled. Coincidence with atypical flutter was observed in 2.7%. Patients had a history of flutter of 31.0 +/- 53.6 month (range 1-403) and concomitant atrial fibrillation was observed in 42.9%. Structural heart disease was present in 38.9%. Amount of re-ablated cases was 14%. RF energy was applied during 60 sec in power-controlled mode at a setting between 40 to 50 W with an average flow rate of 19.0 ml/min.

RESULTS

Acute success rate defined as bi-directional block was achieved in 93.1%, although 94.7% of cases were assessed successful by the treating electrophysiologist. Average number of RF applications was 12.0 +/- 7.0 (range 2-40) per procedure. Average delivered power varied between a minimum of 36.1 +/- 15.1 W till a maximum of 45.3 +/- 13.0 W, while the average maximum temperature observed at the same time was varied between 39.0 +/- 3.4 degrees C and 45.4 +/- 4.0 degrees C. Total procedure time was 100.1 +/- 42.7 min (range 20-280 min) and fluoroscopy time was 15.8 +/- 9.6 min (range 4-45 min). In comparable French TC registry Average total and fluoroscopy time were 46.4 +/- 33.6 min, and 10.0 +/- 6.8 min resp. In the Middle European centres total and fluoroscopy time was 96.1 +/- 40.9 min, and 15.0 +/- 8.9 min resp. In centres from Eastern Europe it was 120.3 +/- 51.2 min, and 20.4 +/- 11.9 min resp. Two adverse events were reported. Both patients had strong chest pain during ablation. These results are comparable with the literature data published.

CONCLUSIONS

Irrigated tip catheters are effective and safe in ablation of common atrial flutter. This technology helps to accelerate and facilitate achievement of bi-directional isthmus block. Most of procedures were terminated to one hour in experienced centers in France as early as 2002. Procedures not exceeding one hour are feasible in case of spreading this method as method of first choice with gaining of experiences in centres of Middle and Eastern Europe.

[The activation of haemostasis during radiofrequency catheter ablation]

The aim of the study was to investigate chosen haemostasis activation markers during electrophysiologic study (EPS) with consequent radiofrequency catheter ablation (RFA). Sixty-three patients were studied prospectively. Indications for EPS and RFA were supraventricular tachycardias with the arrhythmogenic substrate located in the right atrium. Blood samples were drawn 24 hours before the procedure (T -1), at the beginning of the procedure (T0), at the end of EPS (T1), 30 minutes after completion of RFA (T2), and 24 hours after the procedure (T3). To study coagulation, fibrinolytic and platelet activation were measured concentrations of thrombin-antithrombin III (TAT), D-dimers (DD), platelet count and parameters, and circulating platelet aggregates (CPAi). During the EPS and RFA, TAT levels increased from the baseline 5.03 +/- 2.53 microg/l (T -1) to 12.90 +/- 12.83 microg/l at T0 (p < 0.001) to 36.07 +/- 15.59 microg/l at T1 (p < 0.001) and decreased to 28.85 +/- 13.14 microg/l at T2 (p < 0.001). Levels of DD increased from 0.30 +/- 0.20 mg/l at T0 to 0.44 +/- 0.25 mg/l at T1 (p < 0.001) and to 0.87 +/- 0.74 mg/l at T2 (p < 0.001). The number of platelets was significantly decreased (-13.7%) before and during the procedure (T -1 vs. T3; p < 0.001). Marked platelet activation (CPAi 0.62 +/- 0.32) was observed before the procedure opposite to the physiological values (CPAi 1.0 +/- 0.1), without changes during the procedure (CPAi at T2 0.69 +/- 0.23). Our results confirmed activation of several haemostasis parameters during EPS and RFA, and support eligibility of the antithrombotic prevention in patients indicated for EPS and RFA.

