[Aspects of developing an education programme based on pulmonologists' appraisal related to chronic obstructive pulmonary disease]. / Egy oktatóprogram fejlesztésének lehetoségei tüdogyógyász szakorvosok krónikus obstruktív tüdobetegséggel kapcsolatos megítélése alapján.

Introduction: Chronic obstructive pulmonary disease (COPD) is a health burden for the patient and the society. We have sought to find the optimal education content to alleviate this burden. Aim: (1) To create patient education content based on the pulmonologists' opinion; (2) to understand the pulmonologists' attitudes and perceptions; (3) to evaluate the options to improve patient adherence. Method: We have performed 20 interviews with pulmonologists working in inpatient, outpatient and rehabilitation settings. The structure of the interviews has been designed to determine the key elements of a patient education programme and to discover perception and therapeutic attitudes. Results: The average COPD patient is a smoker, male, under-socialized, coughs, has dyspnoea and is older than 40 years. He does not take his illness seriously, and seeks medical attention only in case of worsening of the disease, and improvement in adherence is only present in such cases. The latter phenomenon is frequently transient, and limited to worse periods. Three adherence groups can be defined: marginal good adherence (approx. 10%), the average is around 30-40%, and minimal adherence (60%). Correct inhaler use should be taught in maximum three steps, which should be easily reproduced and explained. Conclusion: The aspects defining the framework of the education programme are the adequate patient profile (tailor-making), on-the-spot education in the pulmonology centre, the relationship between the patient and the doctors, patient attitudes and lifestyle changes (smoking cessation), and choosing the adequate inhaler. Orv Hetil. 2020; 161(3): 95-102.

[Immunoadsorption in a patient with dilated cardiomyopathy. The first case in Hungary]. / Dilatatív cardiomyopathia immunadszorpciós kezelése. Az elso magyarországi eset kapcsán.

Dilated cardiomyopathy is the main cause of heart transplantation. The etiology is unknown in almost half of the cases. Many cardiac specific antibodies have been identified till now which can cause decreased cardiac function, ventricular tachycardia or sudden heart death. The prognosis of DCM is poor despite the development of medical treatment. Immunoadsorption is hopeful since, with the removal of antibodies, cardiac function and NYHA class can improve and LVAD/heart transplantation-free survival can be prolonged. At the University of Debrecen, Faculty of Medicine, Department of Internal Medicine, Division of Angiology, Intensive Care and Therapeutic Apheresis Unit we performed the first immunoadsorption. Our patient was a 43-year-old man with idiopathic dilated cardiomyopathy, NYHA class IV, a heart transplantation candidate, whose cardiac specific antibody, type IgG was indentified by Western blot. Before the treatment he had ejection fraction of 18%. Discussing with his cardiologists we decided for immunoadsorption therapy. We performed 5 cycles on consecutive days in Intensive Care Unit. After 1 month we detected improvement in exercise capacity. We detected improvement in isovolemic contraction (from 465 mmHg/s to 575 mmHg/s), increased stroke volume (from 49 ml to 66 ml). After 3 months we repeated SPECT investigation which showed improvement in ejection fraction, from 18% to 32%. Orv Hetil. 2018; 159(13): 532-536.

Hemodiafiltration and hemodialysis differently affect P wave duration and dispersion on the surface electrocardiogram.

