Long-Term Renal Function after Catheter Ablation of Atrial Fibrillation.

Background: Atrial fibrillation (AF) is associated with the development and progression of chronic kidney disease (CKD). This study evaluated the impact of long-term rhythm outcome after catheter ablation (CA) of AF on renal function. Methods and results: The study group included 169 consecutive patients (the mean age was 59.6 ± 10.1 years, 61.5% were males) who underwent their first CA of AF. Renal function was assessed by eGFR (using the CKD-EPI and MDRD formulas), and by creatinine clearance (using the Cockcroft-Gault formula) in each patient before and 5 years after index CA procedure. During the 5-year follow-up after CA, the late recurrence of atrial arrhythmia (LRAA) was documented in 62 patients (36.7%). The mean eGFR, regardless of which formula was used, significantly decreased at 5 years following CA in patients with LRAA (all p < 0.05). In the arrhythmia-free patients, the mean eGFR at 5 years post-CA remained stable (for the CKD-EPI formula: 78.7 ± 17.3 vs. 79.4 ± 17.4, p = 0.555) or even significantly improved (for the MDRD formula: 74.1 ± 17.0 vs. 77.4 ± 19.6, p = 0.029) compared with the baseline. In the multivariable analysis, the independent risk factors for rapid CKD progression (decline in eGFR > 5 mL/min/1.73 m2 per year) were the post-ablation LRAA occurrence (hazard ratio 3.36 [95% CI: 1.25-9.06], p = 0.016), female sex (3.05 [1.13-8.20], p = 0.027), vitamin K antagonists (3.32 [1.28-8.58], p = 0.013), or mineralocorticoid receptor antagonists' use (3.28 [1.13-9.54], p = 0.029) after CA. Conclusions: LRAA after CA is associated with a significant decrease in eGFR, and it is an independent risk factor for rapid CKD progression. Conversely, eGFR in arrhythmia-free patients after CA remained stable or even improved significantly.

Sex-related differences in self-reported treatment burden in patients with atrial fibrillation.

Background: Treatment burden (TB) is defined as the patient's workload of healthcare and its impact on patient functioning and wellbeing. High TB can lead to non-adherence, a higher risk of adverse outcomes and lower quality of life (QoL). We have previously reported a higher TB in patients with atrial fibrillation (AF) vs. those with other chronic conditions. In this analysis, we explored sex-related differences in self-reported TB in AF patients. Materials and methods: A single-center, prospective study included consecutive patients with AF under drug treatment for at least 6 months before enrollment from April to June 2019. Patients were asked to voluntarily and anonymously answer the Treatment Burden Questionnaire (TBQ). All patients signed the written consent for participation. Results: Of 331 patients (mean age 65.4 ± 10.3 years, mean total AF history 6.41 ± 6.62 years), 127 (38.4%) were females. The mean TB was significantly higher in females compared to males (53.7 vs. 42.6 out of 170 points, p < 0.001), and females more frequently reported TB ≥ 59 points than males (37.8% vs. 20.6%, p = 0.001). In females, on multivariable analysis of the highest TB quartile (TB ≥ 59), non-vitamin K Antagonist Oral Anticoagulant (NOAC) use [Odds Ratio (OR) 0.319; 95% Confidence Interval (CI) 0.12-0.83, P = 0.019], while in males, catheter ablation and/or ECV of AF (OR 0.383; 95% CI 0.18-0.81, P = 0.012) were negatively associated with the highest TB quartile. Conclusion: Our study was the first to explore the sex-specific determinants of TB in AF patients. Females had significantly higher TB compared with males. Approximately 2 in 5 females and 1 in 5 males reported TB ≥ 59 points, previously shown to be an unacceptable burden of treatment for patients. Using a NOAC rather than vitamin K antagonist (VKA) in females and a rhythm control strategy in males could decrease TB to acceptable values.

Physiological behavior during stress anticipation across different chronic stress exposure adaptive models.

