[The role of day hospital in optimization of medical care for patients of a therapeutic department of an outpatient clinic].

Day hospital (DH) provides consultations and treatment for all referred patients according to standards of medical care quality. DH has facilities for therapeutic and gastroenterological patients. Treatment in DH is performed according to current standards which cover basic treatment of the diseases (documented medicines, duration of treatment). Efficacy of DH's use of the Standards of Diagnosis and Therapy of Acid-Dependent Diseases associated with Helicobacter pylori (standards of Moscow consensus) is used as illustration. As a result of treatment in DH 93% outpatients resumed their jobs, improvement occurred in 96.7% patients, a complete response was seen in 23%, 1.9% cases failed treatment. Most DH patients (83%) were satisfied with treatment given in DH and think it a convenient replacement of hospital stay.

[Chronic hepatitis B, hemosiderosis, and hepatic fibrosis in a renal graft recipient].

Chronic hepatitis B is a frequent concomitant disease in recipients of a renal graft that worsens results of kidney transplantation due to renal and extrarenal complications. Much rarer hemochromatosis either has genetic roots (hereditary hemochromatosis) or results from multiple blood transfusions and hemolysis during treatment by hemodialysis (secondary hemochromatosis). Combination of chronic hepatitis B and hemochromatosis increases the risk of chronic liver disease leading to cirrhosis and hepatocellular carcinoma. Success of antiviral therapy combined with massive phlebotomy is illustrated by a case of kidney transplantation to a patient with chronic hepatitis B of large duration and iron overload syndrome.

Treatment of chronic hepatitis B with lamivudine in renal transplant recipients.

Treatment of chronic hepatitis B in renal transplant recipients remains one of the major problems in clinical nephrology. Lamivudine is considered to be a drug of choice for these patients, however, its efficacy in patients with hepatitis B after renal transplantation (RT) has not been completely proven. Twenty-two RT recipients treated with lamivudine were evaluated. The duration of treatment was 15.6+/-1.9 months. Fourteen patients (64%) had normalization of aminotransferase (ALT); in 9 of them (41% of the whole group), serum HBV DNA was eliminated. Serum HBeAg was undetectable in 4 out of 15 (27%) previously positive patients. It has been statistically proven that the efficacy of lamivudine therapy correlates with degree of fibrosis and higher histological activity index values. We could not establish any correlation between the outcome of antiviral therapy and patients' age, sex, conditions of contagion (while on dialysis or after RT), time lapsed after the infection had been detected, duration of post-transplant period, type of immunosuppression, HBeAg positivity or negativity, ALT levels, concomitant HCV infection. The efficacy of antiviral HBV therapy is limited by the duration of lamivudine treatment: in 4 out of 5 patients with virologic response, the viremia condition relapsed several weeks after the medication had been stopped. Two patients continued to sustain their biochemical response and 1 patient had ALT levels elevated to above normal, but the value was almost twice as low as initially reported. Liver biopsy was repeated in 4 RT recipients after the end of antiviral therapy; in 3 of them positive morphologic changes were observed.

[Chronic hepatitis B and C in renal graft recipients].

Clinical and morphological features of chronic hepatitis B (CHB), C (CHC), and B+C (CHB+C) were studied in 283 renal graft recipients. High total bilirubin serum levels were detected significantly more often in CHB and CHB+C patients vs. CHC patients. High ALT activity was noted in 65% of CHB patients and only in 45% of CHC patients (p = 0.003). Stable low activity of hepatitis prevailed in renal recipients; it was noted in 56.7% of CHB patients, 66.2% of CHC patients, and 62% of CHB+C patients. The character of pathomorphological liver changes in chronic viral hepatitis was studied in 53 renal graft recipients using puncture biopsy. Histopathological activity index (HAI, Knodell R.G. et al., 1981) witnessed a more severe liver lesion in CHB vs. CHC and CHB+C. Thus, inflammatory activity in CHB was found to be minimal or low in 13 patients, and moderate or high in 11 patients, whilst a minimal or low activity in CHC or CHB+C was found in 16 and 10 patients, respectively, and a moderate activity was detected only in two and one, respectively (p = 0.016 and 0.024 compared with CHB). Advanced hepatic fibrosis or cirrhosis was significantly more frequent (p = 0.006) in CHB patients (eight out of 24) than in CHC ones (none out of 18). The rate of advanced sclerotic changes in CHB+C was lower (one out of 10 patients) than that in CHB, and similar to CHC. Thus, clinico-morphological manifestations were more prominent in renal graft recipients with CHB vs. CHC.

