Paroxysmal and persistent atrial fibrillation ablation outcomes with the pulmonary vein ablation catheter GOLD duty-cycled phased radiofrequency ablation catheter: quality of life and 12-month efficacy results from the GOLD Atrial Fibrillation Registry.

AIMS: The GOLD AF Registry has been designed to prospectively assess the population, indications, and outcomes using second-generation phased radiofrequency (RF) ablation (pulmonary vein ablation catheter GOLD) in a global examination of standard-of-care use for the treatment of paroxysmal and persistent atrial fibrillation (AF). METHODS AND RESULTS: GOLD AF (NCT02433613) is a prospective, observational, multi-centre registry designed to characterize efficacy and safety of phased RF ablation in patients with AF. The primary endpoint was freedom from AF recurrence at 12-month follow-up after a 90-day blanking period. Ancillary objectives include safety, procedural efficiency, and quality of life (QoL). The QoL assessment using the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) and the European Heart Rhythm Association (EHRA) Score of AF-related symptoms was collected at baseline and 12 months. In total, 1054 patients were included in this analysis (age 60.6, 67.6% male, 26.5% PersAF). Kaplan-Meier estimate of freedom from AF recurrence was 77.7% at 12 months. Peri-procedural device or procedure-related complications were observed in 26 (2.5%) patients, with a low stroke rate of 0.3%. One-year post-ablation, the EHRA AF Symptom score decreased in 68% of patients. The AFEQT score improvement was observed in 88.4% and 90.4% of patients who completed the questionnaire in-person or interviewed by phone at 12 month follow-up, respectively. CONCLUSION: Phased RF ablation for the treatment of paroxysmal and persistent AF demonstrated a 77.7% freedom from AF recurrence at 12 months in addition to a significant reduction in arrhythmia symptoms and clinically meaningful improved QoL. Low peri-procedural complication rate of <3% was reported.

Diagnostic value of implantable loop recorder in patients undergoing cryoballoon ablation of atrial fibrillation.

BACKGROUND: Due to limited data, implantable loop recorders (ILR) are not currently recommended by the guidelines to routinely monitor patients after atrial fibrillation (AF) ablation. AIMS: To validate the diagnostic value of ILR after AF ablation, modern generation ILRs (LINQ) were implanted in patients scheduled for cryoballoon ablation of AF (CBA). METHODS: We included 29 patients with frequent and symptomatic episodes of paroxysmal AF. ILR was implanted 3 months prior to CBA, and data were collected before and for 6 months after the procedure. The device was programmed to maximize sensitivity of AF/ atrial tachycardia (AT) detection. All EGM recordings were "manually" assessed and annotated as true AF, pseudo AF, unrecognized AF, and episodes with no EGM available. Duration and episode-based standard performance metrics were evaluated. RESULTS: A total number of 5,842 episodes were recorded. A total of 4,403 episodes were true AF, 453 episodes were pseudo AF, and 986 episodes had no EGM available. The device did not recognize 144 episodes of AF. Duration-based sensitivity was 95.2%, duration-based specificity 99.9%, duration-based PPV 99.2%, duration-based NPV 99.9%, episode-based sensitivity 98.0%, and episode-based PPV 91.0%. Misdiagnosis happened in 1 in 10 episodes. Total data review time was 166 hr. CONCLUSIONS: Implantable loop recorders is a valuable tool in evaluation of AF episodes in patients undergoing CBA. However, for high precision all recorded episodes need to be evaluated "manually." The memory storage space is too low for frequent AF episodes, resulting in overwriting of stored EGMs and data loss.

Transfer Information Assessment in Diagnosis of Vasovagal Syncope Using Transfer Entropy.

