Longer Hospitalizations and Higher In-Hospital Mortality for Acute Heart Failure during the COVID-19 Pandemic in Larger vs. Smaller Cardiology Departments: Subanalysis of the COV-HF-SIRIO 6 Multicenter Study.

Background: The coronavirus disease-2019 (COVID-19) pandemic is surging across Poland, leading to many direct deaths and underestimated collateral damage. We aimed to compare the influence of the COVID-19 pandemic on hospital admissions and in-hospital mortality in larger vs. smaller cardiology departments (i.e., with ≥ 2000 vs. < 2000 hospitalizations per year in 2019). Methods: We performed a subanalysis of the COV-HF-SIRIO 6 multicenter retrospective study including all patients hospitalized in 24 cardiology departments in Poland between January 1, 2019 and December 31, 2020, focusing on patients with acute heart failure (AHF) and COVID-19. Results: Total number of hospitalizations was reduced by 29.2% in larger cardiology departments and by 27.3% in smaller cardiology departments in 2020 vs. 2019. While hospitalizations for AHF were reduced by 21.8% and 25.1%, respectively. The length of hospital stay due to AHF in 2020 was 9.6 days in larger cardiology departments and 6.6 days in smaller departments (p < 0.001). In-hospital mortality for AHF during the COVID-19 pandemic was significantly higher in larger vs. smaller cardiology departments (10.7% vs. 3.2%; p < 0.001). In-hospital mortality for concomitant AHF and COVID-19 was extremely high in larger and smaller cardiology departments accounting for 31.3% vs. 31.6%, respectively. Conclusions: During the COVID-19 pandemic longer hospitalizations and higher in-hospital mortality for AHF were observed in larger vs. smaller cardiology departments. Reduced hospital admissions and extremely high in-hospital mortality for concomitant AHF and COVID-19 were noted regardless of department size.

Safety and efficacy of a sirolimus-eluting coronary stent with ultra-thin strut for treatment of atherosclerotic lesions (TALENT): a prospective multicentre randomised controlled trial.

BACKGROUND: Supraflex is a sirolimus-eluting stent with a biodegradable polymer coating and ultra-thin struts. We aimed to compare Supraflex with the standard of care, Xience, an everolimus-eluting stent with a durable polymer coating, regarding clinical outcomes with a randomised trial in an all-comer population. METHODS: We did a prospective, randomised, single-blind, multicentre study (TALENT) across 23 centres in Europe (the Netherlands, Poland, the UK, Spain, Bulgaria, Hungary, and Italy). Eligible participants were aged 18 years or older, had one or more coronary artery stenosis of 50% or greater in a native coronary artery, saphenous venous graft, or arterial bypass conduit, and had a reference vessel diameter of 2·25-4·50 mm. Patients underwent percutaneous coronary intervention in an all-comer manner. We randomly assigned patients (1:1) to implantation of either a sirolimus-eluting stent with a biodegradable polymer coating and ultra-thin struts (Supraflex) or an everolimus-eluting stent with a durable polymer coating (Xience). Randomisation was done by local investigators by use of a web-based software with random blocks according to centre. The primary endpoint was a non-inferiority comparison of a device-oriented composite endpoint-cardiac death, target-vessel myocardial infarction, or clinically indicated target lesion revascularisation-between groups at 12 months after the procedure, assessed in an intention-to-treat population. On assumption of 1-year composite endpoint prevalence of 8·3%, a margin of 4·0% was defined for non-inferiority of the Supraflex group compared with the Xience group. This trial is registered with ClinicalTrials.gov, number NCT02870140. FINDINGS: Between Oct 21, 2016, and July 3, 2017, 1435 patients with 1046 lesions were randomly assigned to Supraflex, of whom 720 received the index procedure, and 715 patients with 1030 lesions were assigned to Xience, all receiving the index procedure. At 12 months, the primary endpoint had occurred in 35 patients (4·9 %) in the Supraflex group and in 37 patients (5·3%) in the Xience group (absolute difference -0·3% [one-sided 95% upper confidence bound 1·6%], pnon-inferiority<0·0001). Definite or probable stent thrombosis prevalence, a safety indicator, was low in both groups and did not differ between them. INTERPRETATION: The Supraflex stent was non-inferior to the Xience stent for a device-oriented composite clinical endpoint at 12 months in an all-comer population. Supraflex seems a safe and effective alternative drug-eluting stent to other stents in clinical practice. FUNDING: European Cardiovascular Research Institute.