[Lethal vascular erosion after percutaneous dilatation tracheostomy]. / Tödliche Gefässarrosion nach Dilatationstracheotomie.

We report on a patient who underwent dilatational tracheostomy (Ciaglia technique) because of ARDS. 29 days after the procedure she died of hemorrhage from an arrosion of the bracheocephalic trunk, caused by the cuff of the tracheal cannula. This complication has, so far, been reported only after surgical tracheostomy. The fracture of tracheal cartilages is considered to be the specific cause of this fatal complication. The consequent loss of circular stability of the trachea demands increased cuff insufflation and pressure to tighten the airway. Prevention and therapy consist in control of the cuff pressure and caudal placement of the tracheal cannula.

[Pediatric polytrauma. A retrospective comparison between pediatric, adolescent and adult polytrauma]. / Das polytraumatisierte Kind. Ein retrospektiver Vergleich zwischen polytraumatisierten Kindern, Jugendlichen und Erwachsenen.

Numerous epidemiological studies about multiple trauma patients do not include an analysis of patients under the age of 18. To study this, the data of 682 patients with multiple traumata, treated between 1981 and 1991 at Hannover Medical School, Germany, were retrospectively analyzed. The patients were divided into four age-related groups: preschool age (< 6 years), school age (< 13 years), teenagers (< 18 years) and adults (> or = 18 years). Analyzed were the cause of trauma, localization of injuries and the cause of death. Children were less often injured as passengers in cars, but more often injured as pedestrians and bicyclists than adults. However, children showed a significant higher mortality than adults, with threefold increased risk of death when they injured as passengers in car accidents. In all groups injuries to the head and the legs were most common. Children showed a lower incidence of trauma to the thorax, abdomen, hip and arms than the adult group. Nevertheless, trauma to the thorax, abdomen and head was associated with the highest risk of death in all groups. Spinal cord injuries, especially injuries to the neck, also showed a high risk of death. Children younger than 6 years had the most severe head injuries. Safety improvements for children in cars, helmet usage on bicycles and early training in traffic safety for children might decrease the lethality in this group of trauma patients.

[Evaluation of antiarrhythmic efficacy of sotalol in various doses in patients with ventricular tachyarrhythmias]. / Ocena skutecznosci przeciwarytmicznej sotalolu w róznych dawkach u chorych z komorowymi zaburzeniami rytmu.

