Evaluation of Mathematical Arterialization of Venous Blood in Intensive Care and Pulmonary Ward Patients.

BACKGROUND: Arterial blood gases are important when assessing acute or critically ill patients. Capillary blood and mathematical arterialization of venous blood have been proposed as alternative methods, eliminating pain and complications of arterial puncture. OBJECTIVES: This study compares the arterial samples, arterialized venous samples, and capillary samples in ICU and pulmonary ward patients. METHOD: Ninety-one adult patients with respiratory failure were included in the analysis. Arterial, peripheral venous, and mathematically arterialized venous samples were compared in all patients using Bland-Altman analysis, with capillary samples included in 36 patients. RESULTS: Overall for pH and PCO2, arterialized venous values, and in the subset of 36 patients, capillary values, compared well to arterial values and were within the pre-defined clinically acceptable differences (pH ± 0.05 and PCO2 ± 0.88 kPa). For PO2, arterialized or capillary values describe arterial with similar precision (PO2 arterialized -0.03, LoA -1.48 to 1.42 kPa and PO2 capillary 0.82, LoA -1.36 to 3 kPa), with capillary values underestimating arterial. CONCLUSIONS: Mathematical arterialization functions well in a range of patients in an ICU and ward outside the country of development of the method. Furthermore, accuracy and precision are similar to capillary blood samples. When considering a replacement for arterial sampling in ward patients, using capillary sampling or mathematical arterialization should depend on logistic ease of implementation and use rather than improved measurements of using either technique.

Perioperative Sensor and Algorithm Programming in Patients with Implanted ICDs and Pacemakers for Cardiac Resynchronization Therapy.

BACKGROUND: ICDs and pacemakers for cardiac resynchronization therapy (CRT) are complex devices with different sensors and automatic algorithms implanted in patients with advanced cardiac diseases. Data on the perioperative management and outcome of CRT carriers undergoing surgery unrelated to the device are scarce. METHODS: Data from 198 CRT device carriers (100 with active rate responsive sensor) were evaluated regarding perioperative adverse (device-related) events (A(D)E) and lead parameter changes. RESULTS: Thirty-nine adverse observations were documented in 180 patients during preoperative interrogation, which were most often related to the left-ventricular lead and requiring intervention/reprogramming in 22 cases (12%). Anesthesia-related events occurred in 69 patients. There was no ADE for non-cardiac surgery and in pacemaker-dependent patients not programmed to an asynchronous pacing mode. Post-operative device interrogation showed significant lead parameter changes in 64/179 patients (36%) requiring reprogramming in 29 cases (16%). CONCLUSION: The left-ventricular pacing lead represents the most vulnerable system component. Comprehensive pre and post-interventional device interrogation is mandatory to ensure proper system function. The type of ICD function suspension has no impact on each patient's outcome. Precautionary activity sensor deactivation is not required for non-cardiac interventions. Routine prophylactic device reprogramming to asynchronous pacing appears inessential. Most of the CRT pacemakers do not require surgery-related reprogramming.

Contemporary management of patients with syncope in clinical practice: an EHRA physician-based survey.

Syncope is a heterogeneous syndrome encompassing a large spectrum of mechanisms and outcomes. The European Society of Cardiology published an update of the Syncope Guidelines in 2018. The aim of the present survey was to capture contemporary management of syncope and guideline implementation among European physicians. A 23-item questionnaire was presented to 2588 European Heart Rhythm Association (EHRA) members from 32 European countries. The response rate was 48%, but only complete responses (n = 161) were included in this study. The questionnaire contained specific items regarding syncope facilities, diagnostic definitions, diagnostic tools, follow-up, and therapy. The survey revealed that many respondents did not have syncope units (88%) or dedicated management algorithms (44%) at their institutions, and 45% of the respondents reported syncope-related hospitalization rates >25%, whereas most (95%) employed close monitoring and hospitalization in syncope patients with structural heart disease. Carotid sinus massage, autonomic testing, and tilt-table testing were inconsistently used. Indications were heterogeneous for implanted loop recorders (79% considered them for recurrent syncope in high-risk patients) or electrophysiological studies (67% considered them in bifascicular block and inconclusive non-invasive testing). Non-pharmacological therapy was consistently considered by 68% of respondents; however, there was important variation regarding the choice of drug and device therapy. While revealing an increased awareness of syncope and good practice, our study identified important unmet needs regarding the optimal management of syncope and variable syncope guideline implementation.