The paper presents an application of Transfer Entropy (TE) to the analysis of information transfer between biosignals (heart rate expressed as R-R intervals (RRI), blood pressure (sBP, dBP) and stroke volume (SV)) measured during head up tilt testing (HUTT) in patients with suspected vasovagal syndrome. The study group comprised of 80 patients who were divided into two groups: the HUTT(+) group consisting of 57 patients who developed syncope during the passive phase of the test and HUTT(-) group consisting of 23 patients who had a negative result of the passive phase and experienced syncope after provocation with nitroglycerin. In both groups the information transfer depends on the phase of the tilt test. In supine position the highest transfer occurred between driver RRI and other components. In upright position it is the driver sBP that plays the crucial role. The pre-syncope phase features the highest information transfer from driver SV to blood pressure components. In each group the comparisons of TE between different phases of HUT test showed significant differences for RRI and SV as drivers.

Entropy Measures in Analysis of Head up Tilt Test Outcome for Diagnosing Vasovagal Syncope.

The paper presents possible applications of entropy measures in analysis of biosignals recorded during head up tilt testing (HUTT) in patients with suspected vasovagal syndrome. The study group comprised 80 patients who developed syncope during HUTT (57 in the passive phase of the test (HUTT(+) group) and 23 who had negative result of passive phase and developed syncope after provocation with nitroglycerine (HUTT(-) group)). The paper focuses on assessment of monitored signals' complexity (heart rate expressed as R-R intervals (RRI), blood pressure (sBP, dBP) and stroke volume (SV)) using various types of entropy measures (Sample Entropy (SE), Fuzzy Entropy (FE), Shannon Entropy (Sh), Conditional Entropy (CE), Permutation Entropy (PE)). Assessment of the complexity of signals in supine position indicated presence of significant differences between HUTT(+) versus HUTT(-) patients only for Conditional Entropy (CE(RRI)). Values of CE(RRI) higher than 0.7 indicate likelihood of a positive result of HUTT already at the passive phase. During tilting, in the pre-syncope phase, significant differences were found for: (SE(sBP), SE(dBP), FE(RRI), FE(sBP), FE(dBP), FE(SV), Sh(sBP), Sh(SV), CE(sBP), CE(dBP)). HUTT(+) patients demonstrated significant changes in signals' complexity more frequently than HUTT(-) patients. When comparing entropy measurements done in the supine position with those during tilting, SV assessed in HUTT(+) patients was the only parameter for which all tested measures of entropy (SE(SV), FE(SV), Sh(SV), CE(SV), PE(SV)) showed significant differences.

Presence and severity of obstructive sleep apnea and remote outcomes of atrial fibrillation ablations - a long-term prospective, cross-sectional cohort study.

BACKGROUND: Prior studies suggested that obstructive sleep apnea (OSA) promotes recurrence of arrhythmia in patients after atrial fibrillation (AF) ablation. METHODS: In this prospective, long-term, observational study, we enrolled 290 consecutive patients admitted for AF ablation. Prior to the ablation, all patients underwent a polygraphy sleep study for the diagnosis of OSA. After the procedure, patients were followed up for mean time of 30 months for AF reoccurrence. OSA was diagnosed when apnea-hypopnea index (AHI) was ≥5. Patients were subsequently divided into groups according to the OSA severity: mild OSA (AHI 5-15/h), moderate OSA (AHI >15 and ≤30/h), and severe (AHI >30/h). RESULTS: After excluding patients disqualified from the procedure, and those with central sleep apnea, the study population consisted of 251 patients, mean age 57.6 years [163 (64.9%) male]. OSA was present in 115 (45.8%) patients, while in 137 (54.6%) cases, we observed reoccurrence of AF. Recurrence was more often in patients with, than without, OSA (65.2 vs. 45.6%; p = 0.003). We also observed that along with rising OSA severity rose also the number of patients in whom AF was detected during the follow-up period (45.6 vs. 66.2 vs. 57.6 vs. 81.8%; p = 0.005; for non-OSA, mild, moderate, and severe, respectively). CONCLUSIONS: OSA is highly prevalent in AF patients. The presence of OSA lowers chances on successful AF ablation. Early screening, and treatment for OSA in AF patients, may improve low success rates of AF ablation procedures.

Efficacy of Catheter Ablation Using the Electroanatomical System without the Use of Fluoroscopy in Patients with Ventricular Extrasystolic Beats.