UNLABELLED: Antiarrhythmic efficacy of sotalol--noncardioselective beta-adrenergic blocking agent with class III antiarrhythmic action was evaluated in 34 patients [pts] (mean age 55 +/- 11) with chronic ventricular arrhythmias and coronary artery disease, 38% with previous myocardial infarction. Two schedules of dosing were tested: 3 x 80 mg and 2 x 160 mg during 28 days of therapy. Pts with Lown class II and IV arrhythmia derived from 24-hours Holter recording were assigned. Ventricular premature complexes [VPCs] and couplets reduction by 80% and total elimination of runs defined antiarrhythmic efficacy. Proarrhythmia was defined by four times increase in VPCs, ten times increase in couplets and runs or sustained VT episodes. RESULTS: Antiarrhythmic efficacy of two doses of sotalol according to study criterion was: 31% for lower dose (3 x 80 mg) and 24% for higher dose (2 x 160 mg). Overall efficacy for both doses was 55%. According to Morganroth criterion, lower dose was effective in 29% pts and both doses, lower and higher, in 41% pts. According to other commonly used criterion: 70% VPCs reduction, 90% couplets reduction and total elimination of runs, lower dose of sotalol was effective in 32% pts and both doses in 47% pts. Significant reduction of heart rate and prolongation of QT and QTc were observed. In 3 pts QT was prolonged over 500 ms. Proarrhythmia according to Velebit criterion was suspected in one patient after one week of 3 x 80 mg teratment which caused premature cessation of therapy. No significant abnormalities in laboratory values were observed. CONCLUSIONS: Antiarrhythmic efficacy of sotalol was comparable to other studies. Its value in pts with malignant ventricular tachyarrhythmias: sustained ventricular tachycardia and ventricular fibrillation requires further studies with higher number of patients.

[Evaluation of efficacy and mechanism of action of angioplasty and directed atherectomy assisted by intravascular ultrasonography]. / Ocena skutecznosci i mechanizmów dzialania angioplastyki oraz aterektomii kierunkowej za pomoca ultrasonografii wewnatrznaczyniowej.

Intravascular ultrasound (IVUS) is a unique method of coronary lumen visualization enabling also examination the structure of the artery wall. Aim of this study was to assess efficacy and mechanisms of action of balloon angioplasty (PTCA) and directional atherectomy by means of IVUS. IVUS examination was performed before and after mechanical revascularization procedure in 37 pts (DCA-19 pts, PTCA-18 pts). Both PTCA and DCA resulted in enlargement of the coronary artery lumen (2.29 +/- 1.19 mm2 vs 2.93 +/- 1.55 mm2) but, also external diameter of the vessel increased after the procedure (1.94 +/- 1.10 mm2 and 0.74 +/- 1.01 mm2 retrospectively). In 55.6% of cases after PTCA plaque rupture or artery wall dissection was observed, mainly in eccentric lesions (70%). IVUS allowed to recognize details of artery lumen and define efficiency of procedure. In about 15% cases decision to continue PTCA or DCA was made on the basis of IVUS images only. The mechanism in which PTCA modifies the artery lumen is diverse and depends on the structure of lesion. Factors possibly responsible for enlargement of the lumen are: stretching, squeezing and translocation of atheroma as well as cracking and dissections along the arterial wall. DCA effectiveness depends on the withdraw of the atheromatous deposit, however, in over one-half of cases also stretching has some effect.

[Transcatheter radiofrequency bundle branch ablation in bundle branch reentry ventricular tachycardia: report of a case]. / Ablazione transcatetere con radiofrequenza della tachicardia ventricolare da rientro tra le branche: descrizione di due casi.

Two patients with branch to branch ventricular tachycardia (BBVT) are reported: successful radiofrequency catheter ablation of BBVT was performed in both, delivering energy distally to the point where the maximum amplitude of His deflection occurred, so that a wide ventricular deflection was obtained without any atrial electrogram. No significant conduction delay appeared but a right bundle branch block. HV intervals during BBVT resulted equal or longer than in sinus rhythm: whether this was secondary to anatomical or functional variations or to the possibility that the His bundle may be "bystander" in BBVT, is discussed.

The role of catheter ablation in atrial tachycardia, flutter, and fibrillation.