Anticipation of stress induces physiological, behavioral and cognitive adjustments that are required for an appropriate response to the upcoming situation. Additional research examining the response of cardiopulmonary parameters and stress hormones during anticipation of stress in different chronic stress adaptive models is needed. As an addition to our previous research, a total of 57 subjects (16 elite male wrestlers, 21 water polo player and 20 sedentary subjects matched for age) were analyzed. Cardiopulmonary exercise testing (CPET) on a treadmill was used as the laboratory stress model; peak oxygen consumption (VO2) was obtained during CPET. Plasma levels of adrenocorticotropic hormone (ACTH), cortisol, alpha-melanocyte stimulating hormone (alpha-MSH) and N-terminal-pro-B type natriuretic peptide (NT-pro-BNP) were measured by radioimmunometric, radioimmunoassay and immunoassay sandwich technique, respectively, together with cardiopulmonary measurements, 10 minutes pre-CPET and at the initiation of CPET. The response of diastolic blood pressure and heart rate was different between groups during stress anticipation (p = 0.019, 0.049, respectively), while systolic blood pressure, peak VO2 and carbon-dioxide production responses were similar. ACTH and cortisol increased during the experimental condition, NT-pro-BNP decreased and alpha-MSH remained unchanged. All groups had similar hormonal responses during stress anticipation with the exception of the ACTH/cortisol ratio. In all three groups, ΔNT-pro-BNP during stress anticipation was the best independent predictor of peak VO2 (B = 36.01, r = 0.37, p = 0.001). In conclusion, the type of chronic stress exposure influences the hemodynamic response during anticipation of physical stress and the path of hormonal stress axis activation. Stress hormones released during stress anticipation may hold predictive value for overall cardiopulmonary performance during the stress condition.

LAY SUMMARYThe study revealed differences in hormonal and hemodynamic responses during anticipation of stress between athletes and sedentary participants. Stress hormones released during stress anticipation may hold predictive value for overall cardiopulmonary performance during the stress condition.

Risk factors for late reconnections after circumferential pulmonary vein isolation guided by lesion size index - Data from repeat invasive electrophysiology procedure.

Background: Late reconnections (LR) of pulmonary veins (PVs) after wide antral circumferential ablation (WACA) using point-to-point radiofrequency (RF) ablation are common. Lesion size index (LSI) is a novel marker of lesion quality proposed by Ensite Precision mapping system, expected to improve PV isolation durability. This study aimed to assess the durability of LSI-guided PVI and the risk factors for LR of PVs. Methods: The prospective study included 33 patients with paroxysmal atrial fibrillation (PAF) who underwent (1) the index LSI-guided WACA procedure (with target LSI of 5.5-6.0 for anterior and 5.0-5.5 for posterior WACA segments) and (2) the 3-month protocol-mandated re-mapping procedure in all patients, irrespective of AF recurrence after the index procedure. Ablation parameters reported by Ensite mapping system were collected retrospectively. The inter-lesion distance (ILD) between all adjacent WACA lesions was calculated off-line. Association between index ablation parameters and the LRs of PVs at 3 months was analyzed. Results: The median patient age was 61 (IQR: 53-64) years and 55% of them were males. At index procedure, the first-pass WACA isolation rate was higher for the left PVs than the right PVs (64 vs. 33%, p = 0.014). In addition, a low acute reconnection rates were observed, as follows: in 12.1% of patients, in 6.1% of WACA circles, in 3.8% of WACA segments and in 4.5% of PVs. However, the 3-month remapping study revealed LR of PV in 63.6% of patients, 37.9% of WACA circles, 20.5% of WACA segments and 26.5% of PVs. The LRs were identified mostly along the left anterior WACA segment. Independent risk factors for the LR of WACA were left-sided WACA location (OR 3.216 [95%CI: 1.065-9.716], p = 0.038) and longer ILD (OR 1.256 [95%CI: 1.035-1.523] for each 1-mm increase, p = 0.021). The ILD of > 8.0 mm showed a predictive value for the LR of WACA, with the sensitivity of 84% and specificity of 46%. A single case of cardiac tamponade occurred following the re-mapping invasive procedure. No other complications were encountered. Conclusion: Although the LSI-guided PVI ensures a consistent PVI during the index procedure, LRs of PVs are still common. Besides the LSI, the PVI durability requires an optimal ILD between adjacent lesions, especially along the anterior lateral ridge.

Impact of multimorbidity and polypharmacy on the management of patients with atrial fibrillation: insights from the BALKAN-AF survey.

