Trileaflet Mitral Valve with Three Papillary Muscles Associated with Hypertrophic Cardiomyopathy: A Novel Case.

Congenital mitral valve (MV) malformations are uncommon, except for MV prolapse. Despite their infrequency, most of them are well-known and defined entities, such as congenital MV stenosis with two papillary muscles, parachute MV, supravalvular mitral ring, hypoplastic MV, isolated cleft in the anterior and/or posterior leaflets, and double-orifice MV. A trileaflet MV with three separate papillary muscles with concordant atrioventricular and ventricle-arterial connections is exceptionally rare. To the best of the authors' knowledge, it has been reported only once in association with subaortic valvular stenosis. We hereby describe a novel case associated with hypertrophic cardiomyopathy.

Religion and the Catholic church's view on (heart) transplantation: a recent statement of Pope Benedict XVI and its practical impact.

Heart transplantation is performed on approximately 4,000 patients per year worldwide and is considered the last resort for treatment of end-stage heart diseases. Due to persistent organ shortage, resources are limited, waiting periods are extensive, and patients still die while being on a waiting list for transplantation. The role of all churches and the support of the representatives of the churches are critical for the spiritual wellbeing of patients awaiting heart transplantation as well as for prospective individual organ donors and their families. The supportive role of the Roman Catholic Church and the recent statement of Pope Benedict XVI on organ donation are discussed.

Improved erectile function after cardiac resynchronization therapy in a patient with heart failure-a case report.

INTRODUCTION: Erectile dysfunction (ED) is very common among heart failure patients and has a very dramatic, negative impact on patients' quality of life. Both ED and heart failure have several risk factors in common; however, little data exist on the correlation between the heart failure-targeted interventions and improvement of ED. AIM: To report a case of improved sexual function after cardiac resynchronization. METHODS: We report the case of a 63-year-old man with ischemic cardiomyopathy and long-standing ED, who experienced significant improvement of his sexual function following biventricular pacing device implantation. Notably, earlier interventions attempting to improve his ED, namely, heart failure medication adjustments and phosphodiesterase-5 inhibitors, have failed. RESULTS: Following cardiac resynchronization therapy, patient's erectile function improved without any other ED-specific treatment. CONCLUSIONS: To the best of our knowledge, this is the first report of improved sexual function in a patient with heart failure and ED following cardiac resynchronization therapy. Although the exact mechanisms remain unknown, we believe that cardiac resynchronization improves ED through improved cardiac and endothelial function.

A randomized study of prophylactic catheter ablation in asymptomatic patients with the Wolff-Parkinson-White syndrome.

BACKGROUND: Young age and inducibility of atrioventricular reciprocating tachycardia or atrial fibrillation during invasive electrophysiological testing identify asymptomatic patients with a Wolff-Parkinson-White pattern on the electrocardiogram as being at high risk for arrhythmic events. We tested the hypothesis that prophylactic catheter ablation of accessory pathways would provide meaningful and durable benefits as compared with no treatment in such patients. METHODS: From 1997 to 2002, among 224 eligible asymptomatic patients with the Wolff-Parkinson-White syndrome, patients at high risk for arrhythmias were randomly assigned to radio-frequency catheter ablation of accessory pathways (37 patients) or no treatment (35 patients). The end point was the occurrence of arrhythmic events over a five-year follow-up period. RESULTS: Patients assigned to ablation had base-line characteristics that were similar to those of the controls. Two patients in the ablation group (5 percent) and 21 in the control group (60 percent) had arrhythmic events. One control patient had ventricular fibrillation as the presenting arrhythmia. The five-year Kaplan-Meier estimates of the incidence of arrhythmic events were 7 percent among patients who underwent ablation and 77 percent among the controls (P<0.001 by the log-rank test); the risk reduction with ablation was 92 percent (relative risk, 0.08; 95 percent confidence interval, 0.02 to 0.33; P<0.001). CONCLUSIONS: Prophylactic accessory-pathway ablation markedly reduces the frequency of arrhythmic events in asymptomatic patients with the Wolff-Parkinson-White syndrome who are at high risk for such events.