BACKGROUND: Catheter ablation (CA) has become safe and efficient for the treatment of patients with ventricular extrasystolic beats (VEBs). The three-dimensional electroanatomic mapping (EAM) system allows the elimination of fluoroscopy time during CA procedures. Non-fluoroscopy CA is a challenging procedure requiring intimate knowledge of cardiac anatomy in patients with VEBs. The study aimed to evaluate the efficacy and safety of the non-fluoroscopy CA using the EAM system in patients with VEBs. METHODS: Completely fluoroless CA of VEBs guided by EAM was performed in 86% (94 out of 109) of consecutive patients with VEBs. The remaining 15 patients underwent conventional fluoroscopy-guided CA. Demographic and clinical baseline characteristics, procedure parameters, and following complications were obtained from the medical records. Primary outcomes were the acute procedural success rate, the permanent success rate (6-month follow-up), complications, and procedure time. RESULTS: There were no significant differences between groups regarding baseline characteristics. Acute procedural success was achieved in 85 patients (90%) in the non-fluoroscopy group and in 14 patients (93%) in the fluoroscopy group (ns). A long-term success rate was achieved in 82 patients (87%) in the non-fluoroscopy group and in 14 (82%) patients in the fluoroscopy group (ns). The median procedure time was 85 min in the non-fluoroscopy group and 120 min in the fluoroscopy group (p = 0.029). There was only one major complication in the non-fluoroscopy group (ns). CONCLUSIONS: Completely fluoroless CA of VEBs guided by EAM is a feasible, safe, and efficient procedure.

Efficacy and Safety of Zero-Fluoroscopy Approach during Catheter Ablation of Accessory Pathway.

BACKGROUND: Catheter ablation (CA) is a safe and efficient treatment in patients with an atrioventricular accessory pathway (AP). Electroanatomical mapping (EAM) systems are useful during CA of AP, especially for reducing fluoroscopy. There are limited data about the feasibility of CA procedures performed with the use of the EAM system entirely without fluoroscopy in adults with AP. The aim of the study is to assess the feasibility, efficacy and safety of CA with the use of EAM without fluoroscopy, compared to CA with EAM and fluoroscopy in patients with AP. METHODS: The study included 83 consecutive patients (age 38.25 ± 15.8 years), who were subjected to CA for AP. In 40 patients CA was performed with the use of EAM without fluoroscopy (EAM group), and in 43 patients CA was performed with EAM and fluoroscopy (control group). Baseline characteristics, procedure parameters and complications were obtained from the medical records. Data on permanent success rate was obtained after the mean follow-up time of 1 year. Primary outcomes were acute procedural success rate, long term success rate at 1-year follow-up and complications. Secondary outcomes were the procedure time and number of applications. RESULTS: There were no statistically significant differences in baseline characteristics between the groups, except for the AP locations. Right-sided AP was more common in the EAM group, while left-sided AP was more common in the control group (p = 0.007 and p = 0.004, respectively). Acute procedural success was achieved in 38 patients (95.0%) in the EAM group and in 39 patients (90.7%) in the control group (p = 0.449). Long term success rate was achieved in 36 patients (90.0%) in the EAM group and in 36 (83.7%) patients in the control group (p = 0.399). There was one minor complication in the form of RBBB in the EAM group (p = 0.138). The mean procedure time was shorter in the EAM group compared to the control group (93.0 ± 58.3 min vs. 127.6 ± 57.5 min; p = 0.009). CONCLUSIONS: CA of both right-sided and left-sided AP completely guided by EAM without the use of fluoroscopy is feasible, safe and effective.

Contact Force-Sensing versus Standard Catheters in Non-Fluoroscopic Radiofrequency Catheter Ablation of Idiopathic Outflow Tract Ventricular Arrhythmias.