AIM: The incidence of atrial fibrillation is increased during hemodialysis (HD); however, the effects of hemodiafiltration (HDF) on atrial arrhythmias have not been evaluated. The prolongation of the P wave and P dispersion (Pd) can predict atrial arrhythmias. METHODS: Data from 30 patients receiving HDF over a period of 3 months were collected; the same group of patients was then evaluated during treatment with conventional HD for at least another 3 months. Electrolyte values were obtained, and surface electrocardiograms (ECG), echocardiography, and Holter ECGs were performed. RESULTS: The duration of the P wave and Pd increased significantly during HD. The left atrial diameter decreased significantly only during HDF. During HDF, the left atrial cross diameter measured at the beginning of the session was positively correlated with the incidence of supraventricular premature beats (p = 0.011, r = 0.4556). The decrease in left atrial diameter during HDF was negatively correlated with the incidence of supraventricular premature beats (p = 0.016, r = -0.43). During HDF, the changes in sodium and Pd were significantly positively correlated (p < 0.05, r = 0.478). During HD, the changes in ionized calcium levels and Pd were positively correlated (p < 0.05, r = 0.377). CONCLUSION: Our results suggest that HDF has a more beneficial effect on P wave duration and Pd than HD. The alterations in the ECG markers may be the result of the simultaneous occurrence of certain electrolyte imbalances and renal replacement methods.

Hemodiafiltration beneficially affects QT interval duration and dispersion compared to hemodialysis.

BACKGROUND/AIMS: The prolongation of the QT interval and dispersion could predict ventricular arrhythmias. It is not yet established whether there is a difference between the effects of hemodialysis and hemodiafiltration on QT interval duration and dispersion. METHODS: Data of thirty patients was investigated while they were receiving hemodiafiltration over a period of 3 months; then the same group of patients was evaluated during treatment with conventional hemodialysis for at least another 3 months. Ionic parameters and surface electrocardiograms (ECG) were analyzed five times during each session, and 2D, M-mode echocardiography and Holter ECGs were performed to acquire additional information. RESULTS: QT interval duration (QTmax) and dispersion (QTd) showed a significant increase during hemodialysis, but not during hemodiafiltration. QTmax was 388.66 ± 31.81 ms at the beginning of hemodialysis and increased to 400.66 ± 39.12 ms even at the 30th minute (p < 0.05). QTd was found to be 31.33 ± 10.08 ms before the commencement of hemodialysis with the largest prolongation being seen at the 240th minute (51.33 ± 14.56 ms, p < 0.05). The occurrence of ventricular premature beats was significantly higher during hemodialysis (p = 0.018). The left atrial diameter significantly decreased at the end of hemodiafiltration (at the beginning 45.1 ± 5.25 mm, at the end 40.77 ± 5.76 mm; p < 0.05). CONCLUSION: Our results suggest a beneficial effect of hemodiafiltration on the studied electrocardiographic parameters compared to hemodialysis. The larger decrease in the left atrial diameter suggests a more efficient intracardiac volume-decreasing potential of hemodiafiltration.

Adenosine-dependent concealed accessory pathway.

Adenosine is routinely used during ventricular pacing to exclude the persistence of retrograde accessory pathways conduction after radiofrequency (RF) ablation procedures by blocking conduction over the atrioventricular node. This is the first report of an adenosine-dependent concealed accessory pathway demonstrating transient conduction only after adenosine administration. Our findings may have potential clinical implications in reducing recurrence after accessory pathway ablation. Furthermore, it may add relevant information regarding the ability of adenosine to elicit dormant conduction after RF ablation, a phenomenon that has acquired considerable interest in the era of pulmonary vein isolation.

Long-term arrhythmia variability after monomorphic ventricular tachycardia in patients with an implantable cardioverter defibrillator.

