Patients' knowledge and attitudes regarding living with implantable electronic devices: results of a multicentre, multinational patient survey conducted by the European Heart Rhythm Association.

The purpose of this patient survey was to analyse the knowledge, experiences, and attitudes regarding cardiac implantable electronic devices (CIED) in patients with pacemakers, implantable cardioverter-defibrillators (ICDs), or cardiac resynchronization devices. Of the 1644 patients with CIEDs from seven European countries, 88% were over 50 years of age. Most patients (90%) knew what device they were implanted with and felt sufficiently informed about the indications for therapy. As many as 42% of patients needed additional information on the battery replacement and limitations in physical activity. The self-reported incidence of complications was 9%, and among these, a quarter of the respondents felt insufficiently informed about the possibility of complications and their management. The majority of patients (83%) were followed by face-to-face visits, which was the most commonly preferred follow-up strategy by the patients. Nearly 75% of the patients reported improved quality of life after device implantation, but about 40% had worries about their device. Less than 20% had discussed with their physician or thought about device handling in the end-of-life circumstances or end-stage disease. Notably, almost 20% of the ICD patients did not wish to answer the question regarding what they wanted to be done with their ICD in case of end-stage disease, indicating the challenges in approaching these issues.

Implantable cardioverter-defibrillator therapy in a 34-year-old patient with eating disorders and after the third sudden cardiac arrest.

Eating disorders (ED) such as anorexia nervosa and bulimia are psychiatric diseases associated with the highest mortality rate of any other psychiatric disorders. More recently, long-term outcome studies with follow-up of over 20 years report a mortality of between 15% and 18% (Casiero and Frishman, Cardiol Rev 14(5), 227, 2006). The sudden death secondary to arrhythmias is often the cause of death in these patients (Casiero and Frishman, Cardiol Rev 14(5), 227, 2006). A case of life-threatening ventricular arrhythmia (VA) in a patient with ED is presented. Clinical records (cardiologic, psychiatric), electrocardiograms, echocardiogram, coronary angiogram, cardiac magnetic resonance, and endocrine diagnostics were performed. Finally a cardioverter-defibrillator (ICD) was implanted in the patient after her third cardiac arrest. An optimal approach to antiarrhythmic therapy in such patients is a real challenge for a cardiologist.

Telemedical Intervention and Its Effect on Quality of Life in Chronic Heart Failure Patients: The Results from the Telemedicine and e-Health Solution Pilot Program.

(1) Background: Heart failure (HF) is not only a common cardiovascular disease with a poor prognosis. Its prevalence in developed countries equals 1-2% of the general population of adults, while in Poland HF, patients constitute 3.2% of the total population. Modern heart failure treatment should be focused not only on reducing the risk of death and the number of readmissions due to HF exacerbation but quality of life as well. Telemedicine has been suggested as a viable tool for enhancing HRQL. Therefore, we present the results of telemedical intervention in a group of HF patients and its effect on quality of life in chronic heart failure patients from a pilot study dedicated to reducing social inequalities in health through the use of telemedicine and e-health solutions. (2) Method: The project was a multicenter, open, non-controlled trial conducted by the University of Rzeszów, Poland. The data points were collected in the June 2023-December 2023 period from fourteen primary care units from five voivodeships, mostly considered social exclusion areas. A total of 52.7% of the patients recruited were Podkarpackie Voivodeship inhabitants. The result and discussion are presented based on the Chronic Heart Failure Questionnaire (CHFQ) and the EuroQol Visual Analogue Scale (EQVAS). (3) Results: During the program, a total of over 100,000 telemedicine examinations were conducted in the form of body weight measurement, heart rate, blood pressure tests, and 7-day Holter or 14-day event Holter assessment. Over the course of this study, coordinating the pilot program medical staff has ordered 570 changes in the patient's pharmacotherapy, confirming the positive impact on quality of life in the study group. (4) Conclusions: A comprehensive telemedical intervention can contribute to an improvement in the quality of life of patients with HF beyond what was achieved with the basic standard of care in the group of HF patients from the social exclusion region. It is now unclear if the result of the basic telemedical intervention would be constant after discontinuation of the mentioned pilot program.