Comparison of reorganized versus unaltered cardiology departments during the COVID-19 era: A subanalysis of the COV-HF-SIRIO 6 study.

BACKGROUND: Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, numerous cardiology departments were reorganized to provide care for COVID-19 patients. We aimed to compare the impact of the COVID-19 pandemic on hospital admissions and in-hospital mortality in reorganized vs. unaltered cardiology departments. METHODS: The present research is a subanalysis of a multicenter retrospective COV-HF-SIRIO 6 study that includes all patients (n = 101,433) hospitalized in 24 cardiology departments in Poland between January 1, 2019 and December 31, 2020, with a focus on patients with acute heart failure (AHF). RESULTS: Reduction of all-cause hospitalizations was 50.6% vs. 21.3% for reorganized vs. unaltered cardiology departments in 2020 vs. 2019, respectively (p < 0.0001). Considering AHF alone respective reductions by 46.5% and 15.2% were registered (p < 0.0001). A higher percentage of patients was brought in by ambulance to reorganized vs. unaltered cardiology departments (51.7% vs. 34.6%; p < 0.0001) alongside with a lower rate of self-referrals (45.7% vs. 58.4%; p < 0.0001). The rate of all-cause in-hospital mortality in AHF patients was higher in reorganized than unaltered cardiology departments (10.9% vs. 6.4%; p < 0.0001). After the exclusion of patients with concomitant COVID-19, the mortality rates did not differ significantly (6.9% vs. 6.4%; p = 0.55). CONCLUSIONS: A greater reduction in hospital admissions in 2020 vs. 2019, higher rates of patients brought by ambulance together with lower rates of self-referrals and higher all-cause in-hospital mortality for AHF due to COVID-19 related deaths were observed in cardiology departments reorganized to provide care for COVID-19 patients vs. unaltered ones.

PRECISE-DAPT score for bleeding risk prediction in patients on dual or single antiplatelet regimens: insights from the GLOBAL LEADERS and GLASSY.

AIMS: The five-item PRECISE-DAPT, integrating age, haemoglobin, white-blood-cell count, creatinine clearance, and prior bleeding, predicts bleeding risk in patients on dual antiplatelet therapy (DAPT) after stent implantation. We sought to assess whether the bleeding risk prediction offered by the PRECISE-DAPT remains valid among patients receiving ticagrelor monotherapy from 1 month onwards after coronary stenting instead of standard DAPT and having or not having centrally adjudicated bleeding endpoints. METHODS AND RESULTS: The PRECISE-DAPT was calculated in 14 928 and 7134 patients from GLOBAL LEADERS and GLASSY trials, respectively. The ability of the score to predict Bleeding Academic Research Consortium 3 or 5 bleeding was assessed and compared among patients on ticagrelor monotherapy (experimental strategy) or standard DAPT (reference strategy) from 1 month after drug-eluting stent implantation. Bleeding endpoints were investigator-reported or centrally adjudicated in GLOBAL LEADERS and GLASSY, respectively. At 2 years, the c-indexes for the score among patients treated with the experimental or reference strategy were 0.67 [95% confidence interval (CI): 0.63-0.71] vs. 0.63 (95% CI: 0.59-0.67) in GLOBAL LEADERS (P = 0.27), and 0.67 (95% CI: 0.61-0.73) vs. 0.66 (95% CI: 0.61-0.72) in GLASSY (P = 0.88). Decision curve analysis showed net benefit using the PRECISE-DAPT to guide bleeding risk assessment under both treatment strategies. Results were consistent between investigator-reported and adjudicated endpoints and using the simplified four-item PRECISE-DAPT. CONCLUSION: The PRECISE-DAPT offers a prediction model that proved similarly effective to predict clinically relevant bleeding among patients on ticagrelor monotherapy from 1 month after coronary stenting compared with standard DAPT and appears to be unaffected by the presence or absence of adjudicated bleeding endpoints.

Impact of COVID-19 pandemic on acute heart failure admissions and mortality: a multicentre study (COV-HF-SIRIO 6 study).