High-density mapping-guided corrective HIS bundle pacing after failed CRT upgrade for persistent left superior vena cava.

In patients with persistent left superior vena cava (PLSVC), transvenous device implantation for cardiac resynchronization therapy (CRT) may be challenging. We present a complex case with successful, high-density electroanatomic mapping (EAM) guided corrective His bundle pacing (CHBP) following failed CRT upgrade in a patient with PLSVC, congenital heart disease, and pacing-associated heart failure. CHBP restored physiological conduction in left bundle branch block with complete conduction block leading to clinical improvement and cardiac remodeling. The presented case supports the growing evidence that EAM-guided CHBP may be considered a feasible alternative to conventional CRT when venous anatomy is not favorable for left ventricular lead implantation.

Quinidine-A legacy within the modern era of antiarrhythmic therapy.

Quinidine has a very long history as antiarrhythmic medication. The alkaloid has been used in the treatment of almost all cardiac arrhythmias, especially atrial fibrillation, since the early twentieth century. Despite decreases in clinical prescription over the last two decades, mainly due to side effects like pro-arrhythmia, leading to increased mortality and to the availability of newer anti-arrhythmic drugs and catheter ablation, Quinidine remains an invaluable drug in the modern era of antiarrhythmic therapy. We present a review of the pharmacological properties of quinidine and its pivotal therapeutic role in the treatment of life-threatening arrhythmic storms in patients with congenital arrhythmogenic syndromes like Brugada's syndrome, early repolarization syndrome, short QT syndrome and idiopathic ventricular fibrillation.

Oesophageal injury following magnetically guided single-catheter ablation for atrial fibrillation: insights from the MAGNA-AF registry.

Aims: Oesophagogastroduodenoscopy (OGD) after catheter ablation (CA) of atrial fibrillation (AF) revealed a high rate of procedure related oesophageal lesions. We hypothesized that magnetically guided CA with careful radiofrequency energy titration at the posterior left atrial (LA) wall limits the incidence of oesophageal tissue damage. Methods and results: As a part of the prospective "Remote MAGNetic catheter Ablation for Atrial Fibrillation" (MAGNA-AF) registry, 251 out of 266 consecutive patients underwent OGD after magnetically guided single-CA for AF. All detected pathologies were analysed. Simultaneous pacing and ablation from the tip of the magnetically guided catheter was found to be a safe and feasible method for energy titration. Post-interventional OGD documented midoesophageal tissue damage in four (1.6%) patients. Although a thermal origin of these injuries must be discussed, none of them was located at the anterior oesophageal wall. Risk factors for midoesophageal lesions were female gender and concomitant acetylsalicylic acid (ASA) treatment. Mechanical lesions in 16 patients were attributed to periprocedural transoesophageal echocardiography (TOE). There was no atrio-oesophageal fistula (AOF). Five hundred and one incidental pathologies were found endoscopically, most frequent axial oesophageal herniation (71%), oesophagitis (22%), and gastritis (57%). Conclusion: Magnetically guided CA for AF with careful energy titration at the posterior LA wall and no oesophageal temperature monitoring is not associated with an increased incidence of oesophageal thermal injury. The routine use of periprocedural TOE may cause a low rate of mechanical oesophageal lesions but reliably prevents major complications like transient ischaemic attack, stroke, or cardiac tamponade. An observed high prevalence of upper digestive system inflammation (63%) may further support the recommendation for a routine post-interventional treatment with a proton-pump-inhibitor.

Three-Dimensional Electroanatomic Mapping System-Enhanced Cardiac Resynchronization Therapy Device Implantation: Results From a Multicenter Registry.