BACKGROUND: Adequate contact between the catheter tip and tissue is important for optimal lesion formation and, in some procedures, it has been associated with improved effectiveness and safety. We evaluated the potential benefits of contact force-sensing (CFS) catheters during non-fluoroscopic radiofrequency catheter ablation (NF-RFCA) of idiopathic ventricular arrhythmias (VAs) originating from outflow tracts (OTs). METHODS: A group of 102 patients who underwent NF-RFCA (CARTO, Biosense Webster Inc., Irvine, CA, USA) of VAs from OTs between 2014 to 2018 was retrospectively analyzed. RESULTS: We included 52 (50.9%) patients in whom NF-RFCA was performed using CFS catheters and 50 (49.1%) who were ablated using standard catheters. Arrhythmias were localized in the right and left OT in 70 (68.6%) and 32 (31.4%) patients, respectively. The RFCA acute success rate was 96.1% (n = 98) and long-term success during a minimum 12-month follow-up (mean 51.3 ± 21.6 months) was 85.3% (n = 87), with no difference between CFS and standard catheters. There was no difference in complications rate between CFS (n = 1) and standard catheter (n = 2) ablations. CONCLUSIONS: There is no additional advantage of CFS catheters use over standard catheters during NF-RFCA of OT-VAs in terms of procedural effectiveness and safety.

An assessment of heart rate and blood pressure asymmetry in the diagnosis of vasovagal syncope in females.

Introduction: Heart Rate Asymmetry (HRA) describes a phenomenon of differences between accelerations and decelerations in human heart rate. Methods used for HRA assessment can be further implemented in the evaluation of asymmetry in blood pressure variations (Blood Pressure Asymmetry-BPA). Methods: We have analyzed retrospectively the series of heartbeat intervals extracted from ECG and beat-to-beat blood pressure signals from 16 vasovagal patients (age: 32.1 ± 13.3; BMI: 21.6 ± 3.8; all female) and 19 healthy subjects (age: 34.6 ± 7.6; BMI: 22.1 ± 3.4; all female) who have undergone tilt test (70°). Asymmetry was evaluated with Poincaré plot-based methods for 5 min recordings from supine and tilt stages of the test. The analyzed biosignals were heart rate (RR), diastolic (dBP) and systolic Blood Pressure (sBP) and Pulse Pressure (PP). In the paper we explored the differences between healthy and vasovagal women. Results: The changes of HRA indicators between supine and tilt were observed only in the control group (Porta Index p = 0.026 and Guzik Index p = 0.005). No significant differences in beat-to-beat variability (i.e. spread of points across the line of identity in Poincaré plot-SD1) of dBP was noted between supine and tilt in the vasovagal group (p = 0.433 in comparison to p = 0.014 in healthy females). Moreover, in vasovagal patients the PP was significantly different (supine: 41.47; tilt: 39.27 mmHg) comparing to healthy subjects (supine: 35.87; tilt: 33.50 mmHg) in supine (p = 0.019) and in tilt (p = 0.014). Discussion: Analysis of HRA and BPA represents a promising method for the evaluation of cardiovascular response to orthostatic stressors, however currently it is difficult to determine a subject's underlying health condition based only on these parameters.

Is Increased Resting Heart Rate after Radiofrequency Pulmonary Vein Isolation a Predictor of Favorable Long-Term Outcome of the Procedure?

Background: Increased resting heart rate (RHR) after pulmonary vein isolation (PVI) for treatment of atrial fibrillation (AF) is a common observation, possibly resulting from ganglionated plexus modification during ablation. Previous trials have suggested that an increase in RHR after ablation might be related to higher efficacy of the procedure. The aim of this study was to determine whether or not higher increase in RHR after radiofrequency (RF) PVI might predict better long-term outcome of the procedure in a real-life cohort of patients in whom index ablation for paroxysmal AF was performed. Material and methods: The health records of patients who underwent index point-by-point or drag lesion RF PVI for paroxysmal AF in our department between January 2014 and November 2018 were analyzed. Resting heart rate (RHR) was determined from 12-lead ECG recorded prior to the ablation and before discharge to evaluate changes in RHR after PVI. Only patients in sinus rhythm before the procedure and at discharge were included in the analysis. Telephone follow-up was collected for evaluation of arrhythmia recurrence status. Results: A total of 146 patients who underwent PVI for paroxysmal AF were included. Mean follow-up time was 3.5 years. RHR increased from 64 [58.5−70], prior to procedure, to 72 [64.25−80] bpm at discharge (p < 0.001). Higher increase in RHR was not protective from arrhythmia recurrence in long-term observation in both univariable HR = 1.001 (CI 0.99−1.017, p = 0.857) and multivariable analyses HR = 1.001 (CI 0.99−1.02, p = 0.84). Conclusions: RHR after PVI increased in comparison to baseline in our cohort. However, we did not observe higher increase in RHR to be associated with more favorable long-term effectiveness of the procedure.