AIMS: The coronavirus disease-2019 (COVID-19) pandemic has changed the landscape of medical care delivery worldwide. We aimed to assess the influence of COVID-19 pandemic on hospital admissions and in-hospital mortality rate in patients with acute heart failure (AHF) in a retrospective, multicentre study. METHODS AND RESULTS: From 1 January 2019 to 31 December 2020, a total of 101 433 patients were hospitalized in 24 Cardiology Departments in Poland. The number of patients admitted due to AHF decreased by 23.4% from 9853 in 2019 to 7546 in 2020 (P < 0.001). We noted a significant reduction of self-referrals in the times of COVID-19 pandemic accounting 27.8% (P < 0.001), with increased number of AHF patients brought by an ambulance by 15.9% (P < 0.001). The length of hospital stay was overall similar (7.7 ± 2.8 vs. 8.2 ± 3.7 days; P = not significant). The in-hospital all-cause mortality in AHF patients was 444 (5.2%) in 2019 vs. 406 (6.5%) in 2020 (P < 0.001). A total number of AHF patients with concomitant COVID-19 was 239 (3.2% of AHF patients hospitalized in 2020). The rate of in-hospital deaths in AHF patients with COVID-19 was extremely high accounting 31.4%, reaching up to 44.1% in the peak of the pandemic in November 2020. CONCLUSIONS: Our study indicates that the COVID-19 pandemic led to (i) reduced hospital admissions for AHF; (ii) decreased number of self-referred AHF patients and increased number of AHF patients brought by an ambulance; and (iii) increased in-hospital mortality for AHF with very high mortality rate for concomitant AHF and COVID-19.

Comparison of Investigator-Reported and Clinical Event Committee-Adjudicated Outcome Events in GLASSY.

BACKGROUND: Event adjudication by a clinical event committee (CEC) provides a standardized, independent outcome assessment. However, the added value of CEC to investigators reporting remains debated. GLASSY (GLOBAL LEADERS Adjudication Sub-Study) implemented, in a subset of the open-label, investigator-reported (IR) GLOBAL LEADERS trial, an independent adjudication process of reported and unreported potential outcome events (triggers). We describe metrics of GLASSY feasibility and efficiency, diagnostic accuracy of IR events, and their concordance with corresponding CEC-adjudicated events. METHODS: We report the proportion of myocardial infarction, bleeding, stroke, and stent thrombosis triggers with sufficient evidence for assessment (feasibility) that were adjudicated as outcome events (efficiency), stratified by source (IR or non-IR). Using CEC-adjudicated events as criterion standard, we describe sensitivity, specificity, positive and negative predictive value, and global diagnostic accuracy of IR events. Using Gwet AC coefficient, we examine the concordance between IR- and corresponding CEC-adjudicated triggers. There was sufficient evidence for assessment for 2592 (98.3%) of 2636 triggers. RESULTS: Overall, the adjudicated end point-to-trigger ratio was high and similar between IR- (88%) and non-IR-reported (87%) triggers. The global diagnostic accuracy and concordance between IR-reported and CEC-adjudicated outcome events was 0.70 (95% CI, 0.65-0.74) and 0.54 (95% CI, 0.45-0.62), respectively, for myocardial infarction; 0.77 (95% CI, 0.75-0.79) and 0.71 (95% CI, 0.68-0.74) for bleeding; 0.70 (95% CI, 0.62-0.79) and 0.59 (95% CI, 0.43-0.74) for stroke; 0.59 (95% CI, 0.52-0.66) and 0.39 (95% CI, 0.25-0.53) for stent thrombosis. For IR bleedings, the concordance with the CEC on type of events was generally weak. CONCLUSIONS: Implementing CEC adjudication in a pragmatic open-label trial with IR events is feasible and efficient. Our findings of modest global diagnostic accuracy for IR events and generally weak concordance between investigators and CEC support the role for CEC adjudication in such settings. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03231059.

Ticagrelor monotherapy beyond one month after PCI in ACS or stable CAD in elderly patients: a pre-specified analysis of the GLOBAL LEADERS trial.