OBJECTIVE: We investigated the impact of multimorbidity and polypharmacy on the management of atrial fibrillation (AF) patients in clinical practice and assessed factors associated with polypharmacy and oral anticoagulation (OAC) use in AF patients with multimorbidity and polypharmacy. METHODS: A 14-week prospective study of consecutive non-valvular AF patients was performed in seven Balkan countries. RESULTS: Of 2712 consecutive patients, 2263 patients (83.4%) had multimorbidity (AF + ≥2 concomitant diseases) and 1505 patients (55.5%) had polypharmacy. 1416 (52.2%) patients had both multimorbidity and polypharmacy. Overall, 1164 (82.2%) patients received OAC, 200 (14.1%) patients received antiplatelet drugs alone and 52 (3.7%) patients had no antithrombotic therapy (AT). Non-emergency centre and paroxysmal AF were significantly associated with OAC non-use in patients with multimorbidity, whilst age ≥80 years and non-emergency centre were identified to be independent predictors of OAC non-use in patients with polypharmacy. CONCLUSIONS: Multimorbidity and polypharmacy were common among AF patients in our study. AT was suboptimal and approximately 18% of multimorbid patients with polypharmacy were not anticoagulated. Pattern of AF and non-emergency centre were associated with OAC non-use in AF patients with multimorbidity, whilst non-emergency centre and age ≥80 years were associated with OAC non-use in AF patients with polypharmacy. Key Message Multimorbidity and polypharmacy are common among patients with AF. Antithrombotic therapy was suboptimal in AF patients with multimorbidity and polypharmacy. Approximately, 18% of multimorbid patients with polypharmacy were not anticoagulated.

Treatment implications of renal disease in patients with atrial fibrillation: The BALKAN-AF survey.

BACKGROUND: Atrial fibrillation (AF) often co-exists with renal function (RF) impairment. We investigated the characteristics and management of AF patients across creatinine clearance strata and potential changes in the use of nonvitamin K oral anticoagulants (NOAC) according to different equations for estimation of RF. METHODS: In this post hoc analysis of the BALKAN-AF survey, patients were classified according to RF (Cockcroft-Gault formula) as: preserved/mildly depressed RF (P-RF) ≥50 mL/min, moderately depressed RF (MD-RF) 30-49 mL/min, and severely depressed RF (SD-RF) <30 mL/min. RESULTS: Of 2712 enrolled patients, 2062 (76.0%) had data on RF. Patients with SD-RF and MD-RF were older, had higher mean value of European Heart Rhythm Association score, stroke and bleeding risk scores, and more comorbidities than patients with P-RF (all P < .05). They received oral anticoagulants (OAC), AF catheter ablation, and electrical cardioversion less often than those with P-RF (all P < .05). Rate control, no OAC, single-antiplatelet therapy (SAPT) alone, and loop diuretics were more prevalent in patients with SD-RF and MD-RF than in subjects with P-RF (all P < .005). An important change in NOAC therapy could appear in <1% of patients (Modification of Diet in Renal Disease formula) and in <1% of patients (Chronic Kidney Disease Epidemiology Collaboration group formula). CONCLUSIONS: Patients with SD-RF and MD-RF were older, more symptomatic, had higher stroke and bleeding risk and more comorbidities than those with P-RF. They were less likely to receive OAC and more likely to use rate control strategy, SAPT alone, and no OAC than subjects with P-RF.

Self-reported treatment burden in patients with atrial fibrillation: quantification, major determinants, and implications for integrated holistic management of the arrhythmia.

AIMS: Treatment burden (TB) refers to self-perceived cumulative work patients do to manage their health. Using validated tools, TB has been documented in several chronic conditions, but not atrial fibrillation (AF). We measured TB and analysed its determinants and impact on quality of life (QoL) in an AF cohort. METHODS AND RESULTS: A single-centre study prospectively included consecutive adult AF patients and non-AF controls managed from 1 April to 21 June 2019, who voluntarily and anonymously answered the TB questionnaire (TBQ) and 5-item EQ-5D QoL questionnaire; TB was calculated as a sum of TBQ points (maximum 170) and expressed as proportion of the maximum value. Of 514 participants, 331 (64.4%) had AF. The mean self-reported TB was 27.6% among AF patients and 24.3% among controls, P = 0.011. The mean TB was significantly higher in patients taking vitamin K antagonists (VKAs) vs. those taking non-VKA antagonist oral anticoagulants (NOAC; 29.5% vs. 24.7%, P = 0.006). The highest item-specific TB was reported for healthcare system organization-related items (e.g. visit appointment), diet, and physical activity modifications. On multivariable analyses, female sex, younger age, and permanent AF were associated with a higher TB, whereas NOACs and electrical AF cardioversion exhibited an inverse association; TB was an independent predictor of decreased QoL (all P < 0.05). CONCLUSION: Our study provided clinically relevant insights into self-perceived TB among AF patients. Approximately one in four patients with AF have a high TB. Specific AF treatments and optimization of healthcare system-required patient activities may reduce the self-perceived TB in AF patients.