INTRODUCTION: Cardiac resynchronization therapy (CRT) device implantation guided by an electroanatomic mapping system (EAMS) is an emerging technique that may reduce fluoroscopy and angiography use and provide information on coronary sinus (CS) electrical activation. We evaluated the outcome of the EAMS-guided CRT implantation technique in a multicenter registry. METHODS: During the period 2011-2014 we enrolled 125 patients (80% males, age 74 [71-77] years) who underwent CRT implantation by using the EnSite system to create geometric models of the patient's cardiac chambers, build activation mapping of the CS, and guide leads positioning. Two hundred and fifty patients undergoing traditional CRT implantation served as controls. Success and complication rates, fluoroscopy and total procedure times in the overall study population and according to center experience were collected. Centers that performed ≥10 were defined as highly experienced. RESULTS: Left ventricular lead implantation was successful in 122 (98%) cases and 242 (97%) controls (P = 0.76). Median fluoroscopy time was 4.1 (0.3-10.4) minutes in cases versus 16 (11-26) minutes in controls (P < 0.001). Coronary sinus angiography was performed in 33 (26%) cases and 208 (83%) controls (P < 0.001). Complications occurred in 5 (4%) cases and 17 (7%) controls (P = 0.28). Median fluoroscopy time (median 11 minutes vs. 3 minutes, P < 0.001) and CS angiography rate (55% vs. 21%, P < 0.001) were significantly higher in low experienced centers, while success rate and complications rate were similar. CONCLUSIONS: EAMS-guided CRT implantation proved safe and effective in both high- and low-experienced centers and allowed to reduce fluoroscopy use by ≈75% and angiography rate by ≈70%.

Improved outcomes with European Society of Cardiology guideline-adherent antithrombotic treatment in high-risk patients with atrial fibrillation: a report from the EORP-AF General Pilot Registry.

AIMS: Guideline-adherent therapy for stroke prevention in atrial fibrillation has been associated with better outcomes, in terms of thromboembolism (TE) and bleeding. METHODS AND RESULTS: In this report from the EuroObservational Research Programme-Atrial Fibrillation (EORP-AF) Pilot General Registry, we describe the associated baseline features of 'high risk' AF patients in relation to guideline-adherent antithrombotic treatment, i.e. whether they were adherent, over-treated, or under-treated based on the 2012 European Society of Cardiology (ESC) guidelines. Secondly, we assessed the predictors of guideline-adherent antithrombotic treatment. Thirdly, we evaluated outcomes for all-cause mortality, TE, bleeding, and the composite endpoint of 'any TE, cardiovascular death or bleeding' in relation to whether they were ESC guideline-adherent treatment. From the EORP-AF cohort, the follow-up dataset of 2634 subjects was used to assess the impact of guideline adherence or non-adherence. Of these, 1602 (60.6%) were guideline adherent, whilst 458 (17.3%) were under-treated, and 574 (21.7%) were over-treated. Non-guideline-adherent treatment can be related to region of Europe as well as associated clinical features, but not age, AF type, symptoms, or echocardiography indices. Over-treatment per se was associated with symptoms, using the EHRA score, as well as other comorbidities. Guideline-adherent antithrombotic management based on the ESC guidelines is associated with significantly better outcomes. Specifically, the endpoint of 'all cause death and any TE' is increased by >60% by undertreatment [hazard ratio (HR) 1.679 (95% confidence interval (CI) 1.202-2.347)] or over-treatment [HR 1.622 (95% CI 1.173-2.23)]. For the composite endpoint of 'cardiovascular death, any TE or bleeding', over-treatment increased risk by >70% [HR 1.722 (95% CI 1.200-2.470)]. CONCLUSION: Even in this cohort with high overall rates of oral anticoagulation use, ESC guideline-adherent antithrombotic management is associated with significantly better outcomes, including those related to mortality and TE, as well as the composite endpoint of 'cardiovascular death, any TE or bleeding'. These contemporary observations emphasize the importance of guideline implementation, and adherence to the 2012 ESC guidelines for stroke prevention in AF.

Prognosis and treatment of atrial fibrillation patients by European cardiologists: one year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot registry).