Usefulness of ST depression with T-wave inversion in leads V(4) to V(6) for predicting one-year mortality in non-ST-elevation acute coronary syndrome (from the Electrocardiographic Analysis of the Global Use of Strategies to Open Occluded Coronary Arteries IIB Trial).

ST-segment depression (ST-D) on the admission electrocardiogram of patients with non-ST-elevation acute coronary syndromes (NSTEACSs) is associated with higher mortality. However, few studies have evaluated the effect of location of ST-D and T-wave polarity on long-term prognosis of patients with NSTEACS. Electrocardiographic (ECG) and clinical data from 6,770 patients with NSTEACS randomly assigned in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIB trial were analyzed retrospectively. One-year mortality was correlated with location of ST-D (leads I and aVL; II, III, and aVF; V1 to V3; or V4 to V6) and T-wave polarity. ST-D in any of the ECG locations was associated with higher mortality compared with patients without ST-D. Patients with ST-D and T-wave inversion in leads V4 to V6 had the highest 1-year mortality rate of all groups (16.2%), significantly higher compared with patients with ST-D without T-wave inversion in those leads (9.0%, p=0.001). Logistic regression analysis showed that age, hyperlipidemia, Killip class>I, history of myocardial infarction, history of heart failure, history of angina pectoris, systolic blood pressure, heart rate, sum of ST-D (odds ratio 1.061, 95% confidence interval 1.035 to 1.087, p<0.001), and ST-D with T-wave inversion in leads V4 to V6 (odds ratio 1.374, 95% CI 1.023 to 1.844, p=0.035) were independent predictors of 1-year mortality. Conversely, ST-D without T-wave inversion in leads V4 to V6 or other ECG presentations were not independent predictors of high 1-year mortality. In conclusion, ST-D with T-wave inversion in leads V4 to V6 on the admission electrocardiogram in patients with NSTEACS identifies those with higher 1-year mortality than for patients with any other ECG presentation.

Intermittent outpatient nesiritide infusion reduces hospital admissions in patients with advanced heart failure.

Recombinant B-type natriuretic peptide (BNP) is a therapeutic modality in patients with decompensated congestive heart failure. Retrospectively tested are the effects of intermittent outpatient nesiritide infusion on symptoms, hospital readmission rates, endogenous BNP, and renal function in patients with advanced heart failure. Twenty-four patients in heart failure in New York Heart Association (NYHA) classes III-IV received a 6- to 8-hour intermittent nesiritide outpatient infusion (0.01 mcg/kg/min continuously intravenously) once weekly for a total duration of 3 months in addition to standard medical therapy. Data were analyzed retrospectively to compare hospital readmission rates, endogenous BNP levels, blood urea nitrogen, and creatinine levels 1 year before and up to 12 months after starting treatment. All patients tolerated nesiritide infusions well with no significant adverse events. At the end of the observation period, NYHA classes had improved 1 class in 16 patients and 2 classes in 4 patients and remained unchanged in 4 patients. There was a significant reduction in hospital readmissions within 1 year with nesiritide treatment compared with the year before (0.94 +/- 0.8 vs 3.6 +/- 2.2, P < .005). No significant changes were seen regarding endogenous BNP levels (1002 +/- 870 vs 1092 +/- 978 pg/mL, P = .95), blood urea nitrogen levels (45 +/- 28 vs 45 +/- 26 mg/dL, P = .96), and a tendency of slightly elevated creatinine levels that did not differ significantly compared with prior levels (1.76 +/- 0.85 vs 1.1 +/- 0.56 mg/dL, P = .5). Intermittent outpatient nesiritide treatment resulted in improved symptoms and reduced hospital readmission rates without a significant decline in renal function in patients with advanced heart failure but did not alter endogenous BNP levels.

Late right ventricular perforation and hemothorax after transvenous defibrillator lead implantation.