LMNA mutations in Polish patients with dilated cardiomyopathy: prevalence, clinical characteristics, and in vitro studies.

BACKGROUND: LMNA mutations are most frequently involved in the pathogenesis of dilated cardiomyopathy with conduction disease. The goal of this study was to identify LMNA mutations, estimate their frequency among Polish dilated cardiomyopathy patients and characterize their effect both in vivo and in vitro. METHODS: Between January, 2008 and June, 2012 two patient populations were screened for the presence of LMNA mutations by direct sequencing: 66 dilated cardiomyopathy patients including 27 heart transplant recipients and 39 dilated cardiomyopathy patients with heart failure referred for heart transplantation evaluation, and 44 consecutive dilated cardiomyopathy patients, referred for a family evaluation and mutation screening. RESULTS: We detected nine non-synonymous mutations including three novel mutations: p.Ser431*, p.Val256Gly and p.Gly400Argfs*11 deletion. There were 25 carriers altogether in nine families. The carriers were mostly characterized by dilated cardiomyopathy and heart failure with conduction system disease and/or complex ventricular arrhythmia, although five were asymptomatic. Among the LMNA mutation carriers, six underwent heart transplantation, fourteen ICD implantation and eight had pacemaker. In addition, we obtained ultrastructural images of cardiomyocytes from the patient carrying p.Thr510Tyrfs*42. Furthermore, because the novel p.Val256Gly mutation was found in a sporadic case, we verified its pathogenicity by expressing the mutation in a cellular model. CONCLUSIONS: In conclusion, in the two referral centre populations, the screening revealed five mutations among 66 heart transplant recipients or patients referred for heart transplantation (7.6%) and four mutations among 44 consecutive dilated cardiomyopathy patients referred for familial evaluation (9.1%). Dilated cardiomyopathy patients with LMNA mutations have poor prognosis, however considerable clinical variability is present among family members.

Reduction of the inappropriate ICD therapies by implementing a new fuzzy logic-based diagnostic algorithm.

AIMS: The aim of the study was to analyze the value of a completely new fuzzy logic-based detection algorithm (FA) in comparison with arrhythmia classification algorithms used in existing ICDs in order to demonstrate whether the rate of inappropriate therapies can be reduced. METHODS: On the basis of the RR intervals database containing arrhythmia events and controls recordings from the ICD memory a diagnostic algorithm was developed and tested by a computer program. This algorithm uses the same input signals as existing ICDs: RR interval as the primary input variable and two variables derived from it, onset and stability. However, it uses 15 fuzzy rules instead of fixed thresholds used in existing devices. The algorithm considers 6 diagnostic categories: (1) VF (ventricular fibrillation), (2) VT (ventricular tachycardia), (3) ST (sinus tachycardia), (4) DAI (artifacts and heart rhythm irregularities including extrasystoles and T-wave oversensing-TWOS), (5) ATF (atrial and supraventricular tachycardia or fibrillation), and 96) NT (sinus rhythm). This algorithm was tested on 172 RR recordings from different ICDs in the follow-up of 135 patients. RESULTS: All diagnostic categories of the algorithm were present in the analyzed recordings: VF (n = 35), VT (n = 48), ST (n = 14), DAI (n = 32), ATF (n = 18), NT (n = 25). Thirty-eight patients (31.4%) in the studied group received inappropriate ICD therapies. In all these cases the final diagnosis of the algorithm was correct (19 cases of artifacts, 11 of atrial fibrillation and 8 of ST) and fuzzy rules algorithm implementation would have withheld unnecessary therapies. Incidence of inappropriate therapies: 3 vs. 38 (the proposed algorithm vs. ICD diagnosis, respectively) differed significantly (p < 0.05). VT/VF were detected correctly in both groups. Sensitivity and specificity were calculated: 100%, 97.8%, and 100%, 72.9% respectively for FA and tested ICDs recordings (p < 0.05). CONCLUSIONS: Diagnostic performance of the proposed fuzzy logic based algorithm seems to be promising and its implementation could diminish ICDs inappropriate therapies. We found FA usefulness in correct diagnosis of sinus tachycardia, atrial fibrillation and artifacts in comparison with tested ICDs.