Physiologic resynchronization therapy: a case of his bundle pacing reversing physiologic conduction in a patient with CHF and LBBB during 2 years of observation.

This is a case of a patient with congestive heart failure and left bundle branch block who was referred for cardiac resynchronization therapy implantation. Instead, a His bundle pacing was achieved with a narrow QRS complex. During 27 months of observation, the patient improved dramatically from NYHA class IV to I. Echo parameters improved significantly the LV diameter from 75/50 to 60/40 mm, EF from 28 to 50%, and mitral regurgitation from 4 to 2°.

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.

The clinical relevance of the duration of loss of consciousness provoked by tilt testing.

OBJECTIVE: The authors assessed the relationships between the duration of loss of consciousness (dLOC) during tilt testing-induced syncope (TTS) and demographics, medical history as well as tilt testing results. Previous research focused on the relevance of the type of neurocardiogenic reaction during TTS. The importance of dLOC has not been assessed so far. The study was carried out in 274 patients with suspected neurally mediated syncope and total loss of consciousness during tilt testing. RESULTS: The syncope burden, demographics, and data regarding spontaneous syncope orTTS were compared between group I with dLOC > or =47 seconds and group 2 with dLOC <47 seconds. Medical history revealed that patients in group I had more syncopal spells, more frequent syncope-related traumatic injuries, urine incontinence, jerking movements and typical vasovagal history than in group 2. Moreover, group I patients had more frequently a cardioinhibitory type of reaction and a shorter active phase duration. In addition, they manifested more frequent accompanying cerebral hypoperfusion signs and reproduction of symptoms during TTS than patients in group 2. CONCLUSIONS: The loss of consciousness during tilt testing-induced syncope differs in terms of duration among patients with neurally mediated syncope. The dLOC during TTS is associated with medical history and tilt-testing data which confirm the vasovagal aetiology of spontaneous events. The longer dLOC suggests deeper cerebral haemodynamic disturbances during either spontaneous or provoked syncope.

Evaluation of safety and the success rate of cryoballoon ablation of the pulmonary vein ostia in patients with atrial fibrillation--a preliminary report.

BACKGROUND: Cryoballon isolation of the pulmonary veins has recently emerged as a promissing technique for ablation of atrial fibrillation (AF). AIM: To present our initial experience in cryoballon isolatin of the pulmonary veins in patients with AF. METHODS: Eight patients (5 males; age 59+/-2 years) with AF: 2 with persistent and 6 with paroxysmal (5 of them after unsuccessful RF ablation) with >or=6 month follow-up after the procedure were included. One patient after myocardial infarction was treated with primary angioplasty with stent implantation. Another one had biatrial pacemaker. The procedure was performed with cryobaloon with 28 mm diameter (Arctic Front--Cryocath). After transseptal puncture mapping of the pulmonary vein ostia was performed with Lasso catheter (Johnson and Johnson). At each pulmonary vein ostium with pulmonary vein potentials 2 cryoapplications of 300 s duration was performed. Correct balloon placement before cryoapplication was checked using contrast injection into the pulmonary veins. During cryoapplication in the right pulmonary vein ostia permanent pacing of the phrenic nerve 30 beats per minute was performed to prevent its paralysis. After cryoapplications in all veins remapping with Lasso catheters was performed. In the absence of pulmonary vein potentials the procedure was finished, otherwise next cryoapplications were performed. During follow-up ECG was performed if any palpitations occurred, and 24-hour Holter monitoring was performed 1, 2 ,4, 6, 8, 10 and 12 months after the procedure. A 2-month blanking period after the procedure was used. The lack of symptomatic AF and the absence of AF>30 s on Holter ECG monitoring were defined as successful procedure. An improvement was defined as reduction of frequency/duration of AF paroxysm and reduction of the EHRA index>or=1. RESULTS: During 8 procedures isolation of 31 pulmonary vein was performed. Procedure duration was 3.5+/-0.85 h, fluoroscopy time--33.55+/-15.44 min, and total cryoapplication time--38.33+/-4.1 min. There were no complications. After the follow-up of 8.5+/-0.99 months 6 (75%) patients were free from arrhythmia, including the patient after myocardial infarction and one patient with permanent AF prior ablation. In another patient an improvement was observed (EHRA score II/III to I) whereas in one patient with permanent AF the procedure was unsuccessful. CONCLUSION: Cryoballoon ablation of pulmonary vein ostia is effective and safe, and can be an alternative to RF ablation. Easier procedure technique make possible shortening of the learning curve and increase the number of treated patients.