BACKGROUND: The EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot) provides systematic collection of contemporary data regarding the management and treatment of 3119 subjects with AF from 9 member European Society of Cardiology (ESC) countries. In this analysis, we report the development of symptoms, use of antithrombotic therapy and rate vs. rhythm strategies, as well as determinants of mortality and/or stroke/transient ischaemic attack (TIA)/peripheral embolism during 1-year follow-up in this contemporary European registry of AF patients. METHODS: The registry population comprised consecutive in- and out-patients with AF presenting to cardiologists in participating ESC countries. Consecutive patients with AF documented by ECG were enrolled. Follow-up was performed by the local investigator, initially at 1 year, as part of a long-term cohort study. RESULTS: At the follow-up, patients were frequently asymptomatic (76.8%), but symptoms are nevertheless common among paroxysmal and persistent AF patients, especially palpitations, fatigue, and shortness of breath. Oral anticoagulant (OAC) use remains high, ∼78% overall at follow-up, and of those on vitamin K antagonist (VKA), 84% remained on VKA during the follow-up, while of those on non-VKA oral anticoagulant (NOAC) at baseline, 86% remained on NOAC, and 11.8% had changed to a VKA and 1.1% to antiplatelet therapy. Digitalis was commonly used in paroxysmal AF patients. Of rhythm control interventions, electrical cardioversion was performed in 9.7%, pharmacological cardioversion in 5.1%, and catheter ablation in 4.4%. Despite good adherence to anticoagulation, 1-year mortality was high (5.7%), with most deaths were cardiovascular (70%). Hospital readmissions were common, especially for atrial tachyarrhythmias and heart failure. On multivariate analysis, independent baseline predictors for mortality and/or stroke/TIA/peripheral embolism were age, AF as primary presentation, previous TIA, chronic kidney disease, chronic heart failure, malignancy, and minor bleeding. Independent predictors of mortality were age, chronic kidney disease, AF as primary presentation, prior TIA, chronic obstructive pulmonary disease, malignancy, minor bleeding, and diuretic use. Statin use was predictive of lower mortality. CONCLUSION: In this 1-year follow-up analysis of the EORP-AF pilot general registry, we provide data on the first contemporary registry focused on management practices among European cardiologists, conducted since the publication of the new ESC guidelines. Overall OAC use remains high, although persistence with therapy may be problematic. Nonetheless, continued OAC use was more common than in prior reports. Despite the high prescription of OAC, 1-year mortality and morbidity remain high in AF patients, particularly from heart failure and hospitalizations.

Long-term outcome of 'super-responder' patients to cardiac resynchronization therapy.

AIMS: To evaluate the long-term changes of clinical and echocardiographic parameters, the incidence of cardiac events and parameters associated with late cardiac events in 'super-responders' to cardiac resynchronization therapy (CRT) with [CRT defibrillator (CRT-D)] or without defibrillator back-up. METHODS AND RESULTS: In all consecutive patients treated with CRT in two Italian centres (Trieste and Udine) with left ventricular ejection fraction (LVEF) ≤0.35 at implantation (Timp) and LVEF > 0.50 1 and/or 2 years (Tnorm) after implantation, the long-term outcome and the evolution of echocardiographic parameters were assessed; factors associated with a higher risk of cardiac events, defined as hospitalization or death for heart failure (HF), sudden death, or CRT-D appropriate interventions, were also analysed. Among the 259 patients evaluated, 62 (24%) had LVEF ≥ 0.50 at Tnorm (n = 44 with at 1 year, n = 18 at 2 years). During a mean follow-up of 68 ± 30 months, one cardiac death (for HF) and eight cardiovascular events (two hospitalization for HF and six appropriate CRT-D interventions) occurred. At the last echo evaluation (Tfup) performed 51 ± 26 months after Timp, LVEF was <0.50 in five patients (>0.45 in four of them). At univariable analysis, only LV end-systolic volume evaluated at Tfup was associated with a higher risk of cardiac events during follow-up. CONCLUSION: In 'super-responders' to CRT long-term outcome is excellent. However, cardiac events, mainly CRT-D appropriate interventions, can occur despite the persistence of LVEF > 0.50. Early identification of these patients is still an unsolved issue.

Expanded application of wearable cardioverter defibrillators beyond current guidelines: proposal for a European register explained through single clinical scenarios.

The wearable cardioverter defibrillator (WCD) is becoming a more and more widely used instrument for the prevention of sudden cardiac death of patients either with a secondary prevention implantable cardioverter defibrillator indication or with a transient high risk of sudden cardiac death. Although clinical practice has demonstrated a benefit of protecting patients for a period as long as 3-6 months with such devices, the current European guidelines concerning ventricular arrhythmias and sudden cardiac death are still extremely restrictive in the patient selection in part because of the costs derived from such a prevention device, in part because of the lack of robust randomised trials.To illustrate expanded use cases for the WCD, four real-life clinical cases are presented where patients received the device slightly outside the established guidelines. These cases demonstrate the broader utility of WCDs in situations involving acute myocarditis, thyrotoxicosis, pre-excited atrial fibrillation and awaiting staging/prognosis of a lung tumour. The findings prompt expansion of the existing guidelines for WCD use to efficiently protect more patients whose risk of arrhythmic cardiac death is transient or uncertain. This could be achieved by establishing a European register of the patients who receive a WCD for further analysis.