High in-hospital mortality and prevalence of cardiogenic shock in patients with ST-segment elevation myocardial infarction and concomitant COVID-19.

Introduction: Published data suggest worse outcomes in acute coronary syndrome (ACS) patients with concomitant coronavirus disease (COVID-19) due to delays in standard management caused by burdened healthcare. Aim: To report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ST-elevation myocardial infarction (STEMI) patients and to compare these with the non-COVID-19 cohort hospitalized during the same period with the same access to medical care. Material and methods: From October 23rd, 2020 to April 23rd, 2021 (exactly 6 months) data were collected into a prospective ACS Registry. STEMI patients underwent invasive coronary angiography and were tested for COVID-19. Outcomes were in-hospital mortality and prevalence of cardiogenic shock. Results: 125 patients, of whom 25 were COVID-19 positive, were admitted to the cardiology ward, and completed their hospital stay (i.e. discharge or death). There were no differences with regard to the time from symptom onset to reperfusion (median (Q1-Q3); 165 (130-202) vs. 170 (123-210), p = 0.86) and door-to-balloon time between the compared groups (25 (21-35) vs. 29 (21-59), p = 0.26). There was a higher GRACE risk score and mortality in the COVID-19 positive patients (180 (154-226) vs. 155 (132-181) and 48% vs. 10%, respectively, both p < 0.0001). Cardiogenic shock occurred more often in this group (32% vs. 13%; p = 0.035). COVID-19 positive patients had elevated high-sensitivity C-reactive protein (hsCRP) (p < 0.0001) and D-dimer (p = 0.003) and reduced left ventricular ejection fraction (p = 0.037). Postprocedural TIMI 3 flow grade was observed less frequently in this group (p = 0.044). Conclusions: High in-hospital mortality in patients with STEMI and COVID-19 did not result from delays in standard management, and could be related to increased thrombogenicity.

Employment of the Evolution RL sheath as a first-choice device shortens transvenous lead extraction time without affecting procedural safety and efficacy compared to its auxiliary use: Insights from the prospective multicenter EVO registry.

BACKGROUND: Transvenous lead extraction (TLE) is recommended in cases of local and systemic infections related to cardiac implantable electronic devices (CIEDs). Additionally, TLE is indicated in the event of lead damage or CIED malfunction. The extraction procedure is associated with a risk of life-threatening complications. OBJECTIVES: The aim of the EVO registry was to assess the safety and efficacy of birotational Evolution tool usage. MATERIAL AND METHODS: This registry study was prospectively conducted in 8 high-volume implantation centers in Poland. The study included 133 patients aged 63.5 ±15.1 years, and 76.69% were male. Indications for the procedure were: local or systemic infection (33.1%) and lead dysfunction (66.9%). The number of leads extracted varied from 1 (39.84%) to 3 (9.77%). RESULTS: Clinical procedural success was achieved in 99.1% of cases. A total of 226 leads were extracted, and 206 used the Evolution system. Two procedural strategies were identified while using the Evolution system: (1) usage of locking stylet, propylene sheaths and the Evolution system (118 leads, 52%) - group A; (2) usage of locking stylet and Evolution (88 leads, 39%) - group B. There were no differences in the number of complications between these 2 groups. The extraction time was significantly shorter (p = 0.02) in group B than in group A. Major complications occurred in 5.2% of cases with 2 intraprocedural deaths. Minor complications occurred in 1.5% of patients. CONCLUSIONS: The registry confirmed the efficacy and relative safety of the birotational Evolution sheath. Using the rotational sheath as a first attempt significantly reduces extraction time without compromising its safety.