Non-fluoroscopic radiofrequency catheter ablation of right- and left-sided ventricular arrhythmias.

INTRODUCTION: Radiofrequency catheter ablation (RFCA) is an important method of treatment of ventricular arrhythmias (VAs). In the majority of RFCA, fluoroscopy is used, exposing patients and medical staff to all related side effects. Current experience of non-fluoroscopic (NF)-RFCA in VAs from the left side is limited. AIM: Analysis of safety and effectiveness of NF-RFCA of VAs from left- and right-sided cardiac chambers. MATERIAL AND METHODS: From 2014 to 2018, a group of 128 patients who underwent RFCA of VAs were retrospectively divided into two groups: NF-RFCA and fluoroscopic (F)-RFCA. Patients in each group were then subsequently subdivided into two groups based on VAs localization - left- (LS-Va) and right-sided (RS-Va) VAs. In all patients the CARTO Biosense Webster mapping system was used. RESULTS: In group 1 (NF-RFCA n = 88) 66 (75%) patients underwent RFCA of RS-Va and 22 (25%) of LS-Va. Early success was achieved in 89.8% (n = 79) and long term success in 81.8% (n = 72). In group 2 (F-RFCA n = 40) 19 patients (47.5%) had RFCA of RS-Va and 21 (52.5%) patients of LS-Va. Acute procedural success rate was 80% (n = 32) and long-term success 72.5% (n = 29). There were 4 (4.6%) perioperative complications in NF-RFCA and 2 (5%) in F-RFCA. Success rate, procedure time and complications were not significantly different between groups and subgroups in follow-up. CONCLUSIONS: NF-RFCA in VAs from the right and left cardiac chamber is safe and equally effective as F-RFCA, and it should be implemented as often as possible for protection of patients and electrophysiology staff.

Electrocardiographic characteristics of atrioventricular block induced by tilt testing.

AIMS: The electrocardiographic (ECG) characteristics of atrioventricular (AV) block during reflex syncope may be unique due to the presence of hypervagotonia. The aim of the present study was to define the ECG characteristics of the AV block induced by neurocardiogenic reflex provoked by tilt testing (TT). METHODS AND RESULTS: A series of 31 patients with presumed vasovagal syncope and AV block provoked by TT was studied. The duration of PP and PR interval, AV block grade and type, concomitant arrhythmias, and timing of the AV block occurrence were assessed. The AV block occurred at TT termination in 26 patients, in the recovery in 4 patients, and in both periods in 1 patient. Atrioventricular block was preceded by sinus slowing, and sinus rhythm during AV block was slow and instable. Mobitz I, 2:1 second-degree AV block, and advanced second-degree AV block were recognized in 35.5, 48.4, and 67.8% of patients, respectively. Third-degree AV block was diagnosed in 41.9% of patients. Twenty-one patients had at least two AV block forms. The most prevalent concomitant arrhythmia was junctional escape rhythm (61.3%). CONCLUSION: (i) The occurrence of the AV block during neurocardiogenic reaction induced by TT is always preceded by sinus rhythm slowing and usually by PR interval prolongation. (ii) The AV block provoked by TT usually occurs at TT termination, but may occur even in the recovery period in a supine position. Sometimes the AV block may be present both at TT termination and during the recovery period.