A 53-year-old man with ischemic cardiomyopathy underwent prophylactic transvenous implantable cardioverter-defibrillator (ICD) placement. Nine days after the procedure, he had recurrent chest pain and left pleural effusion associated with a drop in hemoglobin. Hemothorax and right ventricular (RV) lead perforation were suspected on chest radiography and lead interrogation, and confirmed by thoracentesis and contrast computed tomography (CT) scanning, respectively. The CT-scan clearly demonstrated the RV lead tip projecting beyond the cardiac border into the anterior left pleural space. The perforated lead was removed in the operating room under transesophageal echocardiography guidance and a new transvenous lead was successfully placed a month later. This case highlights: 1) the importance of suspecting late RV perforation in patients with ICD implantation presenting with recurrent chest pain and/or pleural effusion; 2) the value of CT in its diagnosis; and 3) the need for a more careful management of this potentially life threatening complication.

Statins are associated with lower risk of gastrointestinal bleeding in patients with unstable coronary syndromes: analysis of the Orbofiban in Patients with Unstable coronary Syndromes-Thrombolysis In Myocardial Infarction 16 (OPUS-TIMI 16) trial.

BACKGROUND: It has recently been shown that statins increase the myocardial content of prostaglandin (PG) I2 (prostacyclin) and PGE2. A systemic increase of PG production may protect the gastric mucosa and prevent gastrointestinal (GI) bleeding. We hypothesized that statins would lower the risk of GI bleeding associated with antiplatelet therapy in patients with acute coronary syndromes (ACS). METHODS: We retrospectively analyzed data on 10288 patients with ACS included in the OPUS-TIMI 16 trial and received aspirin and either the oral IIb/IIIa inhibitor orbofiban or placebo. RESULTS: Inhospital GI bleeding rate was significantly lower in patients who were receiving lipid-lowering drugs before admission compared with those who were not (0.2% vs 0.6%, P = .031). Throughout 10 months of follow-up, GI bleeding occurred in 1.8% of non-statin users compared with 1.0% of statin users (P = .001). Statin use was associated with less overall bleeding in both the orbofiban (1.4% vs 2.4%, P = .006) and the placebo groups (0.2% vs 0.8%, P = .047). Severe and major bleeding occurred less frequently with statin use (0.8% vs 1.5%, P = .001) in both the orbofiban (1.1% vs 2.0%, P = .006) and the placebo groups (0.1% vs 0.5%, P = .119). Logistic regression analysis showed that age > 65 years, orbofiban treatment, Killip class > 1, history of cerebrovascular disease, and calcium-channel blocker use were associated with higher risk of GI bleeding, whereas statin therapy was associated with a lower risk (odds ratio 0.68, 95% CI 0.45-1.04, P = .079). CONCLUSIONS: Statins may exert protective effect against GI bleeding in patients with ACS. Additional studies are warranted to explore this additional potential benefit of statins.

"How do cardiomyocytes die?" apoptosis and autophagic cell death in cardiac myocytes.

BACKGROUND: Cell death constitutes one of the key events in biology. Historically, apoptosis and necrosis have been considered to represent the 2 fundamental forms of cell death. Apoptosis is a tightly regulated, energy-dependent process in which cell death follows a programmed set of events. Necrosis refers to the sum of degenerative changes that follow any type of cell death. METHODS AND RESULTS: The role of apoptosis in development of ischemic heart disease, hypertensive heart disease, and end-stage heart failure has been well documented. Recent evidence suggests the potential role of a third mechanism of cell death, autophagy, in loss of cardiac myocytes. Autophagic cell death has been recently documented in myocardial cells from hypertrophied, failing, and hibernating myocardium. CONCLUSION: In this review, we will list the basic mechanisms of apoptosis and autophagic cell death and examine the recent developments in apoptosis and autophagic cell death as it pertains to cardiovascular disease.

A case and review of acromegaly-induced cardiomyopathy and the relationship between growth hormone and heart failure: cause or cure or neither or both?