AIMS: Antiplatelet treatment in the elderly post percutaneous coronary interventions (PCI) remains a complex issue. Here we report the results of the pre-specified subgroup analysis of the GLOBAL LEADERS trial evaluating the long-term safety and cardiovascular efficacy of ticagrelor monotherapy among patients categorised according to the pre-specified cut-off value of 75 years of age. METHODS AND RESULTS: This was a pre-specified analysis of the randomised GLOBAL LEADERS trial (n=15,991), comparing 23-month ticagrelor monotherapy (after one month of DAPT) with the reference treatment (12-month DAPT followed by 12 months of aspirin). Among elderly patients (>75 years; n=2,565), the primary endpoint (two-year all-cause mortality or new Q-wave core lab-adjudicated myocardial infarction [MI]) occurred in 7.2% and 9.4% of patients in the ticagrelor monotherapy and the reference group, respectively (hazard ratio [HR] 0.75, 95% confidence interval [CI]: 0.58-0.99, p=0.041; pint=0.23); BARC-defined bleeding type 3/5 occurred in 5.2% and 4.1%, respectively (HR 1.29, 95% CI: 0.89-1.86; p=0.180; pint=0.06). The elderly with stable CAD had a higher rate of BARC 3/5 type bleeding (HR 2.05, 95% CI: 1.18-3.55) with ticagrelor monotherapy versus the reference treatment (pint=0.02). Elderly patients had a lower rate of definite or probable stent thrombosis (ST) with ticagrelor monotherapy (0.4% vs 1.4%, p=0.015, pint=0.01), compared with the reference group. CONCLUSIONS: In this pre-specified, exploratory analysis of the overall neutral trial, there was no differential treatment effect of ticagrelor monotherapy (after one-month dual therapy with aspirin) found in elderly patients undergoing PCI with respect to the rate of the primary endpoint of all-cause death or new Q-wave MI. The lower rate of ST in the elderly with ticagrelor monotherapy is hypothesis-generating. ClinicalTrials.gov identifier: NCT01813435.

Rationale and design of a prospective substudy of clinical endpoint adjudication processes within an investigator-reported randomised controlled trial in patients with coronary artery disease: the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY).

INTRODUCTION: The GLOBAL LEADERS is an open-label, pragmatic and superiority randomised controlled trial designed to challenge the current treatment paradigm of dual antiplatelet therapy (DAPT) for 12 months followed by aspirin monotherapy among patients undergoing percutaneous coronary intervention. By design, all study endpoints are investigator reported (IR) and not subject to formal adjudication by an independent Clinical Event Committee (CEC), which may introduce detection, reporting or ascertainment bias. METHODS AND ANALYSIS: We designed the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY) to prospectively implement, in a large sample of patients enrolled within the GLOBAL LEADERS trial (7585 of 15 991, 47.5%), an independent adjudication process of reported and unreported potential endpoints, using standardised CEC procedures, in order to assess whether 23-month ticagrelor monotherapy (90 mg twice daily) after 1-month DAPT is non-inferior to a standard regimen of DAPT for 12 months followed by aspirin monotherapy for the primary efficacy endpoint of death, non-fatal myocardial infarction, non-fatal stroke or urgent target vessel revascularisation and superior for the primary safety endpoint of type 3 or 5 bleeding according to the Bleeding Academic Research Consortium criteria.This study will comprehensively assess the comparative safety and efficacy of the two tested antithrombotic strategies on CEC-adjudicated ischaemic and bleeding endpoints and will provide insights into the role of a standardised CEC adjudication process on the interpretation of study findings by quantifying the level of concordance between IR-reported and CEC-adjudicated events. ETHICS AND DISSEMINATION: GLASSY has been approved by local ethics committee of all study sites and/or by the central ethics committee for the country depending on country-specific regulations. In all cases, they deemed that it was not necessary to obtain further informed consent from individual subjects. TRIAL REGISTRATION NUMBER: NCT01813435.

Predictive ability of ACEF and ACEF II score in patients undergoing percutaneous coronary intervention in the GLOBAL LEADERS study.