Biochemical Markers for Prediction of Hypertensive Disorders of Pregnancy.

BACKGROUND: Gestational hypertension (GH) and pre eclampsia (PE) are the most common gestational complications. Several placental biochemical markers are used to predict GH/PE, but with conflicting results. METHODS: The study aim was to estimate the biochemical markers' ability to predict hypertensive disorders in pregnancy. On the first ultrasonographic examination, 104 healthy pregnant women were recruited. At the regular pregnancy check-ups, BMI, blood pressure, occurrence of gestational hypertension (early or late onset), preeclampsia, eclampsia and other complications were recorded. Serum concentrations (in multiples of median - MoM) of human chorionic gonadotropin (HCG) and pregnancyassociated plasma protein A (PAPPA) were measured from the 11th to 14th gestational week, while HCG, alpha feto protein (AFP), estriol and inhibin were determined between the 16th and 19th gestational week. RESULTS: Hypertensive disorders throughout pregnancy were diagnosed in 20.2% women. Early-onset GH was registered in 7 and PE in 6 patients, while 14 had late-onset GH and 10 additional women PE. There were no significant differences (p≥0.05) in biochemical markers concentrations between women with and without GH/PE. PAPPA levels in the first and HCG in the second trimester correlated with early and late GH/PE. Moreover, higher AFP concentrations were registered in women with preeclampsia signs/symptoms. According to ROC analysis, AFP>1.05 MoM properly identified 80% of GH/PE cases. Obtained models imply that HCG, PAPPA and AFP should be used for GH/PE prediction. CONCLUSIONS: Biochemical markers HCG, PAPPA and AFP could be useful in predicting gestational hypertension and preeclampsia. However, different markers should be used for early and late onset GH/PE.

Management and Outcome of Periprocedural Cardiac Perforation and Tamponade with Radiofrequency Catheter Ablation of Cardiac Arrhythmias: A Single Medium-Volume Center Experience.

INTRODUCTION: Cardiac tamponade (CT) is a life-threatening complication of radiofrequency ablation (RFA). The course and outcome of CT in low-to-medium volume electrophysiology centers are underreported. METHODS: We analyzed the incidence, management and outcomes of CT in 1500 consecutive RFAs performed in our center during 2011-2016. RESULTS: Of 1500 RFAs performed in 1352 patients (age 55 years, interquartile range: 41-63), 569 were left-sided procedures (n = 406 with transseptal access). Conventional RFA or irrigated RFA was performed in 40.9% and 59.1% of procedures, respectively. Ablation was performed mostly for atrioventricular nodal reentrant tachycardia (25.4%), atrial fibrillation (AF; 18.5%), atrial flutter (18.4%), accessory pathway (16.5%) or idiopathic ventricular arrhythmia (VA; 12.3%), and rarely for structural VA (2.1%). CT occurred in 12 procedures (0.8%): 10 AF ablations, 1 idiopathic VA and 1 typical atrial flutter ablation. Factors significantly associated with CT were older age, pre-procedural oral anticoagulation, left-sided procedures, transseptal access, AF ablation, irrigated RFA and longer fluoroscopy time (on univariate analysis), and AF ablation (on multivariable analysis). The perforation site was located in the left atrium (n = 7), right atrium (n = 3), or in the left ventricle or coronary sinus (n = 1 each). Upon pericardiocentesis, two patients underwent urgent cardiac surgery because of continued bleeding. There was no fatal outcome. During the follow-up of 19 ± 14 months, eight patients were arrhythmia free. CONCLUSION: Incidence of RFA-related CT in our medium-volume center was low and significantly associated with AF ablation. The outcome of CT was mostly favorable after pericardiocentesis, but readily accessible cardiothoracic surgery back-up should be mandatory in RFA centers.

Patient preferences at ten years following initial diagnosis of atrial fibrillation: the Belgrade Atrial Fibrillation Study.