Growth hormone plays an integral role in the development and maintenance of structure and function of the heart. Specific involvement of the heart in acromegaly is termed acromegalic cardiomyopathy, manifested as concentric left ventricular hypertrophy and diastolic dys-function. Left untreated, it ultimately progresses to systolic heart failure. Heart failure from acromegalic cardiomyopathy is one of the most common causes of death in acromegaly. Current treatment options include different approaches to lower elevated growth hormone levels with improvement in symptoms, exercise tolerance, and echocardiographic improvement in regression of left ventricular hypertrophy and indices of diastolic dysfunction. On the other hand, growth hormone is essential for cardiac growth and function and exerts beneficial and protective effects on the cardiovascular system. Its potential role as adjunctive therapy in the treatment of heart failure as derived from experimental studies and clinical trials is discussed.

Prostaglandins mediate the cardioprotective effects of atorvastatin against ischemia-reperfusion injury.

OBJECTIVES: Statins attenuate myocardial ischemic injury by activating nitric oxide synthase (NOS). It is unknown whether cyclooxygenase-2 (COX2), which mediates late ischemic preconditioning, also mediates statins-induced cardioprotection. We investigated the involvement of the prostaglandins and NOS in the cardioprotective effect of atorvastatin (ATV) in the rat. METHODS: Sprague-Dawley rats were randomized to a 3-day oral treatment with ATV 10 mg/kg, valdecoxib, a selective COX2 inhibitor (VAL) 3 mg/kg, ATV+VAL or water alone. Rats underwent 30-min myocardial ischemia followed by 4-h reperfusion. RESULTS: Infarct size was smaller in the ATV group (31.3+/-1.9%) than controls (44.5+/-3.1%; p=0.011) and VAL (44.5+/-3.1%; p=0.008). VAL attenuated the protective effect of ATV when administered together (40.2+/-2.5%). ATV pretreatment increased myocardial content of 6-keto-PGF(1alpha) (69.5+/-1.5 pg/mg) and PGE2 (57.9+/-0.6 pg/mg) compared with controls (16.2+/-0.2 and 42.1+/-2.0 pg/mg, respectively) and ATV+VAL (15.8+/-0.3 and 39.9+/-1.9 pg/mg, respectively). ATV increased myocardial content of cytosolic phospholipase A2 (cPLA2) (174.8+/-0.5%), COX2 (446.2+/-0.9%), PGI2 synthase (201.8+/-1.1%) and PGE2 synthase (122+/-0.7%), whereas ATV+VAL did not (123.0+/-7.9%, 93.8+/-8.5%, 103.0+/-1.6% and 99.0+/-0%, respectively). ATV did not change the myocardial content of eNOS and nNOS, but increased the concentration of phosphorylated eNOS (231.8+/-2.4%) and iNOS (154.5+/-1.2%). This effect was not blocked by coadministration of VAL (231.5+/-3.0% and 154.5+/-1.8%, respectively). CONCLUSIONS: Our results suggest that the prostaglandins are essential for mediating the myocardial protective effects of ATV and their production is downstream to eNOS phosphorylation and iNOS.

Efficacy and safety of novel anticoagulants versus vitamin K antagonists in patients with mild and moderate to severe renal insufficiency: Focus on apixaban.

The high risk of both stroke and major bleeding in atrial fibrillation (AF) patients with chronic kidney disease (CKD) defines an important population for whom the assessment of the balance between the risk of ischemic stroke and of bleeding is essential. The use of novel oral anticoagulants (NOACs) may be a viable option in this population due to their greater net clinical benefit than warfarin, as demonstrated by the results of the clinical phase III trials. NOACs have been found to have a greater net clinical benefit than warfarin in patients at high risk of either stroke (CHADS2≥1 or CHA2DS2-VASc score≥2) or bleeding (HAS-BLED≥3). Noteworthy, it has been found also a positive net clinical benefit with apixaban and dabigatran 110mg BID in patients with CHADS2 score=0 and HAS-BLED score≥3. At CHA2DS2-VASc score=1, apixaban and both doses of dabigatran were superior to warfarin in terms of the net clinical benefit. Available scientific evidence might help in clinical decision-making regarding the use of NOACs in patients with CKD who are at high risk for both stroke and bleeding. Overall, current findings provide a rationale for the choice of apixaban or rivaroxaban over dabigatran in patients with AF and stage III CKD. Out of the NOACs, only apixaban has been recently approved for the use in patients with end-stage renal dysfunction on hemodialysis (the recommended dose of 5mg twice daily should be halved in patients with body weight of ≤60kg and or age≥80years).