BACKGROUND: ACEF score has been shown to have predictive ability in the patients undergoing percutaneous coronary intervention (PCI). The ACEF II score has recently been developed to predict short-term mortality after cardiac surgery. We compared the predictive ability of the ACEF and ACEF II scores to predict mortality after PCI in the all-comers population. METHODS: The ACEF and ACEF II scores were calculated in 15,968 patients enrolled in the GLOBAL LEADERS study. Discrimination and calibration were assessed for outcomes after PCI. Recalibration of the regression model by updating the intercept and slope were performed to adjust the original ACEF model to the PCI setting. In a stratified approach, patients were divided into quintiles according to the score. Outcomes were compared between quintiles. RESULTS: The ACEF and ACEF II score were available in 14,941 and 14,355 patients respectively. Discrimination for 30-day all-cause mortality was acceptable for both scores (C-statistic ACEF 0.75 and ACEF II 0.77). For 2-year all-cause mortality, the discrimination of ACEF score was acceptable (C-statistic 0.72) while the discrimination of ACEF II score was moderate (C-statistic 0.69). Both scores identified patients at high risk of mortality but overestimated all-cause mortality at 30 days in all quintiles. After recalibration, agreement between predicted and observed 30-day all-cause mortality in both scores are close to the identity line. CONCLUSIONS: The ACEF II model did not improve the predictive ability of the ACEF score. Recalibrated ACEF model can be used to estimated all-cause mortality rate at 30 days after PCI.

Ticagrelor Alone Versus Dual Antiplatelet Therapy From 1 Month After Drug-Eluting Coronary Stenting.

BACKGROUND: The GLOBAL LEADERS (GLOBAL LEADERS: A Clinical Study Comparing Two Forms of Anti-platelet Therapy After Stent Implantation) study randomly assigned 15,991 patients undergoing percutaneous coronary intervention to 1-month dual antiplatelet therapy (DAPT) followed by 23-month ticagrelor monotherapy or conventional 12-month DAPT followed by 12-month aspirin. Apart from Q-wave myocardial infarction (MI), all study endpoints were analyzed as investigator reported. OBJECTIVES: This was a pre-specified ancillary study assessing whether experimental therapy is noninferior, and if met, superior, to conventional treatment for the coprimary efficacy endpoint of all-cause death, nonfatal MI, nonfatal stroke, or urgent target vessel revascularization and superior in preventing BARC 3 (Bleeding Academic Research Consortium) or 5 bleeding (coprimary safety endpoint) at 2 years with a 0.025 significance level to preserve nominal 5% alpha error. METHODS: An independent clinical event committee adjudicated investigator-reported and eventually unreported events of 7,585 patients from the 20 top-enrolling participating sites. RESULTS: The 2-year coprimary efficacy endpoint occurred in 271 (7.14%) and in 319 (8.41%) patients in the experimental and conventional groups, respectively (rate ratio [RR]: 0.85; 95% confidence interval [CI]: 0.72 to 0.99), fulfilling noninferiority (p noninferiority <0.001), but not superiority (p superiority = 0.0465). The rates of BARC 3 or 5 bleeding did not differ (RR: 1.00; 95% CI: 0.75 to 1.33; p = 0.986). A time-dependent treatment effect was observed with the experimental strategy being associated with a lower risk of MI (RR: 0.54; 95% CI: 0.33 to 0.88; p interaction = 0.062) and definite stent thrombosis (RR: 0.14; 95% CI: 0.03 to 0.63; p interaction = 0.007) after 1-year post-percutaneous coronary intervention. CONCLUSIONS: Ticagrelor monotherapy after 1-month DAPT was noninferior, but not superior, to conventional treatment in the prevention of ischemic events, and it did not decrease major bleeding risk as compared with conventional treatment. (GLOBAL LEADERS Adjudication Sub-Study [GLASSY]; NCT03231059).

Electrophysiologic parameters suggesting significant acute cellular rejection of the transplanted heart.