Fusion Imaging of Non-Invasive and Invasive Cardiac Electroanatomic Mapping in Patients with Ventricular Ectopic Beats: A Feasibility Analysis in a Case Series.

In patients with premature ventricular contractions (PVCs), non-invasive mapping could locate the PVCs' origin on a personalized 3-dimensional (3D) heart model and, thus, facilitate catheter ablation therapy planning. The aim of our report is to evaluate its accuracy compared to invasive mapping in terms of assessing the PVCs' early activation zone (EAZ). For this purpose, non-invasive electrocardiographic imaging (ECGI) was performed using the Amycard 01C system (EP Solutions SA, Switzerland) in three cases. In the first step, a multichannel ECG (up to 224 electrodes) was recorded, and the dominant PVCs were registered. Afterward, a cardiac computed tomography (in two cases) or magnetic resonance imaging (in one case) investigation was carried out acquiring non-contrast torso scans for 8-electrode strip visualization and contrast heart acquisition. For the reconstructed epi/endocardial meshes of the heart, non-invasive isochronal maps were generated for the selected multichannel ECG fragments. Then, the patients underwent an invasive electrophysiological study, and the PVCs' activation was evaluated by a 3D mapping system (EnSite NavX Precision, Abbott). Finally, using custom-written software, we performed 3D fusion of the non-invasive and invasive models and compared the resulting isochronal maps. A qualitative analysis in each case showed the same early localization of the dominant PVC on the endocardial surface when comparing the non-invasive and invasive isochronal maps. The distance from the EAZ to the mitral or tricuspid annulus was comparable in the invasive/non-invasive data (36/41 mm in case N1, 73/75 mm in case N2, 9/12 mm in case N3). The area of EAZ was also similar between the invasive/non-invasive maps (4.3/4.5 cm2 in case N1, 7.1/7.0 cm2 in case N2, 0.4/0.6 cm2 in case N3). The distances from the non-invasive to invasive earliest activation site were 4 mm in case N1, 7 mm in case N2, and 4 mm in case N3. Such results were appropriate to trust the clinical value of the preoperative data in these cases. In conclusion, the non-invasive identification of PVCs before an invasive electrophysiological study can guide clinical and interventional decisions, demonstrating appropriate accuracy in the estimation of focus origin.

Radiation protection for healthcare professionals working in catheterisation laboratories during pregnancy: a statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Heart Rhythm Association (EHRA), the European Association of Cardiovascular Imaging (EACVI), the ESC Regulatory Affairs Committee and Women as One.

The European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Heart Rhythm Association (EHRA), the European Association of Cardiovascular Imaging (EACVI), the European Society of Cardiology (ESC) Regulatory Affairs Committee and Women as One support continuous review and improvement, not only in the practice of assuring patients a high quality of care but also in providing health professionals with support documents to help them in their career and enhance gender equity. Recent surveys have revealed that radiation exposure is commonly reported as the primary barrier for women pursuing a career in interventional cardiology or cardiac electrophysiology (EP). The fear of foetal exposure to radiation during pregnancy may lead to a prolonged interruption in their career. Accordingly, this joint statement aims to provide a clear statement on radiation risk and the existing data on the experience of radiation-exposed cardiologists who continue to work in catheterisation laboratories (cath labs) throughout their pregnancies. In order to reduce the barrier preventing women from accessing these careers, increased knowledge in the community is warranted. Finally, by going beyond simple observations and review of the literature, our document suggests proposals for improving workplace safety and for encouraging equity.

His bundle pacing guided by automated intrinsic morphology matching is feasible in patients with narrow QRS complexes.

