Implementation of zero or near-zero fluoroscopy catheter ablation for idiopathic ventricular arrhythmia originating from the aortic sinus cusp.

Complete elimination of fluoroscopy during radiofrequency ablation (RFA) of idiopathic ventricular arrhythmias (IVAs) originating from the aortic sinus cusp (ASC) is challenging. The aim was to assess the feasibility, safety and a learning curve for a zero-fluoroscopy (ZF) approach in centers using near-zero fluoroscopy (NOX) approach in IVA-ASC. Between 2012 and 2018, we retrospectively enrolled 104 IVA-ASC patients referred for ZF RFA or NOX using a 3-dimensional electroanatomic (3D-EAM) system (Ensite, Velocity, Abbott, USA). Acute, short and long-term outcomes and learning curve for the ZF were evaluated. ZF was completed in 62 of 75 cases (83%) and NOX in 32 of 32 cases (100%). In 13 cases ZF was changed to NOX. No significant differences were found in success rates between ZF and NOX, no major complications were noted. The median procedure and fluoroscopy times were 65.0 [45-81] and 0.0 [0-5] min respectively, being shorter for ZF than for NOX. With growing experience, the preference for ZF significantly increased-43% (23/54) in 2012-2016 vs 98% (52/53) in 2017-2018, with a simultaneous reduction in the procedure time. ZF ablation can be completed in almost all patients with IVA-ASC by operators with previous experience in the NOX approach, and after appropriate training, it was a preferred ablation technique. The ZF approach for IVA-ASC guided by 3D-EAM has a similar feasibility, safety, and effectiveness to the NOX approach.

Association between the geographic region and the risk of familial atrioventricular nodal reentrant tachycardia in the Polish population.

Introduction: Atrioventricular nodal reentrant tachycardia (AVNRT) is one of the most common regular supraventricular arrhythmias referred for catheter ablation (CA). In Poland, several families with familial AVNRT (FAVNRT) were reported in Podkarpacie Province (PP). Objectives: We aimed to determine the frequency of FAVNRT in PP compared with other south-eastern provinces of Poland. Patients and methods: Clinical data of 1544 patients with AVNRT diagnosed by invasive electrophysiological study between 2010 and 2019 were screened for FAVNRT. From January 2017 to June 2019, patients were asked to provide details on family history and origin to obtain 3-generation pedigrees. Families with at least 2 members with previous CA of AVNRT were divided into those from south-eastern provinces (SEPs; including PP and bordering provinces [BPs]) and the remaining parts of Poland (RPP). Results: There were 932 patients from SEPs and 612 from RPP. FAVNRT was reported in 45 patients (2.91%) from 27 families, with a higher frequency in SEPs than RPP (4.02% vs 1.17%; P = 0.002) and the highest frequency in PP (6.33% vs 2.47% in BPs; P = 0.004). The risk of FAVNRT was higher in PP compared with BPs (odds ratio, 2.67; 95% CI, 1.36­5.23; P = 0.004) and similar in BPs compared with RPP (odds ratio, 2.14; 95% CI, 0.86­5.34; P = 0.1). Conclusions: A relationship exists between the geographic region and frequency of FAVNRT. A greater distance from PP was associated with less frequent FAVNRT. International cooperation and genetic testing are needed to confirm the genetic impact of FAVNRT in this part of Central Europe.

Feasibility and performance of catheter ablation with zero-fluoroscopy approach for regular supraventricular tachycardia in patients with structural and/or congenital heart disease.