BACKGROUND: Many atrial fibrillation (AF) patients have a poor understanding of the management of this condition. We investigated patient attitudes towards AF and a potential invasive treatment following an average 10-year period of prospective rhythm control in a cohort of newly diagnosed AF patients. METHODS: This was a prospective registry-based study. At the regular annual visit in 2007, patients were asked at random to answer several AF-related questions. RESULTS: Of 390 patients, 277 (71.0%) reported symptom reduction over time, but only 45 (11.5%) reported that they had "got used" to AF; 201 patients (51.5%) stated they would always prefer sinus rhythm, and 280 (71.2%) would accept an invasive AF treatment. Independent predictors for choosing an invasive procedure were younger age, impaired career/working capacity, and male gender (all P < 0.05). CONCLUSION: Our findings suggest that most AF patients prefer sinus rhythm and would readily accept an invasive procedure if it offered the possibility of a cure for their AF.

Brain natriuretic peptide predicts forced vital capacity of the lungs, oxygen pulse and peak oxygen consumption in physiological condition.

Brain natriuretic peptide (NT-pro-BNP) is used as marker of cardiac and pulmonary diseases. However, the predictive value of circulating NT-pro-BNP for cardiac and pulmonary performance is unclear in physiological conditions. Standard echocardiography, tissue Doppler and forced spirometry at rest were used to assess cardiac parameters and forced vital capacity (FVC) in two groups of athletes (16 elite male wrestlers (W), 21 water polo player (WP)), as different stress adaptation models, and 20 sedentary subjects (C) matched for age. Cardiopulmonary test on treadmill (CPET), as acute stress model, was used to measure peak oxygen consumption (peak VO2), maximal heart rate (HRmax) and peak oxygen pulse (peak VO2/HR). NT-pro-BNP was measured by immunoassey sandwich technique 10min before the test - at rest, at the beginning of the test, at maximal effort, at third minute of recovery. FVC was higher in athletes and the highest in W (WP 5.60±0.29 l; W 6.57±1.00 l; C 5.41±0.29 l; p<0.01). Peak VO2 and peak VO2/HR were higher in athletes and the highest in WP. HRmax was not different among groups. In all groups, NT-pro-BNP decreased from rest to the beginning phase, increased in maximal effort and stayed unchanged in recovery. NT-pro-BNP was higher in C than W in all phases; WP had similar values as W and C. On multiple regression analysis, in all three groups together, ΔNT-pro-BNP from rest to the beginning phase independently predicted both peak VO2 and peak VO2/HR (r=0.38, 0.35; B=37.40, 0.19; p=0.007, 0.000, respectively). NT-pro-BNP at rest predicted HRmax (r=-0.32, B=-0.22, p=0.02). Maximal NT-pro-BNP predicted FVC (r=-0.22, B=-0.07, p=0.02). These results show noticeable predictive value of NT-pro-BNP for both cardiac and pulmonary performance in physiological conditions suggesting that NT-pro-BNP could be a common regulatory factor coordinating adaptation of heart and lungs to stress condition.

Correlation of biochemical parameters and neonatal outcome in patients with gestational hypertension.

Hypertensive disorders in pregnancy are one of the leading causes of maternal death in the world and one of the major causes of perinatal mortality. The incidence of hypertensive disorders in pregnancy is 8%-15%. Significant changes of biochemical parameters in cases of hypertensive disorders in pregnancy are increased levels of blood glucose, urea, creatinine, uric acid (hyperuricemia), transaminases, and LDH. The most increased is the level of proteinuria. Bad laboratory results and the intensification of clinical signs, with multiorgan dysfunction, are indications for termination of pregnancy.

[Long-term follow-up after catheter-ablation of atrioventricular junction and pacemaker implantation in patients with uncontrolled atrial fibrillation and heart failure].