Pace mapping and visual comparison of the local pacing response with the intrinsic QRS morphology form the mainstay of His bundle pacing (HBP). We evaluated the performance of a surface lead morphology match algorithm for automated classification of the pacing response in patients with narrow intrinsic QRS undergoing electroanatomic mapping (EAM)-guided HBP. HBP was attempted in 43 patients. In 28 cases with narrow QRS, the EnSite AutoMap Module was used for automated assessment of the QRS morphology resulting from pace mapping in the His cloud area with either a diagnostic catheter or the His lead. An intrinsic morphology match score (IMS) was calculated for 1.546 QRS complexes and assessed regarding its accuracy and performance in classifying the individual pacing response as either selective HBP (S-HBP), nonselective HBP (NS-HBP) or right ventricular stimulation. Automated morphology comparison of 354 intrinsic beats with the individual reference determined a test accuracy of 99% (95% CI 98.96-99.04) and a precision of 97.99-99.5%. For His-lead stimulation, an IMS ≥ 89% identified S-HBP with a sensitivity, specificity and positive predictive value of 1.00 (0.99, 1.00) and a negative predictive value of 0.99 (0.98, 1.00). An IMS between 78 and < 89% indicated NS-HBP with a sensitivity and specificity of 1.00 (0.99, 1.00) and 0.99 (0.98, 1.00), respectively. IMS represents a new automated measure for standardized individual morphology classification in patients with normal QRS undergoing EAM-guided HBP.Clinical trial registration: NCT04416958.

Minielectrode catheter technology for near zero-fluoroscopy substrate-guided ablation of typical atrial flutter.

BACKGROUND: MicroFidelity catheter technology may facilitate voltage-guided ablation by high-resolution electroanatomic mapping (HR-EAM) and precisely targeted energy application. OBJECTIVE: To evaluate the performance of minielectrode (ME) technology for zero-fluoroscopy substrate-guided cavotricuspid isthmus (CTI) ablation. METHODS: Eighty-two patients underwent near zero-fluoroscopy substrate-guided CTI ablation using a nonirrigated large-tip catheter with 3 MEs. The CTI was subdivided into 15 electroanatomic segments. Bipolar voltage maps were compared with ME signals. The outcome was compared with a historic cohort of 92 patients who underwent linear ablation. RESULTS: Compared with linear ablation, the substrate-guided approach was associated with an almost halved ablation duration (336 ± 228 vs 649 ± 409 seconds, P < .001), halved radiofrequency energy applied (14.2 ± 10.6 vs 28.6 ± 19.6 kJ, P < .001), and shorter procedure duration (60.8 ± 33.8 vs 76.3 ± 40.9 minutes, P = .008) limiting the extent of energy delivery to 22.7% of the CTI area. HR-EAM visualized 2.03 ± 0.88 conductive pathways with a diameter of 5.35 ± 1.98 mm. A higher number of ME-detected bundles and a larger channel diameter correlated with increased ablation requirements. In 97.6% of the voltage-guided and 88.0% of the linear procedures, fluoroscopy was not used. CONCLUSION: HR-EAM-based substrate-guided CTI ablation may improve procedural outcome compared with the linear approach. Enhanced identification of discrete conductive pathways correlates with ablation efficacy. The electroanatomic subdivision of the CTI into 15 segments was feasible and may improve the understanding and comparability of anatomic variants and ablation results. Independent of the ablation strategy, modern EAM technology enables safe zero-fluoroscopy procedures in the majority of cases.

Impact of Different Geriatric Conditions on Choice of Therapy and In-Hospital Outcomes in Elderly Patients with Acute Coronary Syndrome.

INTRODUCTION: The clinical benefit of invasive therapy in elderly patients with acute coronary syndrome (ACS) remains unclear. Furthermore, the decision-making process to treat this growing patient group is also debatable. The purpose of this study was to assess the association between elderly ACS patients, the treatment choice and their in-hospital outcomes after non-ST-elevation (NSTE)-ACS in a consecutive series of patients >75 years of age. METHODS AND RESULTS: Consecutive patients >75 years presenting with NSTE-ACS in our hospital between July 2017 and July 2018 were included during the first 2 days of hospital admission. Demographic data, prior medical history and present medical condition were documented. During day 0 and day 2, geriatric assessments (Clinical Frailty Scale [CFS], Barthel index, Charlson comorbidity index, "timed up and go" test [TUG], Mini-Mental Status Test [MMS], Geriatric Depression Scale [GDS], SF-36 for quality of life, instrumental activities of daily living [IADL], Killip-score, Grace-score and Euro-score) were conducted. After 6 months, patients were re-evaluated. In 106 patients (mean age 81.9±5.3 years, 57% male gender), 68 patients (64%) were treated interventionally, and 38 patients had conservative treatment (36%). Patients treated with intervention were significantly younger (80.9±4.7 years vs 83.5±6.0 years, p=0.015), had a lower rate of prior cerebral events (17.6% vs 26.3%; p=ns) and suffered more often from chronic obstructive pulmonary disease (17.6% vs 34.2%; p=0.050). All other demographic variables were comparable between both groups. The composite clinical endpoint (death, re-infarction, bleeding) was reached in 7 patients (10.3%) of the invasive and in 2 patients (5.3%) of the conservative group. They were not significantly different between both groups. A frailty index, consisting of commonly used parameters of functional impairment in elderly patients, namely, MMS ≤2 at baseline, IADL ≤7, CFS ≥7 and age ≥85 years, significantly predicted conservative treatment. CONCLUSION: Effective revascularization techniques are still underused in patients of older age in the case of ACS. For decision-making, geriatric tests alone may not predict treatment in those patients, but the combination of different tests may better predict treatment and perhaps the clinical outcomes in those patients. Furthermore, frail patients are at higher risk for not receiving guideline recommended therapy.