Clinical relevance of syncope and presyncope induced by tilt testing.

OBJECTIVE: The authors investigated the relation between presyncope and syncope induced by tilt testing (HUTT) and demographics, medical history and HUTT data.The demographics, syncopal burden, data regarding the spontaneous syncope and reproduction of symptoms during HUTT were compared among patients with induced syncope and presyncope. The study group consisted of 574 patients (371 women, 203 men), aged 43.7 +/- 18.5 years. METHODS AND RESULTS: Patients with syncope induced by HUTT (418 patients, 63.9% women) had a higher number of syncopal episodes in their medical history. Stepwise logistic regression revealed that syncope provocation was independently related to the cardiodepressive type of neurocardiogenic reaction (OR 7.8, CI 4.2-14.4, P < 0.001), NTG use (OR 1.7, CI: 1.0-2.7, P < 0.05), the reproduction of the symptoms during HUTT (OR 2.0, CI: 1.3-3.1, P < 0.01) and the higher number of syncopal episodes (OR 2.0, CI: 1.3-3.0, P < 0.01). In patients with positive HUTT during a passive phase it was related to the cardiodepressive type of reaction (OR 26.5, CI: 5.9-118.5, P < 0.001). In the group with positive HUTT after NTG syncope was related to the cardiodepressive type (OR 5.7, CI: 2.9-11.2, P < 0.001), vasovagal history (OR 2.0, CI: 1.2-3.3, P < 0.01), reproduction of the spontaneous symptoms (OR 1.9, CI: 1.1-3.1, P < 0.05) and higher number of syncopal episodes (OR 2.1, CI: 1.3-3.3, P < 0.01). CONCLUSIONS: Syncope is more frequently a HUTT outcome than presyncope. The provocation of syncope in the passive phase of HUTT depends only on the cardiodepressive type of neurocardiogenic reaction. The induction of presyncope after nitroglycerin provocation is related to the possibility of a false positive reaction.

Direct results of a prospective randomized study comparing ablation with the nMARQ catheter and the PVAC catheter used with and without a 3D system (MAPER 3D Study).

INTRODUCTION: Our aim was to compare in a prospective randomized study the safety, direct results and periprocedural data of ablation using an nMARQ catheter, a PVAC catheter used with the EnSite system, or a PVAC catheter only under fluoroscopy control. MATERIAL AND METHODS: One hundred two patients (70 male, 57 ±11 years) with atrial fibrillation (AF) were prospectively randomized to: group 1 - ablation performed with an nMARQ catheter and the CARTO 3 system; group 2 - a PVAC catheter used with the EnSite system; group 3 - ablation with a PVAC catheter without a 3D system. RESULTS: Complete isolation of 400/402 pulmonary veins (PV) (99.5%). Linear ablation was performed in 23 patients in group 1 (small distance between lines isolating PV), in 3 patients in group 2, in 1 patient in group 3. The superior vena cava was isolated in 1 patient, 9 patients, and 9 patients respectively. Duration of fluoroscopy and dose area product were significantly smaller in group 1 (6.5 ±2.9 min/808.8 ±393.9 cGy/cm2 vs. 13.6 ±5.6 min/1662.6 ±677.8 cGy/cm2 and 18.8 ±7.6 min/2327.9 ±975.5 cGy/cm2; p < 0.001). Procedure duration was shorter in group 1 (82.9 ±18.8 min vs. 101.2 ±19.6 min, p < 0.001 and 99.8 ±20.8 min, NS). Contrast injection was necessary in 2 patients in group 1, in 8 patients in group 2 and in all patients in group 3. Because nMARQ is a thermocool catheter, the volume of fluid injection was significantly greater (2348.5 ±543.5 ml vs. 1077.9 ±280.5 ml and 1076.5 ±375.6 ml, p < 0.001). There were no periprocedural deaths. We observed no cardiac tamponade, neurological complications and no atrioesophageal fistula during follow-up. CONCLUSIONS: The lowest radiological exposure was observed during ablation performed with an nMARQ catheter. 3D systems reduced fluoroscopy duration and the necessity of contrast injection. The nMARQ catheter requires injection of a large volume of fluid.