Subcutaneous implantable cardioverter-defibrillator therapy in Poland: Results of the Polish S-ICD Registry.

BACKGROUND: The use of subcutaneous implantable cardioverter-defibrillators (S-ICD) has been growing in Poland since 2014. The Polish Registry of S-ICD Implantations was run by the Heart Rhythm Section of the Polish Cardiac Society between May 2020 and September 2022 to monitor the implementation of that therapy in Poland. AIMS: To investigate and present the state-of-the-art of S-ICD implantation in Poland. METHODS: Implanting centers reported clinical data of patients undergoing S-ICD implantations and replacements, including age, sex, height, weight, underlying disease, history of pacemaker and defibrillator implantations, indications for S-ICD, electrocardiographical parameters, procedural techniques, and complications. RESULTS: Four hundred and forty patients undergoing S-ICD implantation (411) or replacement (29) were reported by 16 centers. Most patients were in New York Heart Association class II (218 patients, 53%) or I (150 patients, 36.5%). Left ventricular ejection fraction was 10%-80%, median (IQR) was 33% (25%-55%). Primary prevention indications were present in 273 patients (66.4%). Non-ischemic cardiomyopathy was reported in 194 patients (47.2%). The main reason for the choice of S-ICD were: young age (309, 75.2%), risk of infectious complications (46, 11.2%), prior infective endocarditis (36, 8.8%), hemodialysis (23, 5.6%), and immunosuppressive therapy (7, 1.7%). Electrocardiographic screening was performed in 90% of patients. The rate of adverse events was low (1.7%). No surgical complications were observed.

Therapeutic challenges and management of heart failure during pregnancy (part 2).

A particularly dangerous condition in pregnant women is already dilated left ventricle with severe functional impairment. Taking as an example the case of woman with dilated cardiomyopathy (DCM) first diagnosed in 17th week of pregnancy, the paper discusses diagnostic, therapeutic challenges and management of heart failure during pregnancy. Repeat measurements of brain natiuretic peptide levels should be helpful in diagnosing heart failure. To distinguish DCM from peripartum cardiomyopathy the time of manifestation should be considered. The risk of serious events is associated with NYHA class and impairment of left ventricular ejection fraction. Angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin-II receptor blockers are contraindicated in pregnancy because of fetal toxicity. The incidence of sight effects is associated with time of administration of ACE-I and duration of treatment. Possible sight effects of drugs in fetus should be monitored (mainly ultrasonographically). ICD can be implanted during pregnancy if indicated. To assess the time and mode of delivery, a multidisciplinary team of different specialists is required. Subsequent pregnancy is contraindicated in a patient with DCM and low ejection fraction of left ventricle.

Therapeutic challenges and management of heart failure during pregnancy (part I).

Therapeutic management in pregnant patients with heart failure still remains a challenge, even though in most pregnant women with cardiac diseases an outcome is good. A 32-year-old woman, 17 weeks pregnant, was admitted to hospital with heart failure (HF) NYHA class III/IV. Echocardiography revealed enlarged LV, LVEF 13%, significant mitral insufficiency and pulmonary hypertension. The patient wished to continue the pregnancy. In a life-threatening condition, metoprolol, enalapril, spironolactone (for 5 days), furosemide, and digitalis were administered. Enalapril was continued for 42 days. Then the patient was switched to a dihydralazine and isosorbide mononitrate regimen. The fetus was controlled ultrasonographically. In the 19th week of pregnancy, the patient's condition improved (NYHA class II, LVEF 23%). The patient experienced 2 more episodes of HF exacerbation. In the 26th week of pregnancy, in a primary prevention of sudden cardiac death and because of 2nd-degree AV block, an ICD was implanted. In the 32nd week of pregnancy a cesarean section was performed. A male infant was delivered. The patient made a good recovery and was discharged on the 7th postoperative day. The newborn was discharged after 4 weeks, in good general condition. At 1-year follow-up the patient presented NYHA class II.