The first experiences of nonpharmacological treatment of ectopic atrial tachycardia (EAT), common atrial flutter (AFl), and atrial fibrillation (AF) were performed by surgical techniques. Many studies reported a very high success rate on the use of catheter ablation with radiofrequency current for the treatment of supraventricular arrhythmias; and recently, various preliminary reports are dedicated to the treatment of EAT, AFl, and AF with that source of energy. To our knowledge 108 cases of EAT treated by catheter ablation of the ectopic focus are reported in the literature with a success rate superior to 90%. On the basis of our personal experience regarding 11 cases (4 of right atrium EAT and 7 of left) we discuss here the essential role of unipolar leads derived from the mapping catheter to select the target for radiofrequency applications. Two hundred and one cases of AFl tested by catheter ablation were previously reported. The majority of them (> 80%) were successfully treated with radiofrequency. Some working groups performed the procedure as the basis of electrophysiological findings, while others preferred an anatomical approach applying radiofrequency energy at the isthmus lying between the coronary sinus ostium and the tricuspid ring, near the vena cava orifice. On the basis of these assumptions, we obtained 83% of final success in 12 cases of AFl treated by radiofrequency. Finally, we discuss the problem related to the modulation of atrioventricular (AV) nodal conduction during AF. In our laboratory, five cases with chronic AF and very fast ventricular response were treated with radiofrequency with a posterior septal approach. In all patients, we obtained very encouraging results with a constant decrease of ventricular rate (from 137 +/- 33 to 69 +/- 14 beats per minute). All cases treated by modulation of AV nodal conduction demonstrated an appropriate chronotropic response to the variations of the functional state that persists during the follow-up. More experience with longer follow-up and accurate pre- and postprocedure evaluations are needed to finalize the most appropriate technique of radiofrequency applications in these cases.

Spontaneous incessant AV reentrant tachycardia related to left bundle branch block and concealed left-sided accessory AV pathway.

Three patients in whom permanent AV reentrant tachycardia became the clinical manifestation of Wolff-Parkinson-White syndrome are described. The substrate for the arrhythmia was created by coexistence of a concealed left-sided accessory pathway and an ipsilateral bundle branch block. Pharmacologic therapy in all three patients failed to control the tachycardia, which in two cases led to severe left ventricular failure. After successful radiofrequency ablation of the accessory pathway (in two) or AV junction (in one), left ventricular function gradually returned to normal.

[Atrioventricular reciprocating tachycardia with QRS type left branch block in patients undergoing radiofrequency catheter ablation: analysis of the substrate and mechanism of tachycardia]. / Tachicardia reciprocante atrioventricolare con QRS tipo blocco di branca sinistra in soggetti da sottoporre ad ablazione transcatetere mediante radiofrequenza: analisi del substrato e del meccanismo della tachicardia.