AIM OF THE STUDY: Was to estimate an influence of acute cellular rejection on electrophysiologic parameters of allograft and remnants of recipient's heart, in patients after orthotopic heart transplantation (OHT). PATIENTS AND METHODS: Analysis was performed in 25 OHT recipients (24M/1F, age 48.4 +/- 9 y., ischemic time 197 +/- 51 min., donor age 30 +/- 9 y.), who underwent electrophysiological study (EPS), along with elective endomyocardial biopsy (EMB), scheduled for the 1st month after the surgery. Results of EPS were correlated with a degree of rejection, assessed with the ISHLT grading system. Grades > or =3A were considered a significant cellular rejection. RESULTS: ISHLT grade 0 was observed in 8 patients, grade 1A or 1B in 12 patients, and 3A in 5 patients. Frequency of transplanted heart rhythm (TH-R) was 691.3+/- 37 ms in patients with ISHLT grade 0, 690.4 +/- 41 ms in patients with grade 1A or 1B, and 744.4 +/- 668 ms in individuals with 3A rejection (p < 0.04, for difference between 0 and 3A groups). Intraatrial conduction time (IntrtaCT) was significantly shorter in grade 3A group (20.4 +/- 1.6 ms), when compared with patients without rejection (36.2 +/- 4.9 ms, p < 0.03), or with 1A or 1B rejection (41.5 +/- 13 ms, p < 0.032). Also interatrial conduction time (InterCT) was the shortest in patients with 3A rejection (53.8 +/- 4.3 ms), when compared with ISHLT grade 0 group (78.5 +/- 7.6 ms, p < 0.02) and 1A/1B group (74.1 +/- 12 ms, p < 0.023). The other characteristics of atria, ventricles and AV-junction performance were comparable in all patients. CONCLUSIONS: TH-R, IntraCT and InterCT should be considered as the markers of significant cellular rejection in patients after OHT. Further analysis involving higher number of patients is warranted.

Use of the LocaLisa mapping system during ablation procedures in patients with atrioventricular nodal reentrant tachycardia.

INTRODUCTION: LocaLisa is a novel system for anatomical mapping. It enables an assessment of the three-dimensional position of electrodes within cardiac chambers without fluoroscopy. With this technique it may be possible to reduce radiation exposure during catheter-based ablation procedures. AIM: To evaluate the efficacy and safety of ablation procedures performed using the LocaLisa mapping system in patients with atrioventricular nodal reentrant tachycardia (AVNRT). METHODOLOGY: This study evaluated the course of the first 26 ablations performed using the LocaLisa system (studied group). The control group involved 30 consecutive patients with AVNRT treated with the conventional ablation technique that was routinely used prior to the introduction of the novel system into clinical practice. RESULTS: In the studied group procedural duration was 72.4+/-24.9 minutes, in the control group 80.1+/-18.2 minutes (NS). However, radiation exposure was significantly lower in the examined group -- 74.4+/-109.2 mGy compared to 184.8+/-59.9 mGy in the control group (p <0.05). All procedures were successful. No complications related to the ablation were observed. CONCLUSIONS: Employment of the LocaLisa mapping system enables the reduction of fluoroscopic exposure without any decrease of efficacy or elevation of risk of any complications during AVNRT ablations.

Radiofrequency ablation of typical atrial flutter with the use of electro-anatomical mapping system CARTO.

BACKGROUND: Radiofrequency (RF) ablation of typical atrial flutter (AFL) is a well-established method of treatment. Although its efficacy is high, a search for new, more effective techniques is continuing. These new methods include modern systems for electro-anatomical mapping and new types of ablating electrodes such as cooled-tip or dual-sensor catheters. AIM: To assess the efficacy of RF ablation of typical AFL with the use of electro-anatomical mapping system CARTO and to compare the effectiveness of various ablating catheters. METHODS: The study group consisted of 60 consecutive patients who underwent RF ablation of typical AFL with the use of the CARTO system. In 35 patients standard ablating electrodes were used, in 15 -- cooled-tip catheters (Thermo-Cool), and in 10 -- Dual-Sensor catheters. RESULTS: Overall efficacy of RF ablation was 96.6%. In two procedures which occurred ineffective, standard ablating electrodes were used. In 4 (6.6%) patients a recurrence of AFL was noted -- also these patients had RF ablation performed with the use of standard ablating electrodes. None of the patients had procedure-related complications. CONCLUSIONS: RF ablation of typical AFL with the use of electro-anatomical system CARTO is effective, safe and associated with reduced fluoroscopy time. The use of cooled-tip or dual sensor ablating electrodes further enhances efficacy of the procedure.

Effectiveness of radiofrequency catheter ablation of right ventricular outflow tract tachycardia using the CARTO system.