The GRACE risk score in patients with ST-segment elevation myocardial infarction and concomitant COVID-19.

Introduction: Acute coronary syndrome represents a major cause of mortality throughout the world. To date, there are only a few reports of ST-segment elevation type 1 myocardial infarction in patients with COVID-19. The aim of this study was to describe the clinical and angiographic characteristics alongside the prediction of in-hospital mortality using the GRACE risk score in this group. Material and methods: This was a single-center, retrospective study of consecutive patients admitted to a multi-specialist hospital with confirmed ST-segment elevation myocardial infarction (STEMI) and treated with primary percutaneous coronary intervention. Demographic, clinical and angiographic characteristics were compared between survivors and non-survivors. Results: Twenty-five patients, of whom 23 (92%) were men, with confirmed STEMI and COVID-19, with a median age of 70 years and high comorbidity burden, were included in this study. They were treated with percutaneous coronary intervention and 12 (48%) of them died. Non-survivors had elevated high-sensitivity C-reactive protein (hsCRP) (p = 0.026) and D-dimer (p = 0.042) and reduced left ventricular ejection fraction (30 ±9 vs. 41 ±7; p = 0.003). Postprocedural TIMI 3 flow grade was less frequently observed in this group (p = 0.039). There was a higher GRACE score in the non-survivor group (mean ± SD; 210 ±35 vs. 169 ±42, p = 0.014). In ROC analysis, GRACE score predicted in-hospital death with an AUC of 0.788 (95% CI: 0.6-0.98, p = 0.014). A score of 176 was identified as the optimal cut-off with a sensitivity of 92% and specificity of 69%. Conclusions: The GRACE risk score is a good predictor of in-hospital mortality in patients presenting with STEMI with concomitant COVID-19.

The cost of CIED infectious complications treatment in Poland from the perspective of Polish hospitals.

INTRODUCTION: Cardiac implantable electronic devices (CIED) are a recognized form of therapy in cardiology. Apart from the benefits, the use of CIEDs is also associated with the risk of complications, and the most important ones influencing treatment results and prognosis are infectious complications. AIM: This study aimed to calculate the cost of treatment of CIED-related infections, including transvenous lead extraction and device reimplantation, from the perspective of a Polish hospital. METHODS: A retrospective analysis of hospitalization costs of patients referred to transvenous lead extraction (TLE) for CIED infection was performed. The study covers cases from three Polish reference centers specializing in the comprehensive treatment of cardiac electrotherapy complications. RESULTS: It was shown that the average cost of treating a CIED infection is 34 000 PLN (8010 EUR) and is the highest in the cardiac resynchronization therapy with defibrillator function (CRT-D) group, where it amounts to almost 50 000 PLN (11 440 EUR). Thus, treatment of CIED infections is associated with an average loss of 3000 PLN for the healthcare provider and the length of hospitalization has a major influence on final outcomes. CONCLUSIONS: The hospital cost of treatment of CIED-related infections was high and related mainly to the type of device and length of hospitalization. Despite the low utilization of costly extraction tools, the hospitalization was still likely to be unprofitable.

Implantable cardiac defibrillator events in patients with arrhythmogenic right ventricular cardiomyopathy.