BACKGROUND: Among patients (pts) with atrioventricular accessory pathway (AP), some cases show wide complex arrhythmias with different QRS morphology. In a subset of these pts, an atrioventricular reentrant tachycardia with left bundle branch block morphology (LBBBM-AVRT) is observed. The aim of this study is: 1) to identify the substrate and the reentrant mechanism underlying the LBBBM-AVRT in pts undergoing radiofrequency catheter ablation (RFCA) of AP; 2) to report the results achieved by RFCA of the identified substrate. METHODS: From May 1991 to April 1993, among the 168 pts who underwent RFCA for arrhythmias related to an AP, 12 (7.1%) (8M, 4F, mean age 35 +/- 21 yrs, range 8-65) showed LBBBM-AVRT, alone or associated with other arrhythmias. Pts, in whom LBBBM was rate-related during orthodromic AVRT, were excluded from this study. During sinus rhythm, QRS complex was normal in 1 pt, while ventricular preexcitation due to a right-sided Kent bundle (KB) was present in 4 pts; among the other pts without preexcitation, 3 showed left bundle branch block (LBBB) and 4 right bundle branch block. In 2 pts, an Ebstein disease was present, while dilated cardiomyopathy was observed in another. The LBBBM-AVRT was iterative in 3 pts and in 6 pts it was the only arrhythmia observed; the mean tachycardia cycle length was 341 +/- 49 msec (range 250-428). In 1 pt, the LBBBM-AVRT was induced only after successful RFCA of a right-sided AP, responsible for orthodromic AVRT. All pts underwent diagnostic electrophysiologic study and RFCA during the same session. RESULTS: In 6/12 pts one or more KBs were observed, while in the remaining 6 an atrioventricular or atriofascicular "Mahaim like" bundle (MB) was present; the patient population was divided into 4 groups on the basis of the substrate and the reentrant mechanism responsible for LBBBM-AVRT. In Group 1, 3 pts were included: the LBBBM-AVRT was an orthodromic AVRT involving the nodal conduction antegradely (showing LBBB also during sinus rhythm) and a left-sided unidirectional KB, retrogradely. In all the 3 pts, the LBBBM-AVRT was iterative and not controlled by antiarrhythmic agents and RFCA of the KB abolished the arrhythmia. Two further pts were included in Group 2: in these pts with multiple bilateral KBs, the LBBBM-AVRT involved a right-sided KB antegradely and a left-sided one, retrogradely. In these 2 pts both KBs were successfully ablated. In 1 pt, considered in Group 3, the LBBBM-AVRT was sustained by an antidromic circuit involving a right-sided KB antegradely and the nodal conduction retrogradely; in this pt the KB was completely interrupted after two RFCA procedures. The remaining 6 pts with MB were included in Group 4: at least one associated electrophysiologic abnormality was present in all (dual A-V nodal pathway in 4/6 and a right-sided KB in 4/6); Ebstein disease was also observed in 2 of them. In 4/6 pts the LBBBM-AVRT was an antidromic tachycardia involving the nodal conduction retrogradely and the MB antegradely; in 3/4 pts the MB was ablated (along with a nodal reentrant tachycardia in 1 pt), while in the remaining pt in whom the non-sustained LBBBM-AVRT, inducible only after RFCA of a right-sided KB, had not been clinically observed, no further ablation was mandatory. In the remaining 2 pts in Group 4, the LBBBM-AVRT was due to the involvement of MB in other arrhythmias such as an AVRT due to a right-sided KB and a "slow-slow" nodal reentrant tachycardia, respectively; the LBBBM-AVRT were abolished by RFCA of these two underlying arrhythmias. All pts are asymptomatic during a 7.9 +/- 6.9 months follow-up. CONCLUSIONS: The LBBBM-AVRT is observed in a minority (7.1%) of the cases referred for RFCA of AP. (ABSTRACT TRUNCATED)

[Radiofrequency catheter ablation in patients with Mahaim-type slow-conduction accessory right atrioventricular pathway]. / Ablazione transcatetere mediante radiofrequenza in pazienti con via anomala atrioventricolare destra a conduzione lenta tipo Mahaim.

In some cases undergoing radiofrequency catheter ablation (RFCA) of accessory pathway (AP), a Mahaim-like right-sided atrioventricular AP (M-AP) showing slow and decremental conduction is observed. Among 200 consecutive patients referred to our Institution up to September 1993 for arrhythmias related to an AP and undergoing RFCA, 8 patients (6 males, 2 females; mean age 24 +/- 8 years, range 8-35) showed a M-AP. Seven out of 8 patients have been complaining episodes of palpitation for 13 +/- 7 years (range 1-20), while 1 subject was an asymptomatic young athlete. In 2/8 patients an Ebstein disease (Eb) was present and they had previously undergone right-sided Kent bundle (Kb) ablation elsewhere. During sinus rhythm, QRS was normal in 1 patient, while it showed ventricular preexcitation due to right-sided Kb in 3 patients and right bundle branch block in another 4 patients. A left bundle branch block morphology (LBBBM) reentrant tachycardia (RT) was observed in 7 patients (in 1, only after RFCA of a right-sided Kb); 3 showed also orthodromic RT. In the asymptomatic young athlete, a preexcitation atrial fibrillation with very rapid ventricular response was inducible. All patients underwent diagnostic electrophysiologic (EP) study and RFCA in the same session. In 2/8 patients M-AP was manifest only after right-sided Kb RFCA. In all patients, associated EP abnormalities were noted: in 5/8 patients a dual A-V node pathway was present and in 5/8 patients 6 right-sided Kbs were associated. Patients have been divided in 3 groups, according to the mechanism involving the M-AP in the RT. In the 2 Group I patients showing also Eb, antidromic LBBBM RT and orthodromic RT involving the M-AP anterogradely and retrogradely, respectively, were observed; both arrhythmias were abolished by ablating the M-AP. The 3 Group II patients showed only antidromic LBBBM RT, involving a fast A-V node pathway retrogradely; also in these patients, the M-AP was the target of RFCA. This was performed only in 1 patient, in whom A-V node RT was also observed and ablated after RFCA of M-AP; as to the other 2 patients, in 1 the ablation of M-AP was not considered mandatory, since it was responsible for inducible not sustained LBBBM RT observed only after RFCA of a Kb in the same EP session, while in the other it was not possible because of a prolonged traumatic conduction block through the M-AP.(ABSTRACT TRUNCATED AT 400 WORDS)