INTRODUCTION: Atrioventricular (AV) junction ablation coupled with pacemaker implantation is an effective therapeutic option for rate control in atrial fibrillation (AF) and heart failure (HF). However, there is controversy regarding the long-term outcome of the procedure, since right ventricular stimulation can lead to left ventricular remodelling and HF. OBJECTIVE: The aim of the study was to determine a 5-year outcome of the procedure on survival, HF control and myocardial function in patients with HF and uncontrolled AF. METHODS: All patients with AF and HF who underwent AV-junction ablation with pacemaker implantation in our institution were followed after the procedure. HF diagnosis was established if > or = 2 of the following criteria were present: 1) ejection fraction (EF) < or = 45%; 2) previous episode of congestive HF (CHF); 3) NYHA-class > or = 2; and 4) use of drug-therapy for HF. RESULTS: Study included 32 patients (25 males; 53.4 +/- 9.6 years). The mean heart rate was 121 +/- 25 bpm before and 75 +/- 10 bpm after ablation (p=0.001). Over the follow-up of 5.0 +/- 4.0 years nine patients (28.1%) died (five died suddenly, three of terminal CHF and one of stroke). After the procedure, CHF occurrence was reduced (p=0.001), as well as the annual number of hospitalizations (p=0.001) and the number of drugs for CHF (p=0.028). In addition, NYHA-class and EF were improved, from 3.3 +/- 0.7 to 1.6 +/- 0.8 (p<0.001) and from 39 +/- 11% to 51 +/- 10% (p<0.001), respectively. CONCLUSION: In HF patients with uncontrolled AF, 5-year mortality after AV-junction ablation and pacemaker implantation was 28%. In the majority of these patients good rate of AF and HF control were achieved, as well as the improvement of functional status and myocardial contractility.

The occurrence of new arrhythmias after catheter-ablation of accessory pathway: delayed arrhythmic side-effect of curative radiofrequency lesion?

INTRODUCTION: New arrhythmias (NA) may appear late after accessory pathway (AP) ablation, but their relation to curative radiofrequency (RF) lesion is unknown. OBJECTIVE: The aim of this study was to determine the prevalence and predictors for NA occurrence after AP ablation and to investigate pro-arrhythmic effect of RF. METHODS: Total of 124 patients (88 males, mean age 43 +/- 14 years) with Wolff-Parkinson-White syndrome and single AP have been followed after successful RF ablation. Post-ablation finding of arrhythmia, not recorded before the procedure, was considered a NA. The origin of NA was assessed by analysis of P-wave and/or QRS-complex morphology, and, thereafter, it was compared with locations of previously ablated APs. RESULTS: Over the follow-up of 4.3 +/- 3.9 years, NA was registered in 20 patients (16%). The prevalence of specific NAs was as follows: atrioventricular (AV) block 0.8%, atrial premature beats 1.6%, atrial fibrillation 5.4%, atrial flutter 0.8%, sinus tachycardia 4.8%, ventricular premature beats (VPBs) 7.3%. Multivariate Cox-regression analysis identified (1) pre-ablation history of pathway-mediated tachyarrhythmias >10 years (HR = 3.54, p = 0.016) and (2) septal AP location (HR = 4.25, p = 0.003), as the independent predictors for NA occurrence. In four NA cases (two cases of septal VPBs, one of typical AFL and one of AV-block) presumed NA origin was identified in the vicinity of previous ablation target. CONCLUSION: NAs were found in 16% of patients after AP elimination. In few of these cases, late on-site arrhythmic effect of initially curative RF lesion might be possible. While earlier intervention could prevent NA occurrence, closer follow-up is advised after ablation of septal AP.

Irrigated-tip vs. conventional-tip catheters for primary ablation of posteroseptal and right free-wall accessory pathways: a prospective randomized study.

BACKGROUND: The use of irrigated-tip catheters enables elimination of almost all accessory pathways (APs) resistant to standard radiofrequency ablation (RFA). However, efficacy of irrigation catheter technology in the initial AP ablation has not been studied systematically yet. OBJECTIVES: We tested whether the externally irrigated-tip catheters are more effective than the conventional-tip catheters for initial RFA of the posteroseptal and right free-wall APs, i.e., where application of the conventional RFA is expected to have a lower success rate. METHODS: Fifty consecutive patients (39 +/- 12 years, 32 males), who were subjected to primary catheter-ablation of the posteroseptal or right free-wall AP were randomly assigned to RFA with an externally irrigated-tip catheter (group I, n = 25; 45 degrees C/40 W outside the coronary sinus (CS) and 45 degrees C/30 W inside the CS) or a conventional-tip catheter (group C, n = 25; 60 degrees C/60 W outside and 55 degrees C/35 W inside the CS). RESULTS: No significant difference was identified between groups I and C with respect to acute success rate (88% vs. 96%), number of radiofrequency applications (6.8 +/- 4.7 vs. 6.1 +/- 4.3), RFA time (373 +/- 242 sec vs 365 +/- 241 sec), energy (11,022 +/- 7833 J vs. 12,870 +/- 11,414 J), fluoroscopy time (669 +/- 443 sec vs. 789 +/- 578 sec) and recurrence rate (18.2% vs. 16.7%). The only complication was encountered in group I, manifested as AV-block I-II degree after elimination of the right posteroseptal AP. CONCLUSIONS: Irrigated-tip catheters are not more efficient than conventional catheters in initial RFA of the posteroseptal and right free-wall APs. Therefore, the use of irrigated-tip catheters is justifiable only for ablation of the APs resistant to previously attempted conventional RFA.