OBJECTIVE: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is associated with a risk of sudden cardiac death. Optimal risk stratification is still under debate. The main purpose of this long-term, single-centre observation was to analyse predictors of appropriate and inappropriate implantable cardioverter-defibrillator (ICD) interventions in the population of patients with ARVC with a high risk of life-threatening arrhythmias. METHODS: The study comprised 65 adult patients (median age 40 years, 48 men) with a definite diagnosis of ARVC who received ICD over a time span of 20 years in primary (40%) or secondary (60%) prevention of sudden cardiac death. The study endpoints were first appropriate and inappropriate ICD interventions (shock or antitachycardia pacing) after device implantation. RESULTS: During a median follow-up of 7.75 years after ICD implantation, nine patients died and six individuals underwent heart transplantation. Appropriate ICD interventions occurred in 43 patients (66.2%) and inappropriate ICD interventions in 18 patients (27.7%). Multivariable analysis using cause-specific hazard model identified three predictors of appropriate ICD interventions: right ventricle dysfunction (cause-specific HR 2.85, 95% CI 1.56 to 5.21, p<0.001), age <40 years at ICD implantation (cause-specific HR 2.37, 95% CI 1.13 to 4.94, p=0.022) and a history of sustained ventricular tachycardia (cause-specific HR 2.55, 95% CI 1.16 to 5.63, p=0.020). Predictors of inappropriate ICD therapy were not found. Complications related to ICD implantation occurred in 12 patients. CONCLUSIONS: Right ventricle dysfunction, age <40 years and a history of sustained ventricular tachycardia were predictors of appropriate ICD interventions in patients with ARVC. The results may be used to improve risk stratification before ICD implantation.

Utilization of Subcutaneous Cardioverter-Defibrillator in Poland and Europe-Comparison of the Results of Multi-Center Registries.

The implantation of a subcutaneous cardioverter-defibrillator (S-ICD) may be used instead of a traditional transvenous system to prevent sudden cardiac death. Our aim was to compare the characteristics of S-ICD patients from the multi-center registry of S-ICD implantations in Poland with the published results of the European Snapshot Survey on S-ICD Implantation (ESSS-SICDI). We compared data of 137 Polish S-ICD patients with 68 patients from the ESSS-SICDI registry. The groups did not differ significantly in terms of sex, prevalence of ischemic cardiomyopathy, concomitant diseases, and the rate of primary prevention indication. Polish patients had more advanced heart failure (New York Heart Association (NYHA) class III: 11.7% vs. 2.9%, NYHA II: 48.9% vs. 29.4%, NYHA I: 39.4% vs. 67.7%, p < 0.05 each). Young age (75.9% vs. 50%, p < 0.05) and no vascular access (7.3% vs. 0%, p < 0.05) were more often indications for S-ICD. The percentage of patients after transvenous system removal due to infections was significantly higher in the Polish group (11% vs. 1.5%, p < 0.05). In the European population, S-ICD was more frequently chosen because of patients' active lifestyle and patients' preference (both 10.3% vs. 0%, p < 0.05). Our analysis shows that in Poland, compared to other European countries, subcutaneous cardioverters-defibrillators are being implanted in patients at a more advanced stage of chronic heart failure. The most frequent reason for choosing a subcutaneous system instead of a transvenous ICD is the young age of a patient.

A new approach to ticagrelor-based de-escalation of antiplatelet therapy after acute coronary syndrome. A rationale for a randomized, double-blind, placebo-controlled, investigator-initiated, multicenter clinical study.

The risk of ischemic events gradually decreases after acute coronary syndrome (ACS), reaching a stable level after 1 month, while the risk of bleeding remains steady during the whole period of dual antiplatelet treatment (DAPT). Several de-escalation strategies of antiplatelet treatment aiming to enhance safety of DAPT without depriving it of its efficacy have been evaluated so far. We hypothesized that reduction of the ticagrelor maintenance dose 1 month after ACS and its continuation until 12 months after ACS may improve adherence to antiplatelet treatment due to better tolerability compared with the standard dose of ticagrelor. Moreover, improved safety of treatment and preserved anti-ischemic benefit may also be expected with additional acetylsalicylic acid (ASA) withdrawal. To evaluate these hypotheses, we designed the Evaluating Safety and Efficacy of Two Ticagrelor-based De-escalation Antiplatelet Strategies in Acute Coronary Syndrome - a randomized clinical trial (ELECTRA-SIRIO 2), to assess the influence of ticagrelor dose reduction with or without continuation of ASA versus DAPT with standard dose ticagrelor in reducing clinically relevant bleeding and maintaining anti-ischemic efficacy in ACS patients. The study was designed as a phase III, randomized, multicenter, double-blind, investigator-initiated clinical study with a 12-month follow-up (ClinicalTrials.gov Identifier: NCT04718025; EudraCT number: 2020-005130-15).