Usefulness of invasive electrophysiologic testing to stratify the risk of arrhythmic events in asymptomatic patients with Wolff-Parkinson-White pattern: results from a large prospective long-term follow-up study.

OBJECTIVES: The aim of this study was to assess in a large cohort of asymptomatic subjects with Wolff-Parkinson-White (WPW) pattern the usefulness of invasive electrophysiologic testing (EPT) in predicting the occurrence of arrhythmic events over a five-year follow-up. BACKGROUND: Sudden death may be the first clinical manifestation of the WPW syndrome in previously asymptomatic patients. Serial EPTs have been proposed to identify patients at risk. METHODS: A total of 212 consecutive asymptomatic WPW patients were enrolled after a baseline EPT; patients were followed for five years, and 162 patients (115 noninducible and 47 inducible) patients underwent a second EPT. RESULTS: After a mean follow-up of 37.7 months, 33 patients became symptomatic. Of the 115 noninducible patients, 18.2% lost anterograde accessory pathway (AP) conduction, 30% retrograde AP conduction, and only 4 (3.4%) developed symptomatic supraventricular tachycardia (SVT). Of the 47 inducible patients, 25 with sustained atrioventricular reciprocating tachycardia (AVRT) and atrial fibrillation (AF), and 4 with nonsustained AVRT and AF became symptomatic for SVT (n = 21) and AF (n = 8). They were younger, had shorter AP anterograde refractory periods, and multiple APs compared to patients who remained asymptomatic (for all comparisons, p < 0.0001). Of the eight patients with symptomatic episodes of AF and inducible sustained AF, two had a resuscitated cardiac arrest and one died suddenly; all three patients were inducible for AVRT and AF and had multiple APs. CONCLUSIONS: In asymptomatic WPW subjects, EPT may be a valuable tool to stratify the risk of symptomatic and fatal arrhythmic events.

Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study.

OBJECTIVES: This study was designed to investigate the potential of circumferential pulmonary vein (PV) ablation for atrial fibrillation (AF) to maintain sinus rhythm (SR) over time, thus reducing mortality and morbidity while enhancing quality of life (QoL). BACKGROUND: Circumferential PV ablation is safe and effective, but the long-term outcomes and its impact on QoL have not been assessed or compared with those for medical therapy. METHODS: We examined the clinical course of 1,171 consecutive patients with symptomatic AF who were referred to us between January 1998 and March 2001. The 589 ablated patients were compared with the 582 who received antiarrhythmic medications for SR control. The QoL of 109 ablated and 102 medically treated patients was measured with the SF-36 survey. RESULTS: Median follow-up was 900 days (range 161 to 1,508 days). Kaplan-Meier analysis showed observed survival for ablated patients was longer than among patients treated medically (p < 0.001), and not different from that expected for healthy persons of the same gender and calendar year of birth (p = 0.55). Cox proportional-hazards model revealed in the ablation group hazard ratios of 0.46 (95% confidence interval [CI], 0.31 to 0.68; p < 0.001) for all-cause mortality, of 0.45 (95% CI, 0.31 to 0.64; p < 0.001) for morbidities mainly due to heart failure and ischemic cerebrovascular events, and of 0.30 (95% CI, 0.24 to 0.37; p < 0.001) for AF recurrence. Ablated patients' QoL, different from patients treated medically, reached normative levels at six months and remained unchanged at one year. CONCLUSIONS: Pulmonary vein ablation improves mortality, morbidity, and QoL as compared with medical therapy. Our findings pave the way for randomized trials to prospect a wider application of ablation therapy for AF.