BACKGROUND: Ventricular ectopy or ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT) are the most common forms of arrhythmias in patients with structurally normal heart. Pharmacological treatment is effective in no more than 50% of patients, whereas radio-frequency catheter ablation (RFCA) offers a much higher success rate. AIM: To assess early and late outcome in patients with RVOT arrhythmias treated with RFCA combined with electro-anatomical mapping system (CARTO). METHODS: The study group consisted of 34 consecutive patients (mean age 38.8+/-12.0 years, range 21-52 years, 11 males, 23 females) with symptomatic arrhythmias originating from RVOT, who underwent RFCA in our department between December 2001 to July 2003. RFCA was performed with the use of the CARTO system. The power of RF current was set at 40 Watts, duration -- 90 seconds, and maximal temperature -- 55 degrees C. In order to assess short- and long-term RFCA efficacy, a 24-hour Holter ECG monitoring was performed before RFCA and shortly after the procedure as well as one and three months afterwards. Effective RFCA was defined as the reduction of ventricular ectopy <1000 / 24 hours in Holter monitoring performed just after the procedure. RESULTS: Holter ECG monitoring performed after RFCA showed that the procedure was effective in 30 (88.2%) patients. In the remaining four patients no significant reduction in the frequency of ventricular ectopy was noted, however, no complex ventricular arrhythmias were present. In none of the patients neither early nor late complications were observed. The mean follow-up duration was 15.6 months (range 5-26 months). During Holter ECG monitoring performed one and three months after RFCA, a recurrence of frequent ventricular ectopy (7139 beats / 24 hours) was found in one patient, however, without complex arrhythmias. The remaining patients, in whom RFCA was found to be effective at Holter ECG monitoring performed just after the procedure, continue to be free from arrhythmia and do not require antiarrhythmic agents. CONCLUSIONS: RFCA with the use of the CARTO system is effective and safe in the treatment of arrhythmias originating from RVOT.

[Atrio-ventricular nodal reentrant tachycardia--concepts evolution on the propagation of the reentrant wave front]. / Przedsionkowo-komorowy nawrotny czestoskurcz wezlowy--ewolucja pogladów na temat przebiegu frontu aktywacji fali nawrotnej.

Atrio-ventricular nodal reentrant tachycardia (AVNRT) is the most common narrow QRS tachycardia. The arrhythmia affects usually patients without any other structural heart disease. AVNRT may be the cause of the broad spectrum of symptoms, ranging from palpitations to clinical signs of impaired coronary and cerebral perfusion. Mechanism responsible for AVNRT is reentry, which involves right and some part of the left atrium. Employed in the early 80's the technique of radiofrequency current (RF) ablation (which allows removal of arrhythmic substrate by modification or destruction of the slow pathway), is safe and a high effective method of treatment in patients with AVNRT.

Coronary sinus stenting for the stabilization of left ventricular lead during resynchronization therapy.

We report on two patients treated with cardiac resynchronization therapy, in whom early (intra-operatively, 64-year-old man) and late (4 months post-operatively, 57-year-old woman) instability of the left ventricular (LV) lead occurred. In order to stabilize the electrodes, stents were deployed in both patients within the coronary sinus, into the space between the lead and the wall of the vein effectively pinning the lead to the wall. During 3 and 5 months of follow-up, the electrodes remained stable and allowed for successful resynchronization in both cases. Stenting within the coronary sinus seems to be a safe method for LV lead stabilization, which can substantially increase the success rate of resynchronization therapy. This new approach, although promising, has to prove its safety and should not be practised routinely until long-term follow-up data are available.

Effect of percutaneous interventions within the coronary sinus on the success rate of the implantations of resynchronization pacemakers.

BACKGROUND: Cardiac resynchronization therapy (CRT) becomes a "gold standard" in therapy of selected patients with advanced heart failure. We set out to evaluate the feasibility and safety of percutaneous interventions within coronary sinus (CS) and their effect on the success rate of left ventricular (LV) lead implantation during CRT. METHODS: The study analyzed eight consecutive patients with the indications for CRT, who needed additional procedures within CS to overcome technical problems during left ventricular (LV) electrode implantation. The analyzed group consisted of three subgroups: patients in whom percutaneous balloon angioplasty within CS was needed (n = 4); patients with acute instability of the lead, requiring stenting of the vein to fix the electrode (n = 2); and patients with the stenting of CS due to late dislocation of the lead (n = 2). Success rate, procedure duration, fluoroscopy, complications, and electrical parameters of leads were analyzed. RESULTS: Success rate of the procedures was 87.5%; additional interventions increased overall efficacy of CRT implantation at our center from 88% to 98% (P < 0.05). Procedure duration (155.0 minute) and fluoroscopy time (42.5 minute) remained acceptable for the patient and operator; however, both were higher than in the procedures performed routinely in our hospital. Electrical properties of the LV leads were stable and within normal ranges during the observation period. We noted two local dissections of CS during the procedure, which remained clinically silent. CONCLUSION: Percutaneous interventions within CS seem to be feasible and safe treatment options, which can improve the short- and long-term success rates of CRT.