Initial experience with the subcutaneous implantable cardioverter-defibrillator with the real costs of hospitalization analysis in a single Polish center.

BACKGROUND: The recent introduction of an entirely subcutaneous implantable cardioverter-defibril-lator (S-ICD) represents an important progress in the defibrillation technology towards a less invasive approach. This is a single-center observational study of S-ICD implantations in Poland. METHODS: The S-ICD was implanted in 11 patients with standard indications for an ICD. Patients in whom the device was implanted were evaluated for adverse events and device function at hospital discharge. All hospitalization costs were calculated and summed up for all patients. Costs were divided into following categories: medical materials, pharmaceuticals, operating theatre staff, cardiology depart-ment staff, laboratory tests, non-laboratory tests and additional non-medical costs. RESULTS: The mean age of patients was 51.6 ± 16.4 years, 9 were men and 2 were women. Four pa-tients had atrial fibrillation as the basal rhythm, 1 patient had atrial flutter and 6 patients had sinus rhythm. All patients had at least one condition that precluded the use of a traditional ICD system or the S-ICD was preferred due to other conditions, i.e. a history complicated transvenous ICD therapy (18%), anticipated higher risk of infection (27%), lack or difficult vascular access (18%), young age and anticipated high cumulated risk of lifetime device therapy (36%). The mean duration of the im-plantation procedure was 2 h. One patient developed a postoperative pocket hematoma. Mean total time of hospitalization was 28 (6-92) days. Average cost of hospitalization per patient was 21,014.29 EUR (minimal = 19,332.71 EUR and maximal = 24,824.14 EUR). CONCLUSIONS: S-ICD implantation appears to provide a viable alternative to transvenous ICD, espe-cially for patients without pacing requirements.

Radiofrequency catheter ablation of atrial fibrillation in athletes referred for disabling symptoms preventing usual training schedule and sport competition.

INTRODUCTION: Atrial fibrillation (AF) may occasionally affect athletes by impairing their ability to compete, and leading to noneligibility at prequalification screening. The impact of catheter ablation (CA) in restoring full competitive activity of athletes affected by AF is not known. The aim of our study was to investigate the effectiveness of CA of idiopathic AF in athletes with palpitations impairing physical performance and compromising eligibility for competitive activities. METHODS AND RESULTS: Twenty consecutive competitive athletes (all males; 44.4 +/- 13.0 years) with disabling palpitations on the basis of idiopathic drug-refractory AF underwent 46 procedures (2.3 +/- 0.4 per patient) according to a prospectively designed multiprocedural CA approach that consolidates pulmonary veins (PV) isolation through subsequent steps. Preablation, effort-induced AF could be documented in 13 patients (65%) during stress ECG and significantly reduced maximal effort capacity (176 +/- 21 W), as compared with patients with no AF during effort (207 +/- 43 W, P < 0.05). At the end of CA protocol, which also included ablation of atrial flutter (AFL) in 7 patients, 18 (90.0%) patients were free of AF and two (10.0%) reported short-lasting (minutes) episodes of palpitations during 36.1 +/- 12.7 months follow-up. Compared with preablation, postablation maximal exercise capacity significantly improved (from 183 +/- 32 to 218 +/- 20 W, P < 0.02). All baseline quality of life (QoL) parameters pertinent to physical activity significantly improved (P < 0.05) at the end of CA protocol. All athletes obtained reeligibility and could effectively reinitiate sport activity. CONCLUSIONS: AF, alone or in combination with AFL, may significantly impair maximal effort capacity thereby limiting competitive performance. Multiple PV isolation proved very effective in these patients to restore full competitive activity and allow reeligibility.