Benefits, unresolved questions, and technical issues of cardiac resynchronization therapy for heart failure.

This review aims to provide a synthesis of the published evidence regarding the rationale and clinical benefits of cardiac resynchronization therapy (CRT) with implantable atrial-synchronized biventricular pacing (BVP) devices in patients with moderate to advanced heart failure and intra- and interventricular conduction delays. In addition, it addresses clinical and technical issues that have yet to be resolved, such as the selection of the most suitable candidates for CRT; the usefulness of combining BVP with automatic defibrillation backup; the value of CRT in patients with atrial fibrillation; the importance of alternative sites of pacing, such as the atrial septum and the right ventricular (RV) outflow tract; the harmful effects of the long-standing practice of producing an iatrogenic left bundle branch block by conventional RV pacing in patients receiving standard permanent pacemakers; the question of precisely where on the left ventricle optimal pacing is achieved; and the potential applications of CRT in patients with pediatric or congenital heart disease. Considering how major advances have been achieved since the first clinical application of CRT in 1994, one can be optimistic about the future of the electrotherapeutic management of heart failure.

Reperfusion-related polymorphic ventricular tachycardia as a possible mechanism of sudden death in patients with anomalous coronary arteries.

We describe a patient with anomalous origin of the left coronary artery in whom polymorphic ventricular tachycardia developed immediately after an episode of chest pain with ST segment elevation. This is the first report providing direct evidence that reperfusion arrhythmias may be the cause of sudden death in individuals with anomalous coronary arteries.

Combining electrical therapies for advanced heart failure: the Milan experience with biventricular pacing-defibrillation backup combination for primary prevention of sudden cardiac death.

Biventricular pacing (BVP) improves hemodynamics and symptoms in patients with heart failure with bundle branch block. Patients with a left ventricular ejection fraction <0.35 and ventricular tachyarrhythmias are at risk of sudden cardiac death, and they benefit most from implantable cardioverter defibrillators (ICDs). No study has evaluated the efficacy of the BVP-ICD combination in patients with heart failure with no history of syncope or sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Our prospective, observational study was performed on 135 consecutive patients with heart failure (aged, 64 +/- 11 years; 76% male; New York Heart Association functional class, 3.1 +/- 0.8; ejection fraction 0.28 +/- 0.06; ischemic heart failure, 43%; QRS interval duration, 153 +/- 11 msec) treated at our cardiac pacing unit between January 1999 and April 2001. In the first year (control phase), BVP alone was implanted. After that, BVP with ICD backup was used (prophylactic phase). Follow-up data were obtained by outpatient visits with electrocardiographic and echocardiographic examinations done at 3-month intervals. For patients who died, we examined hospital records, death certificates, and autopsy reports. Follow-up time averaged 840 days. The first 47 patients received BVP alone. During follow-up study, 19% of these patients died suddenly, and 11% died of worsening heart failure. None of the patients who died suddenly had hemodynamic deterioration or BVP malfunction before the event. The BVP-ICD group comprised 88 patients (18% with VT/VF inducibility on electrophysiologic testing). During follow-up study, 32% of these patients (18% with positive electrophysiologic testing) had VT/VF episodes successfully treated by ICD; 5% received inappropriate discharges on atrial fibrillation; and 6% died of heart failure with 1 sudden cardiac death. Cox proportional hazards model in the BVP-ICD group compared with BVP alone revealed hazard ratios for all-cause mortality and sudden cardiac death of 0.76 (95% confidence interval [CI], 0.58 to 0.96; p = 0.01) and 0.08 (95% CI, 0.05 to 0.42; p <0.01), respectively, adjusting for baseline characteristics and follow-up duration. Mortality in patients with heart failure remains high after BVP implantation, mainly because of sudden cardiac death. Although there are limitations with an observational study, our experience suggests that ICD backup grants increased security in BVP patients without conventional class I ICD indications.