Patients with structural heart disease (SHD) are more difficult to ablate than those with a structurally healthy heart. The reason may be technical problems. We compared periprocedural data in unselected patients (including SHD group) recruited for zero-fluoroscopy catheter ablation (ZF-CA) of supraventricular arrhythmias (SVTs).Consecutive adult patients with atrioventricular nodal reentry tachycardia (AVNRT), accessory pathways (AP), atrial flutter (AFL), and atrial tachycardia (AT) were recruited. A 3-dimensional electroanatomical mapping system (Ensite Velocity, NavX, St Jude Medical, Lake Bluff, Illinois) was used to create electroanatomical maps and navigate catheters. Fluoroscopy was used on the decision of the first operator after 5 minutes of unresolved problems.Of the 1280 patients ablated with the intention to be treated with ZF approach, 174 (13.6%) patients with SHD (age: 58.2 ±â€Š13.6; AVNRT: 23.9%; AP: 8.5%; AFL: 61.4%; and AT: 6.2%) were recruited. These patients were compared with the 1106 patients with nonstructural heart disease (NSHD) (age: 51.4 ±â€Š16.4; AVNRT: 58.0%; AP: 17.6%; AFL: 20.7%; and AT: 3.7% P ≤ .001). Procedural time (49.9 ±â€Š24.6 vs 49.1 ±â€Š23.9 minutes, P = .55) and number of applications were similar between groups (P = 0.08). The rate of conversion from ZF-CA to fluoroscopy was slightly higher in SHD as compared to NSHD (13.2% vs 7.8%, P = .02) while the total time of fluoroscopy and radiation doses were comparable in the group of SHD and NSHD (P = .55; P = .48).ZF-CA is feasible and safe in majority of patients with SHD and should be incorporated into a standard approach for SHD; however, the procedure requires sufficient experience.

Long-term follow-up and comparison of techniques in radiofrequency ablation of ventricular arrhythmias originating from the aortic cusps (AVATAR Registry).

INTRODUCTION: Radiofrequency ablation (RFA) of outflow tract ventricular arrhythmia (VA) that originates from the aortic cusps can be challenging. Data on long­ term efficacy and safety as well as optimal technique after aortic cusp ablation have not previously been reported. OBJECTIVES: This aim of the study was to determine the short- and long­ term outcomes after RFA of aortic cusp VA, and to evaluate aortic valve injuries according to echocardiographic screening. PATIENTS AND METHODS: This was a prospective multicenter registry (AVATAR, Aortic Cusp Ventricular Arrhythmias: Long Term Safety and Outcome from a Multicenter Prospective Ablation Registry) study. A total of 103 patients at a mean age of 56 years (34-64) from the "Electra" Registry (2005-2017) undergoing RFA of aortic cusps VA were enrolled. The following 3 ablation techniques were used: zero­fluoroscopy (ZF; electroanatomical mapping [EAM] without fluoroscopy), EAM with fluoroscopy, and conventional fluoroscopy­ based RFA. Data on clinical history, complications after RFA, echocardiography, and 24­ hour Holter monitoring were collected. The follow up was 12 months or longer. RESULTS: There were no major acute cardiac complications after RFA. In one case, a vascular access complication required surgery. The median (interquartile range [IQR]) procedure time was 75 minutes (IQR, 58-95), median follow­ up, 32 months (IQR, 12-70). Acute and long term procedural success rates were 93% and 86%, respectively. The long­ term RFA outcomes were observed in ZF technique (88%), EAM with fluoroscopy (86%), and conventional RFA (82%), without differences. During long­ term follow­up, no abnormalities were found within the aortic root. CONCLUSIONS: Ablation of VA within the aortic cusps is safe and effective in long­ term follow up. The ZF approach is feasible, although it requires greater expertise and more imaging modalities.

A simplified approach for evaluating sustained slow pathway conduction for diagnosis and treatment of atrioventricular nodal reentry tachycardia in children and adults.