[Syncope in ventricular tachycardia as a first clinical sign of patent ductus arteriosus in an adulthood]

The case-report describes a 48-year-old-female patient with the patent ductus arteriosus with the following structural changes leading to the malignant arrhythmias manifested as a syncope. The patient was treated by Amplatzer occluder and the implantation of the cardioverter-defibrillator. The authors discuss the patent ductus arteriosus, arrhythmias and sudden cardiac death in the patients with the congenital heart disease in an adulthood.

[Ventricular fibrillation in chronic heart disease]

The objective of the work was to describe in subjects with spontaneous ventricular fibrillation, after elimination of acute cardiac disease, the strategy of antiarrhythmic treatment and to evaluate, based on prospective follow-up, the effectiveness of this treatment. The authors included in the group 36 patients (30 men and 6 women) within the range from 34 to 78 years (mean age 58 +/- 11 years) with spontaneous ventricular fibrillation. They divided the group into a subgroup (15 subjects) without revascularization of the heart muscle, into a subgroup (17 subjects) with revascularization of the myocardium (coronary angioplasty and bypasses) and a subgroup (4 subjects) where ischaemic heart disease was ruled out (mostly cardiomyopathies). In all subgroups they used programmed ventricular stimulation (apparatuses of Quinton Co. USA, Biotronik Co. GFR), in the subgroup with revascularization within 3 months. During the diagnostic procedure of ventricular stimulation they tested antiarrhythmic drugs most frequently amiodarone per os (for 4 weeks). An implantable cardioverter--defibrillator was implanted in 17 patients (8 subjects without revascularization, 6 subjects with revascularization, 3 subjects without ischaemic heart disease). All patients were followed up till death, maximum 24 months. The authors evaluated the rate of cardiac deaths (death on cardiac grounds, incl. sudden arrhythmic death) and sudden arrhythmic deaths (within one hour after the onset of symptoms or the first malignant ventricular tachyarrhythmia recorded after implantation of the defibrillator). In the subgroup without revascularization with electric instability of the ventricles according to programmed stimulation 66.7% they described seven cardiac deaths (46.7%) and 6 sudden "arrhythmic" deaths (40%) incl. 5 subjects with ineffective testing of antiarrhythmic drugs. Conversely in the subgroup with revascularization and with diagnostic programmed stimulation in 47.1% they found 3 cardiac deaths (17.7%), one sudden "arrhythmic" death (5.9%)--a subject with ineffective testing. In the subgroup without ischaemic heart disease they recorded cardiac and sudden "arrhythmic" deaths in half the subjects, in all instances in subjects without inducible ventricular tachyarrhythmia. The authors found in the course of a two-year investigation a relapse of cardiac arrest in 25% of subjects after spontaneous ventricular fibrillation. A third of these subjects (all without a cardioverter-defibrillator) died. They confirm the benefit of implantation of a defibrillator for all subjects regardless of the basic diagnosis and revascularization of the heart muscle.

[Myocardial revascularization in malignant ventricular tachyarrhythmia--prognostic significance]

BACKGROUND

The survival of patients with chronic ischaemic heart disease and malignant ventricular tachyarrhythmia is influenced positively in some instances by revascularization of the heart muscle and implantation of a cardioverter-defibrillator. The objective of the submitted work was to evaluate by perspective follow-up of subjects with chronic ischaemic heart disease and malignant ventricular tachyarrhythmia: a) the effect of revascularization of the heart muscle on the prognosis, making use of programmed stimulation of the ventricles and testing the effectiveness of antiarrhythmic treatment; b) the importance of implantation of a cardioverter-defibrillator in revascularized and non-revascularized subjects for the prevention of sudden "arrhythmic" deaths.