Implantable cardioverter-defibrillator in patients with hypertrophic cardiomyopathy: efficacy and complications of the therapy in long-term follow-up.

INTRODUCTION: Although implantable cardioverter-defibrillators (ICDs) are used in sudden cardiac death (SCD) prevention in high-risk patients with hypertrophic cardiomyopathy (HCM), long-term results as well as precise risk stratification are discussed in a limited number of reports. The aim of the study was to assess the incidence of ICD intervention in HCM patients with relation to clinical risk profile. METHODS AND RESULTS: We studied 104 consecutive patients with HCM implanted in a single center. The mean age of study population was 35.6 (SD, 16.2) years with the average follow-up of 4.6 (SD, 2.6) years. ICD was implanted for secondary (n = 26) and primary (n = 78) prevention of SCD. In the secondary prevention group, 14 patients (53.8%) experienced at least 1 appropriate device intervention (7.9%/year). In the primary prevention (PP) group appropriate ICD discharges occurred in 13 patients (16.7%) and intervention rate was 4.0%/year. Nonsustained VT was the only predictive risk factor (RF) for an appropriate ICD intervention in the PP (positive predictive value 22%, negative predictive value 96%). No significant difference was observed in the incidence of appropriate ICD discharges between PP patients with 1, 2, or more RF. Complications of the treatment included: inappropriate shocks (33.7%), lead dysfunction (12.5%), and infections: 4.8% of patients. Four patients died during follow-up. CONCLUSION: ICD therapy is effective in SCD prevention in patients with HCM, although the complication rate is significant. Nonsustained ventricular tachycardia seems to be the most predictive RF for appropriate device discharges. Number of RF did not impact the incidence of appropriate ICD interventions.

Ablation of severe drug-resistant tachyarrhythmia during pregnancy.

AIMS: The goal of this study was to describe mapping and ablation of severe arrhythmias during pregnancy, with minimum or no X-ray exposure. Treatment of tachyarrhythmia in pregnancy is a clinical problem. Pharmacotherapy entails a risk of adverse effects and is unsuccessful in some patients. Radiofrequency ablation has been performed rarely, because of fetal X-ray exposure and potential maternal and fetus complications. GROUP AND METHOD: Mapping and ablation was performed in 9 women (age 24-34 years) at 12-38th week of pregnancy. Three had permanent junctional reciprocating tachycardia, and 2 had incessant atrial tachycardia. Four of them had left ventricular ejection fraction < or =45%. One patient had atrioventricular nodal reciprocating tachycardia requiring cardioversion. Three patients had Wolff-Parkinson-White syndrome. Two of them had atrial fibrillation with ventricular rate 300 bpm and 1 had atrioventricular tachycardia 300 bpm. Fetal echocardiography was performed before and after the procedure. RESULTS: Three women had an electroanatomic map and ablation done without X-ray exposure. The mean fluoroscopy time in the whole group was 42 +/- 37 seconds. The mean procedure time was 56 +/- 18 minutes. After the procedure, all women and fetuses were in good condition. After a mean period of 43 +/- 23 months follow up (FU), all patients were free of arrhythmia without complications related to ablation either in the mothers or children. CONCLUSION: Ablation can be performed safely with no or minimal radiation exposure during pregnancy. In the setting of malignant, drug-resistant arrhythmia, ablation may be considered a therapeutic option in selected cases.

Long-term follow-up of children and young adults treated with implantable cardioverter-defibrillator: the authors' own experience with optimal implantable cardioverter-defibrillator programming.