PURPOSE: During incremental atrial pacing in patients with atrioventricular nodal reentrant tachycardia, the PR interval often exceeds the RR interval (PR > RR) during stable 1:1 AV conduction. However, the PR/RR ratio has never been evaluated in a large group of patients with pacing from the proximal coronary sinus and after isoproterenol challenge. Our study validates new site of pacing and easier method of identification of PR > RR. MATERIAL AND METHODS: A prospective protocol of incremental atrial pacing from the proximal coronary sinus was carried out in 398 patients (AVNRT-228 and control-170). The maximum stimulus to the Q wave interval (S-Q = PR), SS interval (S-S), and Q-Q (RR) interval were measured at baseline and 10 min after successful slow pathway ablation and after isoproterenol challenge (obligatory). RESULTS: The mean maximum PR/RR ratios at baseline were 1.17 ±â€¯0.24 and 0.82 ±â€¯0.13 (p < 0.00001) in the AVNRT and controls respectively. There were no PR/RR ratios ≥1 at baseline and after isoproterenol challenge in 12.3% of the AVNRT group and in 95.9% of the control group (p < 0.0001). PR/RR ratios ≥1 were absent in 98% of AVNRT cases after slow pathway ablation/modification in children and 99% of such cases in adults (P = NS). The diagnostic performance of PR/RR ratio evaluation before and after isoproterenol challenge had the highest diagnostic performance for AVNRT with PR/RR > = 1 (sensitivity: 88%, specificity: 96%, PPV-97%, NPV-85%). CONCLUSIONS: The PR/RR ratio is a simple tool for slow pathway substrate and AVNRT evaluation. Eliminating PR/RR ratios ≥1 may serve as a surrogate endpoint for slow pathway ablation in children and adults with AVNRT.

Electrocardiographic algorithms to guide the management strategy of idiopathic outflow tract ventricular arrhythmias.

INTRODUCTION    The current guidelines of the European Society of Cardiology outlined electrocardiographic (ECG) differentiation of the site of origin (SoO) in patients with idiopathic ventricular arrhythmias (IVAs). OBJECTIVES    The aim of this study was to compare 3 ECG algorithms for differentiating the SoO and to determine their diagnostic value for the management of outflow tract IVA. PATIENTS AND METHODS    We analyzed 202 patients (mean age [SD]: 45 [16.7] years; 133 women [66%]) with IVAs with the inferior axis (130 premature ventricular contractions or ventricular tachycardias from the right ventricular outflow tract [RVOT]; 72, from the left ventricular outflow tract [LVOT]), who underwent successful radiofrequency catheter ablation (RFCA) using the 3­dimensional electroanatomical system. The ECGs before ablation were analyzed using custom­developed software. Automated measurements were performed for the 3 algorithms: 1) novel transitional zone (TZ) index, 2) V2S/V3R, and 3) V2 transition ratio. The results were compared with the SoO of acutely successful RFCA. RESULTS    The V2S/V3R algorithm predicted the left­sided SoO with a sensitivity and specificity close to 90%. The TZ index showed higher sensitivity (93%) with lower specificity (85%). In the subgroup with the transition zone in lead V3 (n = 44, 15 from the LVOT) the sensitivity and specificity of the V2-transition­ratio algorithm were 100% and 45%, respectively. The combined TZ index+V2S/V3R algorithm (LVOT was considered only when both algorithms suggested the LVOT SoO) can increase the specificity of the LVOT SoO prediction to 98% with a sensitivity of 88%. CONCLUSIONS    The combined TZ­index and V2S/V3R algorithm allowed an accurate and simple identification of the SoO of IVA. A prospective study is needed to determine the strategy for skipping the RVOT mapping in patients with LVOT arrhythmias indicated by the 2 combined algorithms.

Maximum voltage gradient technique for optimization of ablation for typical atrial flutter with zero-fluoroscopy approach.