[New perspectives in the ablation of ectopic atrial tachycardia and atrial flutter]. / Nuove prospettive dell'ablazione nella tachicardia atriale ectopica e nel flutter atriale.

The first experiences on non-pharmacological treatment of ectopic atrial tachycardia (EAT) and common atrial flutter (AFl) were performed by surgical techniques. The surgical abolition of EAT comprised the isolation, the excision or the cryoablation of the ectopic atrial foci using electromapping guide. The AFl was treated by extensive cryoablation of the slow conduction area responsible for the macroreentrant process located in the infero-posterior part of the right atrium (RA). Transcatheter ablation with DC-shock for the treatment of EAT was proposed in 1985 but the technique did not gain wide acceptance due to its risks. The same method was utilized for the treatment of AFl since 1987. Many preliminary studies reported on the use of transcatheter ablation with radiofrequency (RF) current as an energy source since 1992 and no major complications were encountered. According with our knowledge, 81 cases of permanent or iterative EAT were treated by RF in the world with a primary success rate superior than 90%. The low rates of recurrence are reported very early (within 24-48 hours) after the procedure; recurrencies are very easy to recognise and they are successfully ablated in a second session. Cases of EAT due to an ectopic focus localized in the RA are ablated from the superior or inferior vena cava approaches and cases of EAT related to a left atrial (LA) ectopic focus by a trans-septal approach (persistent foramen ovale or atrial septum puncture). On the basis of our personal experience regarding 7 cases (4 LA and 3 RA foci) the role of unipolar leads derived from the mapping catheter appears essential to select the target for RF applications.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transesophageal stimulation of the left cardiac atrium in treatment of atrial flutter]. / Stymulacja przezprzelykowa lewego przedsionka serca w leczeniu trzepotania przedsionków.

Transesophageal stimulation of the left cardiac atrium in the treatment of paroxysmal atrial flutter was assessed. An attempt of such a therapy in paroxysmal atrial flutter involved 20 patients. Cardiac atrium was stimulated with overdrive technique, with single or pair of stimuli and multiple impulses of various frequency and duration. Reversal to sinus rhythm was achieved in 10 patients (in 3 out of them through phase of atrial fibrillation transitory). Results confirm therapeutical value of the transesophageal stimulation of the left cardiac atrium in atrial flutter.

Left atrial size and wall motion in patients with permanent ventricular and atrial pacing.