Effectiveness comparison of various atrial fibrillation ablation methods in patients with common venous trunk.

BACKGROUND: Atrial fibrillation (AF) is a common clinical problem. The left atrium anatomy makes up a factor that may significantly affect the effectiveness of the AF ablation. OBJECTIVES: The aim of the study was to evaluate a long-term effectiveness ablation in patients with common pulmonary vein trunk (CPVT) and AF. MATERIAL AND METHODS: The outcomes of 129 procedures in 95 patients with CPVT out of 1,475 procedures carried out in 1,150 patients with AF treated with ablation, were analyzed. Ablation with CARTO 3 system (Johnson & Johnson, New Brunswick, USA), cryoballoon, and the circular multipolar duty-cycled radiofrequency-based pulmonary vein ablation producer with catheter (PVAC) were considered as advanced methods. The following data was recorded for every patient: age, gender, AF duration and type, previous antiarrhythmic drugs, weight, height, any prior cardioversion, and comorbidities, including hypertension, diabetes, hypothyreosis, thyrotoxicosis, heart failure, and stroke/transient ischemic attack. The following anatomical factors were assessed: the presence of patent foramen ovale (PFO) and localization of the CPVT on the basis of venography or computed tomography (CT). In the 1st year after ablation, 24-h Holter monitoring was performed 3-5 times, and the patients were encouraged to visit their doctor or an emergency department if a cardiac arrhythmia occurred. Long-term ablation effectiveness was assessed based on a telephone interview and patients' answers to the questionnaires including 12-lead electrocardiography (ECG). RESULTS: Sinus rhythm was maintained in 44 patients (43.6 %) after a median of 42 months (range 12-120). A lower number of clinical factors (odds ratio [OR] range 0.09; 95% confidence interval [CI] 0.02-0.56; p < 0.01), and advanced ablation methods (OR 3.1; 95% CI 1.4-7.1; p < 0.01) were related to a better longterm effectiveness. CONCLUSIONS: The long-term effectiveness of pulmonary vein (PV) isolation in patients with AF and CPVT is higher when advanced ablation techniques are used. Accumulation of clinical factors was found to be the most tremendous predictor of AF recurrence.

The LocaLisa system as the key to shortening the procedure duration and fluoroscopy time during ablation of atrial fibrillation.

BACKGROUND: Ablation of atrial fibrillation (AF) can be difficult and time-consuming. Systems facilitating catheter navigation may be helpful. AIM: To compare the efficacy of the LocaLisa system with the conventional mapping/ablation approach to radiofrequency (RF) ablation of AF. METHODS: Group 1, consisting of 64 patients (48 male; aged 51.5+/-10.6 years), underwent segmental isolation of the pulmonary veins with the Lasso catheter and the LocaLisa system. Group 2, consisting of 64 patients (44 male, aged 51.4+/-11.0 years), had RF ablation guided by means of a conventional fluoroscopy-based approach. Clinical and procedural data were analysed. RESULTS: Nine patients from group 1 and three patients from group 2 had persistent AF. In group 1 the mean number of isolated veins was 3.98+/-0.96, while in group 2 - 4.0+/-0.95 (NS). In group 1 cavotricuspid isthmus lines were created in four patients and lines in the roof of the left atrium in two patients. One patient needed slow pathway ablation. In group 2 six patients had ablation of the cavotricuspid isthmus and a line was created at the roof of the left atrium in one patient. Two patients had ectopic activity ablated in the crista terminalis. Procedure times were 131.6+/-40.3 and 170.0+/-56.5 min (p <0.0001) and fluoroscopy times were 16.93+/-9.7 and 35.66+/-12.7 min (p <0.0001) for groups 1 and 2, respectively. Long-term efficacy of RF ablation was similar in both groups (for example, complete success was achieved in 59% of patients using LocaLisa and 50% without using this system, NS). CONCLUSIONS: The LocaLisa navigation system makes it possible to shorten both the duration of the procedure and the total fluoroscopy time during ablation of AF.