[Frequent unifocal ventricular premature contractions that caused dilated cardiomyopathy: resolution of myocardial function after successful catheter-ablation of arrhythmia focus].

INTRODUCTION: In patients with dilated cardiomyopathy (DCM) and frequent ventricular premature beats (VPBs) it may be difficult to evaluate whether ventricular arrhythmia is the cause or consequence of heart failure. However, it is very important to recognize VPBs as a potentially reversible cause of myocardial dysfunction, because arrhythmia suppression in these patients may lead to recovery of myocardial contractility. CASE OUTLINE: An asymptomatic 24-year-old man with DCM and frequent VPBs of left bundle branch morphology with inferior axis was referred to our Department for further evaluation. Echocardiographic examination showed left ventricular dilation with reduced ejection fraction to 40%, while 24 h Holter-monitoring recorded 31,000 isolated VPBs refractory to drug treatment. During the electrophysiologic study a VPBs' focus in the right ventricular outflow tract was identified which was successfully resolved by radiofrequency catheter-ablation. Immediately after the procedure, considerable suppression of VES number to 2500/24 h was confirmed by Holter-recording, while complete recovery of left ventricular function was detected one month later by echocardiographic re-examination. CONCLUSION: Recognition of causal-resultant relation between frequent VPBs and progressive myocardial dysfunction is of primary importance for adequate treatment. Although it has been believed for a long time that idiopathic ventricular arrhythmia, in otherwise healthy persons, has a benign prognosis, there is evidence that frequent VPBs may present a reversible cause of DCM. In these patients catheter-ablation of arrhythmic focus is strongly recommended, because soon after the successful procedure recovery of myocardial function can be expected.

[Newborns from deliveries with epidural anaesthesia].

INTRODUCTION: The use of epidural anaesthesia in delivery with the purpose to reduce pain and fear in a pregnant woman has the influence on the physiological status of the woman in childbirth and the course of delivery. From the epidural space of the pregnant woman, one part of free anaesthetic comes in the foetal circulation through the mother's circulation and placenta and connects with the foetal proteins. A lower value of albumins and serum proteins in the foetal circulation give bigger free fraction of anaesthetic which is accumulated in the foetal liver, brain and heart full of blood. OBJECTIVE: The aim of the study was to examine the influence of epidural anaesthesia on the newborn. METHODS: Retrospective study of 6398 documents of newborns was performed in our Clinic of Gynaecology and Obstetrics "Narodni front" during 2006. The first group was made of 455 newborns from deliveries with epidural anaesthesia and the second was the control group of 5,943 remaining newborns. In both groups we analysed the following: sex, week of gestation, weight, Apgar score, measure of care and resuscitation, perinatal morbidity and then the obtained results were compared. RESULTS: Most of deliveries were vaginal without obstetric intervention (86.6%). The number of deliveries finished with vacuum extractor (4.6%) was statistically significantly bigger in the group with epidural anaesthesia than in the control group. Most of the newborns in the first group were born on time (96.5%) in 39.0 +/- 1.0 week of gestation and with foetal weight 3448 +/- 412 grammes. There was no statistical significance in Apgar score between both groups. Epidural anaesthesia does not increase the degree of the newborn's injury. Lower pH of blood was found in the newborns from deliveries with vacuum extractor or operated on (the Ceasarean section). CONCLUSION: Application of epidural anaesthesia decreases duration of delivery and has no adverse effects on the newborn and hypoxic encephalopathy is lower.

[Recurrence of atrial fibrillation after successful radiofrequency catheter ablation of accessory pathway in patients with Wolff-Parkinson-White syndrome].