It is well known that during permanent ventricular pacing atrial arrhythmias and embolic complications occur much more frequently in comparison to permanent atrial or sequential pacing. Hemodynamic disturbances caused by ventriculoatrial conduction (VAC) are thought to be responsible for those complications. The aim of this study was to compare the left atrial size and its wall motion in three groups of patients with sick sinus syndrome. Group 1: 58 patients with VVI pacing and VAC observed (22 males, 36 females, aged 31-86, mean 62.3). Group 2: 43 patients with primary AAI pacing (13 males, 30 females, aged 27-74, mean 57.8). Group 3: 13 patients with AAI or DDD replacing the primary VVI mode due to pacemaker syndrome and/or heart failure, all with VAC present during VVI pacing (7 males, 6 females, aged 26-80, mean 59.8). Two-dimensional/M-mode echocardiography was performed in all these patients. In group 1 mean diastolic as well as mean systolic atrial diameters were significantly greater (P less than 0.005) and wall motion significantly smaller (P less than 0.005) in comparison to the other groups. Left atrial wall motion amounted to only 7.4% of the mean diastolic diameter in this group. Mean left atrial diastolic and systolic diameters and wall motion in patients with pacemakers preserving atrioventricular synchrony (group 2 and group 3) were almost identical and wall motion amounted to about 22% of the diastolic diameter in both these groups. We conclude that ventriculoatrial conduction leads to significant enlargement of left atrium and to the atrial wall-motion decrease. This predisposes to arrhythmias and embolic complications.(ABSTRACT TRUNCATED AT 250 WORDS)

[Our experience using continuous atrial stimulation in sick sinus syndrome]. / Doswiadczenie wlasne z zastosowaniem stalej stymulacji przedsionkowej w chorobie wezla zatokowego.

Temporary atrial pacing (AAI) was applied in 31 patients with sick sinus syndrome (S.S.S.), including 20 with tachycardia-bradycardia syndrome (t.b.s.). In all patients before pacemaker implantation atrioventricular conduction was estimated using rapid left atrial, transoseophegeal stimulation assuming Wenckebach's point over 120 imp./min to be a physiological one. In all cases, but one ventricular electrodes were implanted and connected with multiprogrammable pacemakers (MP). Follow-up time ranged from 3 to 38 months (mean 18,4). Electrode dislodgment was not observed. In 9 persons sensing disorders were observed but thanks to programming the pacemaker sensitivity they could be resolved almost in all of them. Second degree Mobitz type I a-v block occurred in 3 patients during a long-term follow-up. In one of them changing the pacing mode to VVI was necessary. In persons with tachycardia-bradycardia syndrome cardiac pacing together with pharmacologic therapy allowed to almost eliminate tachycardia attacks. Authors positively estimated AAI pacing mode.

Transesophageal programmed atrial pacing as a method of selecting patients with sick sinus syndrome for permanent atrial pacing.

Many recent studies have shown transesophageal programmed atrial pacing (TP) as a very practical, safe and convenient way for assessment of sinus node function and AV conduction. On the other hand, permanent atrial pacing is known to be superior to ventricular pacing due to arrhythmogenic and hemodynamic reasons. This is the reason why we decided to use TP as a method of choosing patients with sick sinus syndrome (SSS) for permanent atrial pacing. Sixty-three patients with symptomatic (58) and asymptomatic (5) SSS in a variety of clinical situations were examined in this way. The following electrophysiological features were examined: sinus cycle length, sinus node recovery time as well as corrected time, secondary pause after overdrive stimulation, sinoatrial conduction time, Wenckebach point, induction of supraventricular arrhythmias by S1, S2, S3 programmed stimulation and burst pacing. Patients with abnormal parameters were examined once more after intravenous atropine 0.2 mg/kg to evaluate parasympathetic component. Standard 12-lead ECG was performed in all, and Holter monitoring in most of patients. Twenty-six patients were candidates for permanent AAI pacing. Failures occurred in eight patients usually due to low P wave amplitude and electrode instability. Eighteen patients received AAI pacing systems: eight with brady-tachycardia syndrome, nine with bradyarrhythmia and one with sinoatrial block. In the follow-up of 5-28 months in one patient occurred high degree AV block (II degree) during digitalis therapy. Reduction of doses made this block disappear. Examination of Wenckebach point and possibility of inducation of supraventricular tachyarrhythmias in cases of atrial overexcitability are particularly useful in selecting patients for AAI pacing.