BACKGROUND: Arrhythmia burden in patients receiving an implantable cardioverter defibrillator (ICD) after monomorphic ventricular tachycardia (mVT) is higher than in patients with other indications. We investigated the long-term arrhythmia profile in this subset of patients. METHODS: Fifty-two patients with an ICD implanted after mVT were followed up for at least 3 months. The cycle lengths (CLs) of the tachycardias recovered from the device memory were compared with the CL of the index arrhythmia. Morphological analysis of the intracardiac electrograms was performed and the response to antitachycardia pacing (ATP) was also assessed. RESULTS: A total of 833 mVT episodes with intracardiac electrograms occurred during the follow-up (3-58 months; mean: 30.3 months) in 41 of the 52 patients analyzed. mVTs with different CLs as compared with the index mVT were found in 26 (50.0%), and at least two different mVT morphologies were observed in 28 (53.8%) patients. Multiple mVT morphologies were predictive of lower ATP efficacy (95.6%, 85.0%, and 70.3% in the patients with 1, 2, and 3 or more mVT morphologies, respectively; P < 0.0001) and a higher shock burden (4.2%, 19.3%, and 24.7% in the patients with 1, 2, and 3 or more mVT morphologies, respectively; P < 0.0001). CONCLUSION: A high mVT burden was demonstrated with marked variability of the arrhythmias as concerns both CL and morphology in patients with an ICD implanted for mVT. Multiple mVT morphologies during the follow-up were predictive of lower ATP efficacy and a higher shock burden.

The effect of sleep apnea on QT interval, QT dispersion, and arrhythmias.

BACKGROUND: QT interval (QT) and QT dispersion (QTd) are electrocardiograph (ECG) parameters for the evaluation of myocardial repolarization. The inhomogeneity of ventricular repolarization is associated with ventricular arrhythmias. An increased QT, QTd, and increased incidence of nocturnal cardiac rhythm disturbances have been described in patients with obstructive sleep apnea (OSA), while other investigators did not find a relationship between ventricular arrhythmias and OSA. HYPOTHESIS: The aim of this study was to examine the occurrence of ventricular arrhythmias and to measure QT parameters in patients with untreated OSA using an ambulatory Holter-ECG. METHODS: A total of 25 patients with untreated OSA were studied. After routine biochemical investigation and 2-dimensional, M-mode echocardiography, a 24-hour Holter-ECG was recorded to detect cardiac arrhythmias and QT parameters. QT parameters were measured by the QT Guard system. RESULTS: Only the QT interval increased significantly during the nighttime period (nocturnal QT interval: 423.1 +/- 34.6 ms, daytime QT interval: 381.6 +/- 33.8 ms, 24-hour QT interval: 394.7 +/- 31.1 ms). However, during the nighttime QT interval (422.8 +/- 14.9 ms), QTd (31.2 +/- 11.0 ms) and QT dispersion (30.5 +/- 10.2 ms) did not show any change compared to 24-hour (QTc interval: 423.7 +/- 14.2 ms, QTd: 28.8 +/- 9.4 ms, QTcd: 30.5 +/- 9.43 ms) and daytime levels (QTc interval: 423.9 +/- 14.3 ms, QTd: 27.3 +/- 10.7 ms, QTcd: 29.9 +/- 11.1 ms). None of the patients had ventricular arrhythmias. CONCLUSIONS: QTd and QTcd did not increase during the nighttime period. Our study did not show an increased risk of ventricular arrhythmias in this population during the monitoring period.

[Cryoballon isolation of the pulmonary veins in atrial fibrillation: mid-term results after the first 55 patients]. / Pitvarfibrilláció kezelése a pulmonalis vénák krioballon-izolációjával: Középtávú eredmények az elsô 55 beteg alapján.

UNLABELLED: Several transcatheter techniques based on radiofrequency energy were elaborated for the treatment of atrial fibrillation through the last decade. Recently, similar success rates with a better safety profile concerning life threatening complications were reported with the novel methode of cryoballon isolation of the pulmonary veins. This paper summarizes our initial experience with cryoballon ablation after the first 55 patients. METHOD: [corrected] Symptomatic patients refractory to aniarrhythmic medication mostly with paroxysmal atrial fibrillation without significant structural heart disease were enrolled. Cannulation and isolation of all pulmonary veins were attempted using a 28 mm double-wall cryoballon inflated at the ostium of the vein and abolishing eletrical activity of atrial tissue around its perimeter by freezing to -70 C. Intravenous heparin during and oral anticoagulant after the procedure was administered. Conventional ECGs, Holter ECGs and transtelephonic ECG recordings were used through 6 months follow-up for rhythm monitoring. RESULTS: In 55 patients enrolled (18 female; age: 56 + or - 33,64 years) 165 out ot 192 (86%) pulmonary veins were successfully isolated. All pulmonary veins were isolated in 37 patients (67%). Procedure time was 155.67 + or - 100.66 min, while fluoroscopy time was 34.04 + or - 31.89 min. In 34 patients with 6 months follow-up 24 (70%) either remained free of arrhythmia (17 patients) or had a significant decrease in arrhythmia burden (7 patients). CONCLUSION: Based on our initial experience, cryoballon isolation of pulmonary veins appears to be a more simple procedure with similar efficacy to radiofrequency ablation in the treatment of atrial fibrillation.