Radiofrequency catheter ablation (RFCA) is an established effective method for the treatment of typical cavo-tricuspid isthmus (CTI)-dependent atrial flutter (AFL). The introduction of 3-dimensional electro-anatomic systems enables RFCA without fluoroscopy (No-X-Ray [NXR]). The aim of this study was to evaluate the feasibility and effectiveness of CTI RFCA during implementation of the NXR approach and the maximum voltage-guided (MVG) technique for ablation of AFL.Data were obtained from prospective standardized multicenter ablation registry. Consecutive patients with the first RFCA for CTI-dependent AFL were recruited. Two navigation approaches (NXR and fluoroscopy based as low as reasonable achievable [ALARA]) and 2 mapping and ablation techniques (MVG and pull-back technique [PBT]) were assessed. NXR + MVG (n  =  164; age: 63.7 ±â€Š9.5; 30% women), NXR + PBT (n  =  55; age: 63.9 ±â€Š10.7; 39% women); ALARA + MVG (n  =  36; age: 64.2 ±â€Š9.6; 39% women); and ALARA + PBT (n  =  205; age: 64.7 ±â€Š9.1; 30% women) were compared, respectively. All groups were simplified with a 2-catheter femoral approach using 8-mm gold tip catheters (Osypka AG, Germany or Biotronik, Germany) with 15 min of observation. The MVG technique was performed using step-by-step application by mapping the largest atrial signals within the CTI.Bidirectional block in CTI was achieved in 99% of all patients (P  =  NS, between groups). In NXR + MVG and NXR + PBT groups, the procedure time decreased (45.4 ±â€Š17.6 and 47.2 ±â€Š15.7 min vs. 52.6 ±â€Š23.7 and 59.8 ±â€Š24.0 min, P < .01) as compared to ALARA + MVG and ALARA + PBT subgroups. In NXR + MVG and NXR + PBT groups, 91% and 98% of the procedures were performed with complete elimination of fluoroscopy. The NXR approach was associated with a significant reduction in fluoroscopy exposure (from 0.2 ±â€Š1.1 [NXR + PBT] and 0.3 ±â€Š1.6 [NXR + MVG] to 7.7 ±â€Š6.0 min [ALARA + MVG] and 9.1 ±â€Š7.2 min [ALARA + PBT], P < .001). The total application time significantly decreased in the MVG technique subgroup both in NXR and ALARA (P < .01). No major complications were observed in either groups.Complete elimination of fluoroscopy is feasible, safe, and effective during RFCA of CTI in almost all AFL patients without cardiac implanted electronic devices. The most optimal method for RFCA of CTI-dependent AFL seems to be MVG; however, it required validation of optimal RFCA's parameters with clinical follow-up.

Validation of Standard and New Criteria for the Differential Diagnosis of Narrow QRS Tachycardia in Children and Adolescents.

To establish an appropriate treatment strategy and determine if ablation is indicated for patients with narrow QRS complex supraventricular tachycardia (SVT), analysis of a standard 12-lead electrocardiogram (ECG) is required, which can differentiate between the 2 most common mechanisms underlying SVT: atrioventricular nodal reentry tachycardia (AVNRT) and orthodromic atrioventricular reentry tachycardia (OAVRT). Recently, new, highly accurate electrocardiographic criteria for the differential diagnosis of SVT in adults were proposed; however, those criteria have not yet been validated in a pediatric population.All ECGs were recorded during invasive electrophysiology study of pediatric patients (n = 212; age: 13.2 ±â€Š3.5, range: 1-18; girls: 48%). We assessed the diagnostic value of the 2 new and 7 standard criteria for differentiating AVNRT from OAVRT in a pediatric population.Two of the standard criteria were found significantly more often in ECGs from the OAVRT group than from the AVNRT group (retrograde P waves [63% vs 11%, P < 0.001] and ST-segment depression in the II, III, aVF, V1-V6 leads [42% vs 27%; P < 0.05]), whereas 1 standard criterion was found significantly more often in ECGs from the AVNRT group than from the OAVRT group (pseudo r' wave in V1 lead [39% vs 10%, P < 0.001]). The remaining 6 criteria did not reach statistical significance for differentiating SVT, and the accuracy of prediction did not exceed 70%. Based on these results, a multivariable decision rule to evaluate differential diagnosis of SVT was performed.These results indicate that both the standard and new electrocardiographic criteria for discriminating between AVNRT and OAVRT have lower diagnostic values in children and adolescents than in adults. A decision model based on 5 simple clinical and ECG parameters may predict a final diagnosis with better accuracy.

Simplified automated right ventricular overdrive pacing for rapid diagnosis of supraventricular tachycardia.