METHODS AND RESULTS

The authors examined 37 patients (32 men and 5 women), age bracket 34 to 78 years (mean age 61 +/- 11) with IHD and spontaneous ventricular tachyarrhythmia after ruling out acute myocardial infarction. The group was divided into sub-groups without revascularization (21 subjects) and with revascularization (16 subjects). In both sub-groups programmed stimulation of the ventricles was implemented. During the diagnostic finding of programmed stimulation they tested antiarrhythmic drugs, most frequently amiodarone administered orally. A cardioverter-defibrillator was implanted to 10 patients. All patients were followed-up to death, the longest period being 24 months. They evaluated the frequency of cardiac deaths (death on cardiac grounds incl. sudden "arrhythmic" death) and sudden "arrhythmic" deaths (death within on hour after onset of symptoms or first recorded malignant ventricular tachyarrhythmia). In the sub-group without revascularization with diagnostic inducibility of the heart muscle in 85.7% of patients the authors described 9 cardiac deaths (42.9%) and 8 sden "arrhythmic" deaths (38.1%). Conversely in the sub-group with revascularization and with diagnostic programmed stimulation of the ventricles in half the subjects 5 clinical deaths were found (31.3%) and 3 sudden "arrhythmic" deaths (18.8%). Analysis of 11 sudden "arrhythmic" deaths revealed that no subjects with an implanted cardioverter-defibrillator (5) died (documented malignant ventricular tachyarrhythmia). Five of the six patients who died (all without a cardioverter-defibrillator) were not revascularized.

CONCLUSIONS

Revascularization of the heart muscle in patients with ischaemic heart disease (after elimination of acute cardiac infarction) and malignant ventricular tachyarrhythmia reduces the risk of relapse of this arrhythmia. The benefit of implantation of a cardioverter-defibrillator was recorded in all subjects regardless of the revascularization of the heart muscle.

[Revascularization of the myocardium and electrical instability of the ventricles]

The objective of the investigation was to evaluate in patients with chronic ischaemic heart disease (IHD) and malignant ventricular tachyarrhythmia the asset of myocardial revascularization for improvemet of the electric instability of the ventricular myocardium and a subsequent outline of the tactics of antiarrhythmic treatment. The authors included in the group a total of 35 patients (30 men and 5 women), age 34-78 years (mean 61 +/- 11) with IHD (according to selective coronarography) with spontaneous ventricular fibrillation (18 sebjects) or persistent (above 30s) marked symptomatic ventricular tachycardia (17 subjects), after ruling out acute cardiac infarction. The group was divided into a subgroups of 16 subjects with revascularization of the heart muscle (coronary angioplasty, coronary bypass) and a subgroup (19 subjects) without revascularization of the hearth muscle. In both groups programmed stimulation of the cardiac chambers was implemented (PSSK) (apparatuses of Qinton Co. USA, Biotronik, GFR), in the subgroup after revascularization within three months. In case of a PSSK finding the authors tested antiarrhythmic drugs, most frequently amiodarone by the oral route (within one month). Treatment not causing permanent ventricular arrhythmia was considered effective. In the subgroup with revascularization the authors described diagnostic PSSK in 8 subject where testing of antiarrhythmics was made in 6 patients (an effective antiarrhythymic agent was found in one instance, i.e. in 16.7%). In the subgroup without revascularization diagnostic PSSK was implemented in 17 subject. Antiarrythmic drugs were tested in 16 patients (effective treatment in 12.5%--always amiodaroe by the oral route). Diagnostic ventricular tachyarrhythmia was found in patients with spontaneous ventricular tachycardia in all instances with revascularization and in 92.3% without revascularization. In patients with spontaneous ventricular fibrillation they proved diagnostic PSSK in 33.3% of the patients with revascularization and in 66.7% without revascularization. The relative number of implantation of cardioverter-defibrillators in group with and without revascularization was similar (25%, 26.3%). Revascularization of the heart muscle in patients with chronic IHD reduces markedly the electric instability of the ventricular heart muscle, in particular in case of spontaneou ventricular fibrillation. Selective coronarography and possibly revascularization of the heart muscle is esential in those patients. The tactics of antiarrhythymic treatment of revascularization of the heart muscle were not affected.