[Arrhythmias in patients with obstructive sleep apnea]. / Szívritmuszavarok obstruktív alvási apnoéban.

The authors summarize the current knowledge on the types, prevalence, reasons, diagnosis and current therapy of arrhythmias occurring in patients with obstructive sleep apnea. Most of the patients with obstructive sleep apnea have nocturnal bradycardia (5-50%), paroxysmal tachyarrhythmia (atrial 35%; ventricular 0-15%), or both. The frequency of rhythm disturbances associated with the severity of the sleeping disorder. It is important to recognize the factors predisposing to arrhythmias and the early appropriate therapy of patients is essential, in order to protect patients from life threatening arrhythmias which may worsen the clinical outcome.

Radiofrequency catheter ablation of premature ventricular complexes improved left ventricular function in a non-responder to cardiac resynchronization therapy.

Frequent premature ventricular complexes (PVCs) have been demonstrated to cause tachycardiomyopathy in some individuals with a structurally normal heart. We report a patient with severe congestive cardiomyopathy which did not respond to cardiac resynchronization therapy (CRT). Ambulatory monitoring and interrogation of the device memory revealed frequent monomorphic PVCs that were considered a potential cause of the failure of CRT. Radiofrequency ablation of the focus at the postero-inferior left ventricle eliminated the arrhythmia, with a resultant rapid improvement in the clinical status and echo parameters. As PVCs are often associated with severe heart failure, the presence of frequent extrasystoles may be an underrecognized cause of a non-response to resynchronization therapy.

Effects of haemodialysis on maximum P wave duration and P wave dispersion.

BACKGROUND: Analysing a 12-lead surface electrocardiogram (ECG), the inter-lead variability of the P wave interval, i.e. P wave dispersion, is defined as the difference between the maximum and the minimum P wave duration. Our aim was to assess the effect of haemodialysis on P wave duration and dispersion in non-diabetic patients with end-stage renal failure on chronic haemodialysis. METHODS: Twenty-eight patients (14 men and 14 women, mean age 58+/-16 years, average duration of dialysis 4.5+/-2.8 years) were examined. Prior to haemodialysis, echocardiography (M-mode and two-dimensional) was performed. Haemodialysis sessions were carried out with polysulfone dialysers and bicarbonate dialysate fluids. Twelve-lead ECGs were recorded at the beginning, 15 and 30 min after starting dialysis, at the end, and 2 h after completion of each session. Ionic parameters were checked during the study. P wave durations were measured with calipers in three consecutive complexes of each lead by one observer. RESULTS: P maximum was 58+/-16 ms at the beginning, and showed an increase by the end of dialysis to 98+/-8.9 ms (P<0.0001). Pre-dialysis P dispersion was 23+/-10 ms and increased to 41+/-16 ms by the end of the sessions (P<0.0001). In patients with a left atrial diameter larger than 45 mm, P dispersion increased from 23+/-11 to 53+/-10 ms (P<0.0003) by the end of the sessions. CONCLUSIONS: According to our results, ionic imbalance and dialysis itself may cause changes in P duration and dispersion simultaneously.