OBJECTIVES: The purpose of this study was to prospectively evaluate the feasibility and diagnostic value of right ventricular overdrive pacing (RVOP) during supraventricular tachycardia (SVT) using a 2-catheter approach with automatic pacing from the right ventricular inflow (RVIT) and outflow tract (RVOT). METHODS: One hundred and thirty-six consecutive patients (with 138 arrhythmias, mean age 36 ± 20 years, range 4-95) were enrolled in this study. Only coronary sinus and ablation catheters were used. RVOP was delivered from RVIT and then from RVOT. Each attempt consisted of 10 synchronized beats delivered at a cycle length of 10-40 ms longer than the tachycardia cycle length. RESULTS: RVOP was sufficient to confirm the transition zone within the first 9 beats in the majority of SVTs. Atrial perturbation (acceleration, delayed) in the transition zone was detected in all patients with orthodromic atrioventricular (AV) reentry. Patients with typical AV nodal reentry, atypical AV nodal reentry and atrial tachycardia did not show atrial timing perturbation during fusion complexes of RVOP. CONCLUSIONS: Synchronized RVOP from RVIT or RVOT is an easy and accurate method for the quick and reliable differential diagnosis of SVT in various clinical settings, particularly when only a limited number of catheters are used.

Feasibility of implementation of a "simplified, No-X-Ray, no-lead apron, two-catheter approach" for ablation of supraventricular arrhythmias in children and adults.

INTRODUCTION: Although the "near-zero-X-Ray" or "No-X-Ray" catheter ablation (CA) approach has been reported for treatment of various arrhythmias, few prospective studies have strictly used "No-X-Ray," simplified 2-catheter approaches for CA in patients with supraventricular tachycardia (SVT). We assessed the feasibility of a minimally invasive, nonfluoroscopic (MINI) CA approach in such patients. METHODS: Data were obtained from a prospective multicenter CA registry of patients with regular SVTs. After femoral access, 2 catheters were used to create simple, 3D electroanatomic maps and to perform electrophysiologic studies. Medical staff did not use lead aprons after the first 10 MINI CA cases. RESULTS: A total of 188 patients (age, 45 ± 21 years; 17% <19 years; 55% women) referred for the No-X-Ray approach were included. They were compared to 714 consecutive patients referred for a simplified approach using X-rays (age, 52 ± 18 years; 7% <19 years; 55% women). There were 9 protocol exceptions that necessitated the use of X-rays. Ultimately, 179/188 patients underwent the procedure without fluoroscopy, with an acute success rate of 98%. The procedure times (63 ± 26 vs. 63 ± 29 minutes, P > 0.05), major complications (0% vs. 0%, P > 0.05) and acute (98% vs. 98%, P > 0.05) and long-term (93% vs. 94%, P > 0.05) success rates were similar in the "No-X-Ray" and control groups. CONCLUSIONS: Implementation of a strict "No-X-Ray, simplified 2-catheter" CA approach is safe and effective in majority of the patients with SVT. This modified approach for SVTs should be prospectively validated in a multicenter study.

[Non-invasive electrophysiologic study and radiofrequency current ablation of tachycardia responsible for numerous inappropriate ICD interventions in patient with post-infarction dilated cardiomyopathy]. / Nieinwazyjne badanie elektrofizjologiczne i ablacja czestoskurczu bedacego przyczyna bardzo licznych interwencji ICD-DDD u chorego z pozawalowa kardiomiopatia rozstrzeniowa.

We present a case of 75-year-old man with numerous inappropriate interventions of an implanted cardioverter-defibrillator (ICD). In this patient with ischaemic cardiomyopathy, ICD was implanted for primary prevention of sudden cardiac death following recurrent syncope. ICD interrogation and non-invasive electrophysiologic study (NIPS) confirmed a risk of reentry-mediated tachycardia and excluded the presence of a manifest or concealed accessory pathway. Invasive electrophysiologic study revealed a wide zone that triggered atrioventricular nodal reentrant tachycardia, and ablation of the slow pathway resulted in complete remission of the arrhythmia. NIPS performed using atrial and ventricular ICD leads and subsequent ICD interrogation confirmed long-term effectiveness of the procedure. At the same time, clinical improvement of heart failure was seen, leading to a suspicion of tachycardia-induced cardiomyopathy coexisting with ischaemic cardiomyopathy.