Cardiac contractility modulation by electric currents applied during the refractory period in patients with heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.

We assessed the feasibility of cardiac contractility modulation (CCM) by electric currents applied during the refractory period in patients with heart failure (HF). Extracellular electric currents modulating action potential and calcium transients have been shown to potentiate myocardial contractility in vitro and in animal models of chronic HF. CCM signals were biphasic square-wave pulses with adjustable amplitude, duration, and time delay from sensing of local electric activity. Signals were applied to the left ventricle through an epicardial vein (in 12 patients) or to the right ventricular (RV) aspect of the septum endocardially (in 6 patients). Simultaneous left ventricular (LV) and aortic pressure measurements were performed using a Millar catheter (Millar Instruments, Houston, Texas). Hemodynamics during RV temporary dual-chamber pacing was regarded as the control condition. Both LV and RV CCM stimulation increased dP/dt(max) to a similar degree (9.1 +/- 4.5% and 7.1 +/- 0.8%, respectively; p <0.01 vs controls), with associated aortic pulse pressure changes of 10.3 +/- 7.2% and 10.8 +/- 1.1% (p <0.01 vs controls). Regional systolic wall motion assessed quantitatively by color kinesis echocardiography was markedly enhanced near the CCM electrode, and the area of increased contractility involved 4.6 +/- 1.2 segments per patient. In 6 patients with HF with left bundle branch block, CCM signals delivered during biventricular pacing (BVP) produced an additional 16.1 +/- 3.7% increase in dP/dt(max) and a 17.0 +/- 7.5% increase in pulse pressure compared with BVP alone (p <0.01). CCM stimulation in patients with HF enhanced regional and global measures of LV systolic function, regardless of the varied delivery chamber or whether modulation was performed during RV pacing or BVP.

Evolution of non-pharmacological curative therapy for atrial fibrillation. Where do we stand today?

The present review aims at giving a comprehensive synthesis regarding not only the epidemiological aspects but also the evolution, over the last decades, of the curative surgical and catheter-based ablative treatments for atrial fibrillation (AF), with particular emphasis on the experience of Milan working group which has always been committed to the on-going and fascinating therapeutic challenges inherent in this type of cardiac arrhythmia. After discussing the surgical treatment of AF we report the rationale basis of current pulmonary vein (PV) ablation techniques. In particular, we report on circumferential PV ablation, an intellectually appealing strategy, aimed at creation of RF lesions around each PV ostia using a non-fluoroscopic electro-geometric mapping system to reconstruct the anatomy of venous-atrial junction, allowing to tailor number and size of lesions to the complex morphology of the PV-LA junction in each patient. This purely anatomic approach not only disconnects PVs (as demonstrated by elimination of PV ostial potentials and absence of discrete electrical activity inside the lesion during pacing outside the ablation line), but also, like surgery, reduces the "electrically active" atrial tissue, involving substantial parts of the posterior LA wall, with a profound atrial electroanatomic remodeling, as expressed by voltage abatement (<0.1 mV) inside and around the encircled areas.

Pulmonary vein ablation of atrial fibrillation: beyond the traditional.

The present review aims at giving a synthesis on the evolution in the last decade of the catheter-based ablative treatments for atrial fibrillation (AF). We report the rationale of current pulmonary vein (PV) ablation techniques: segmental PV isolation and circumferential PV ablation. The endpoint is the electrical isolation of the PVs from the left atrium, as they house foci triggering AF in 80% to 95% of cases and seem to play a key role in arrhythmia maintenance. Recurrence rates of AF after these PV ablation strategies are very encouraging. Two recent randomized trials, AFFIRM and RACE, showed no significant difference in outcomes between a strategy of pharmacological heart rate control and that of restoration and maintenance of sinus rhythm with antiarrhythmic drugs. However, multicenter randomized trials comparing PV ablation with drug therapy are required. Future refinements in catheter technology and navigation systems should provide simpler and faster procedures and render PV ablation more widespread and accepted from the scientific and medical communities.