AIMS: Young implantable cardioverter-defibrillator (ICD) recipients present a high rate of inappropriate interventions. Some of them are caused by suboptimal pre-discharge programming of the device. There are conflicting data as regards antitachycardia pacing (ATP) effectiveness in children and young adults. We report our experience with ICD programming and a rate of complications during a 10 year follow-up. METHODS AND RESULTS: We analysed the use and effectiveness of ATP and complications rate in 63 patients aged 6-21 years. Antitachycardia pacing (burst or ramp) was programmed ON in 14 patients (22%), 49 patients (78%) had only ventricular fibrillation (VF) therapy when discharged after implantation. The incidence of effective vs. ineffective or harmful ATP therapy: 5% of patients vs. 19% of patients differed significantly (P < 0.05). Fourteen patients (22%) received > or =1 appropriate shock(s) for ventricular tachycardia/VF and 17 patients (27%) had one or multiple inappropriate therapy (IT). Inappropriate therapy resulted from T-wave over-sensing (nine patients), sinus tachycardia (three patients), fast atrial fibrillation (five patients), and lead insulation disruption (1%). Reprogramming of the device eliminated IT in all cases. There were 13 (21%) surgical complications. Serious psychological sequelae developed in 27 (43%) patients. There was one death during the follow-up period. CONCLUSION: Antitachycardia pacing therapy is rarely effective and often harmful in young ICD recipients. In most patients, programming ICD for only VF therapy is sufficient. Routine pre-discharge programming against inappropriate interventions (especially T-wave over-sensing) helps to reduce the incidence of discharges during the follow-up. The incidence of complications and inappropriate therapies is high in young ICD recipients and affects 50% of patients.

Predictors of successful defibrillation threshold test during CRT-D implantation.

BACKGROUND: The assessment of defibrillation energy requirement (DER) is a standard practice during cardioverter-defibrillator (ICD) implantation. It is recommended to assure that the energy at least 10 J below the maximal energy deliverable by the implanted device successfully converts the induced ventricular fibrillation (VF). The cardiac resynchronisation therapy with defibrillator (CRT-D) recipients are at increased risk of developing serious complications due to repeated VF induction. AIM: To define the prevalence of high DER among CRT-D recipients and to determine the factors which allow to obtain defibrillation safety margin. METHODS: We examined all patients who underwent CRT-D implantation between June 2006 and June 2009 in our institution. The verification of the DER required at least one termination of the induced VF with the energy at least 10 J below the maximal energy deliverable by the implanted device. RESULTS: The CRT-D was implanted in 65 patients. The first defibrillation test was successful in 57 (88%) patients. In the remaining 8 patients (12%), the defibrillation test was unsuccessful. These patients required system revision: reprogramming shocking polarity (2), reversing polarity and adjusting waveform (3), lead repositioning (1) and adding a subcutaneous lead (2). The use of high output devices (maximal energy > 30 J) and dual-coil leads was associated with a significantly (p < 0.05) lower rate of high DER, although high DER occurred in one patient implanted with the high output device. There was a correlation between the probability of successful defibrillation and renal function. It was less likely to obtain successful defibrillation safety margin in patients with creatinine > 175 micromol/L. During the follow up, ventricular tachyarrhythmia detected in the VF detection zone occurred in 13 (20%) patients, including two patients, who required system modification during implantation. In both cases, VF was terminated by the first defibrillation with the maximal energy of the implanted devices. CONCLUSIONS: High DER occurred in a significant number of CRT-D recipients. There is a correlation between high DER and impaired renal function. The use of high output devices significantly decreases the number of patients who required system modification in order to obtain an adequate defibrillation safety margin.

[Radiofrequency ablation of ventricular arrhythmia from the non-coronary cusp]. / Ablacja pradem o wysokiej czestotliwosci podloza komorowych zaburzen rytmu serca z niewiencowej zatoki valsalvy.

There is a close anatomical relationship between the non-coronary aortic cusp (NCC) and sites where His bundle (HB) is recorded in the right ventricle (RV). We describe a patient with frequent premature ventricular beats originating near HB. Arrhythmia was successfully ablated from the NCC although local electrogram preceded QRS in NCC and His area. When RV mapping reveals an earliest ventricular activation in the HB region, mapping in the right coronary cusp and NCC should be done to identify the area of arrhythmia origin.