Results of one-year anticoagulation in patients with newly detected chronic thromboembolic pulmonary hypertension not treated with pulmonary endarterectomy.

INTRODUCTION: Currently pulmonary endarterectomy is considered the method of choice in patients with chronic thromboembolic pulmonary hypertension (CTEPH). It is not known if this option should be recommended in all suitable patients as it is highly variable with respect to prognosis. There is also doubt about selection of adequate time to refer patients with CTEPH for surgery. AIM: To establish whether some patients with CTEPH may clinically benefit from isolated anticoagulation with drugs and if the use of anticoagulation may have any impact on the time of patient referral for pulmonary endarterectomy. METHODS: The prospective analysis involved 29 patients (9 male, 20 female) aged 37 to 82 years, with pulmonary arterial systolic pressure ranging from 39 to 133 mmHg and newly diagnosed CTEPH who had not been treated with pulmonary endarterectomy and were not receiving anticoagulation. Survival, functional status according to NYHA classification, duration of thromboembolism, exercise tolerance and echocardiographic parameters of right ventricular overload before and at one year after initiation of therapy with anticoagulants were evaluated. RESULTS: During follow-up, 3 patients with PASP ranging from 120 to 133 mmHg died. In 26 patients with PASP 39-115 mmHg, who survived, improvement in echocardiographic parameters of right ventricular overload, better exercise tolerance as well as functional status according to NYHA classification was observed. In 12 survivors, pulmonary pressure returned to normal. CONCLUSIONS: The results of this study suggest that favourable effects of isolated anticoagulation are likely in patients with newly detected CTEPH, mild and moderate baseline pulmonary hypertension and acceptable exercise tolerance. They also indicate the necessity of anticoagulation in these patients prior to possible referral for pulmonary endarterectomy.

[One-year controlled therapy with doxazosin in patients with pulmonary hypertension due to chronic obstructive pulmonary disease]. / Roczna, kontrolowana ocena stosowania doksazosyny u chorych na nadcisnienie plucne na tie przewlekle j obturacyjnej choroby pluc.

UNLABELLED: It was shown recently that a thirty day doxazosin therapy, that was undertaken to prove alpha1-adrenergic hypothesis for pulmonary hypertension, resulted in a significant improvement of pulmonary hemodynamics in patients with hypoxic pulmonary hypertension (HPH) due to COPD. AIM OF THE STUDY: The objective of this study was to learn if 12 months long therapy with 2 mg of doxazosin daily (dosage effective in recent research) may result in persistent hemodynamical and clinical benefits. MATERIAL AND METHODS: To this end, baseline and after 1 year results of echocardiography, symptom-limited maximal exercise test, and arterial blood gaseous analysis were evaluated at baseline and after 12-month study in 32 patients with HPH randomized either to doxazosin treated group (16 patients, aged 60.2 +/- 12 years, or to control group (16 patients, aging 60.5 +/- 4 years). At baseline doxazosin treated COPD patients had less advanced disease than COPD control patients (FVC 2.4 +/- 0.7 vs 1.3 +/- 0.31, p<0,001 and FEV1 1.6 +/- 0.6 vs 0.7 +/- 0.31, p<0,001). RESULTS: This study showed that results of tricuspid gradient, acceleration time, right ventricular enddiastolic diameter, left ventricular enddiastolic diameter and left ventricular ejection fraction did not differ significantly in both groups between baseline and 1-year assessment. The number of METs achieved during exercise test and results of PaO2 and PaCO2 did not change significantly in both groups either. CONCLUSION: The study indicates lack of hemodynamical and clinical improvement during a 1-year doxazosin therapy in patients with HPH due to COPD.

[Normal coronary angiogram in patient with diagnosis of acute coronary syndrome with ST segment elevation. Was it possible to recognise acute pulmonary embolism earlier?]. / Prawidlowy wynik koronarografii u pacjenta z rozpoznaniem ostrego zespolu wiencowego z uniesieniem ST zakwalifikowanego do przezskórnej interwencji wiencowej. Czy mozna bylo wczesniej rozpoznac ostra zatorowosc plucna?