[Diagnostic difficulties in acute pulmonary embolism diagnosis: ECG changes evolution: a case report]. / Trudnosci diagnostyczne w rozpoznawaniu ostrej zatorowosci plucnej--ewolucja zmian w EKG--opis przypadku.

Pulmonary embolism is a common disease which may cause diagnostic difficulties. To establish a diagnosis additional examinations are needed. Except typical for pulmonary embolism EKG changes the value of untypical ST-T changes connected with cardiac ischaemia is appreciated. The case below presents the usefulness of EKG monitoring in acute pulmonary embolism.

[Permanent junction reciprocating tachycardia--treatment with radiofrequency current ablation]. / Uporczywy czestoskurcz nawrotny przedsionkowo-komorowy--leczenie za pomoca ablacji pradem o czestotliwosci radiowej.

The patients with WPW syndrome demonstrate wide scale of clinical manifestation, from asymptomatic course to sudden cardiac death. Among this patients it is possible to identify the small group of patients with rare kind of atrioventricular reentrant tachycardia named permanent junctional reciprocating tachycardia (PJRT) associated with increased risk of development tachycardia-induced cardiomyopathy. This patients should be successful treated by radiofrequency catheter ablation (RFCA). Aim of the study was assessment of efficacy and safety of RFCA procedure in patients with preexcitation syndrome and PJRT. Analyzed group consisted of 7 patients with PJRT selected from 163 consecutive patients with symptomatic WPW--syndrome undergo electrophysiological study (EPS) and RFCA. Analyzed group consist of 4 women and 3 men. Mean age of patients was 22.71 SD +/- 7.99 (from 14 to 38 years). Every patients underwent EPS and RFCA simultaneously. Success-rate in first session was 71.42% (5 patients were successful ablated). Two women underwent second ablation one who has recurrent symptomatic arrhythmia and another who initially was unsuccessfully treated in first session. This two additional procedures were successful. RFCA-duration time was average 107.85 minutes SD +/- 21.95 (min-80, max-145 min) and fluoroscopy--time amount from 28 min to 55 min average 38.58 min (SD +/- 11.14). Among analyzed patients we did not noticed any complications during ablation procedure. Patients with PJRT could be safe and successfully treated using RFCA.

Electrophysiological features of orthodromic atrioventricular reentry tachycardia in patients with wolff-Parkinson-white syndrome and atrial fibrillation.

The aim of this study was to compare the electrophysiological features of tachycardia between WPW patients with and without AF. The study population consisted of 114 patients with WPW syndrome and reciprocating tachycardia during electrophysiological study. Two groups were selected: group I with AF during the procedure(n = 42)and the control group n = 72 without AF (group II). Cycle length (V-V interval), antero A-V, retrograde V-A conduction time during tachycardia and indexes V-A/V-V were analyzed. In addition, the relation between antero-, retrograde conduction time, and V-V was evaluated. Selection of the most predictive factor for AF presence was performed using regression analysis. Significant differences between the two groups were observed. These included a higher rate of tachycardia, shorter anterograde conduction time, A-V/V-V-indexes, longer retrograde conduction time, and V-A/V-V-indexes in group I compared with group II. Significant, positive correlations between anterograde conduction time and V-V were present in both groups, but retrograde conduction correlated significantly with the V-V-interval only in group II and group I (r = 0.37 vs r =-0.01, respectively). Significant, negative correlations between A-V and V-A conduction time in all analyzed points has been found to exist in group I (r =-0.45 for the point of maximal preexcitation [PMP]), whereas there were no significant correlations between these parameters in group II (r = 0.04). The most powerful AF predictor has been identified as the V-A/V-V index. The presence of AF in WPW syndrome may be associated with discrete patient characteristics. Ventricular activation occurs earlier, and atrial later, in the tachycardia cycle in AF than in patients free of AF. The different ability of the accessory pathway for adaptation to tachycardia rate changes in group I causes prolonged retrograde conduction over the pathway while the tachycardia rate increases.