A case of a 48 year old male scheduled for early invasive treatment of acute coronary syndrome with ST segment elevation is presented. Clinical suspicion of acute pulmonary embolism was undertaken because of normal coronary angiogram and was confirmed by pulmonary angiography. Differential diagnosis based on medical history, electrocardiogram and laboratory findings was discussed.

[Characteristics of acute, hemodynamically stable pulmonary embolism presenting as a syncope]. / Charakterystyka ostrej, hemodynamicznie stabilnej zatorowosci plucnej ujawniajacej sie omdleniem.

Syncope (S) occurs in approximately 10% patients with acute pulmonary embolism (APE) and is commonly ascribed to the massive, hemodynamically instable APE. The aim of the study was to assess the occurrence and significance of S revealing hemodynamically stable APE. We found syncope in 6 of 21 (29%) consecutive patients (16 females, 5 males; age from 46-87 years, mean age of 71 years) who were diagnosed with APE and in whom other reasons for S were excluded. All patients were treated with anticoagulation. They all survived hospitalization and no APE recurrences were found during in-hospital period. Patients with APE-S compared to patients with APE and without S had smaller baseline RVED (21.2 +/- 2 vs. 27.3 +/- 5.6, p = 0.01), however both groups did not differ statistically in baseline vital signs, angiographic, hemodynamic, other echocardiographic parameters as well as in the results of laboratory findings. It is concluded, that S signals hemodynamically stable APE more frequently than is quoted. APE-S patients could not be clearly discriminate from APE patients without S on the basis of the parameters studied and S did not impact the course of APE during in- hospital period.

[Cardiac tamponade due to angiosarcoma--was surgical treatment necessary? A case report]. / Tamponada serca wywolana miesakiem naczyniowym--czy nalezalo wykonac zabieg kardiochirurgiczny?

We present a case of a 49-year-old patient with cardiac tamponade due to haemopericardium. The decision to perform surgery, although controversial, allowed to diagnose cardiac angiosarcoma with metastases to pericardium, vena cava superior and pulmonary trunk. Consequently, chemotherapy was instituted and was initially effective, however, the patient died 12 months later due to the progression of the disease.

[How to manage the patients with hypoxic pulmonary hypertension?]. / Jak postepowac z chorymi na hipoksyjne nadcisnienie plucne?

Hypoxic pulmonary hypertension (HPH) develops in many patients with advanced chronic obstructive pulmonary disease (COPD) and aggravates their quality of life and prognosis. The most proper but as yet not satisfactory management of HPH involves COPD prophylaxis. In this article pathophysiological background to use systemic vasodilators in treatment of HPH are described, and hemodynamical and clinical results of short and long term trials are discussed. Authors explain lack of clinical benefits with currently used systematic vasodilators in HPH and indicate promising preliminary results with 5-phosphodiesterase inhibitors. The substantial role of chronic oxygen therapy and pulmonary rehabilitation in management of HPH is emphasized.

[Effect of a 2-year pulmonary rehabilitation on the 7-year prognosis in patients with advanced chronic obstructive pulmonary disease]. / Wplyw 2-letniej rehabilitacji oddechowej na 7-letnie rokowanie u chorych z zaawansowana przewlekla obturacyjna choroba pluc.

Pulmonary rehabilitation (PR) improve the quality of life in COPD patients, however, little has been known whether it may improve the survival. We assessed 7-year prognosis in 46 patients with advanced COPD, 27 of which completed successfully 2-year course of PR whereas 19 COPD patients made a control (C) group. At the end of 7-year observation 41.3% of total number of patients survived, among them 12 (42.8%) PR patients and 7 (38%) C patients. COPD progression was the main (80%) reason of mortality in both groups. The survivors had better results of baseline FVC, FEV1 and treadmill exercise test. They did not differ from non-survivors with age, baseline results of the weight, PaO2, PaCO2 and the number of PR patients. The Cox proportional hazard analysis showed that neither of baseline parameters influenced significantly the 7-year prognosis in this group of COPD patients. In conclusion, PR failed to improve 7-year prognosis in the studied group of patients with advanced COPD.