INTRODUCTION: Paroxysmal atrial fibrillation (AF) occurs in 11.5-39% of the patients with Wolff-Parkinson-White (WPW) syndrome and frequently, but not always, disappears after successful accessory pathway (AP) ablation. OBJECTIVE: To determine AF recurrence rate, time to AF recurrence and predictors of AF recurrence after radiofrequency (RF) catheter-ablation of AP in WPW-patients with AF. METHODS: Data from 245 consecutive patients with WPW-syndrome who underwent RF catheter-ablation of AP were analysed. A total of 52 patients (43 men, mean age: 42.5 +/- 14.1 years) with preablation history of spontaneous AF were followed up after definitive AP ablation. At baseline, structural heart disease and comorbidities were diagnosed in 19.2% and 21.2% of the patients, respectively. RESULTS: During the follow-up of 5.2-3.7 years, 3 patients (5.7%) died; one of these patients, previously known for recurrent AF, died from ischaemic stroke. Symptomatic recurrence of AF was detected in 9 of 52 patients (17.3%). In 66.7% of these patients, AF recurrence was identified in the first year following the procedure. Kaplan-Meier analysis demonstrated that freedom from recurrent AF after 3 months was 94.2%, after 1 year 87.5% and after 4 years 84.3%. Univariate analysis showed that older age (p = 0.023), presence of structural heart disease (p = 0.05) and dilated left atrium (p = 0.013) were significantly related to AF recurrence. However, using multivariate Cox regression, older age was the only independent predictor of AF recurrence (HR = 2.44 for every life decade; p = 0.006). Analysis of ROC curves showed that, after the age of 36, the risk of AF recurrence abruptly increased. CONCLUSION: Symptomatic recurrence of AF was detected in 17% of WPW-patients after definite RF ablation of AP. The time-dependent occurrence of AF recurrences and age-dependent increase in the rate of AF recurrence were identified. Closer follow-up and/or extension of drug therapy in older patients, at least in the first year after the procedure, seem prudent.

[Relationship between mortality of patients with atrial fibrillation and mortality of general population in Serbia].

INTRODUCTION: Large population-based observational trials have shown atrial fibrillation (AF) to be an independent risk factor for increased mortality. OBJECTIVE: To examine all-cause mortality and cardiovascular mortality of patients with AF compared to corresponding mortality in general population of Serbia. METHODS: This longitudinal observational study included patients with nonvalvular AF as the main indication for in-hospital and/or outpatient treatment at the Clinical Centre of Serbia, Belgrade, during the period 1992-2007, if the latest date of the first diagnosed AF was early January 2003, so that the total follow-up could last at least 5 years (minimum 1 year prospectively), or until death. Patients with acute causes of AF, advanced left ventricular systolic dysfunction (LVEF < or = 25%), preexcitation, known malignancy or any advanced chronic disease and patients with poorly documented history of previous AF were not included. To compare mortality of study population with mortality of general population, we used standardized mortality ratio (SMR) and chi-square test, p < 0.05. RESULTS: Out of 1100 patients (389 females, 35.4%), aged 52.7 +/- 12.2 years, with total follow-up 9.94 +/- 6.05 years (prospective 5.75 +/- 4.28, retrospective 4.21 +/- 5.51), 40% had no underlying disease; others most frequently had arterial hypertension. AF was paroxysmal in 665 (60.5%), persistent in 225 (20.5%) and permanent in 210 patients (19.1%). Newly diagnosed AF was documented in 1058 patients (96.2%). Until the end of the study, 85 patients died (7.7%). Cardiovascular death was noted in 62 patients (72.9%), most frequently in form of sudden death (27/85, 31.7%), death from congestive heart failure (18/85, 21.2%) and stroke (14/85, 16.5%). Most patients (67/85, 78.8%) had AF at the time of death. SMR for all-cause mortality was 2.43 (p < 0.0001) and for cardiovascular mortality 3.03 (p < 0.0001). CONCLUSION: All-cause mortality and cardiovascular mortality of AF patients are higher than corresponding mortality in general population of Serbia, despite active treatment.

[The role of the accessory pathway radiofrequency catheter ablation in the secondary prevention of the malignant tachyarrhythmias in patients with Wolff-Parkinson-White syndrome].

BACKGROUND/AIM: The occurrence of atrial fibrillation (AF) in the presence of an accessory pathway (AP) that conducts rapidly is potentially lethal because the rapid ventricular response may lead to ventricular fibrillation (VF). The aim of the study was to determine long-term efficacy of AP catheter-ablation using radiofrequency (RF) current in secondary prevention of VF in WPW patients. METHODS: Study included a total of 192 symptomatic WPW patients who underwent RF catheter-ablation of AP in our institution from 1994 to 2007 and were available for clinical follow-up for more than 3 months after procedure. RESULTS: Before ablation, VF was recorded in total of 27 patients (14.1%). In 14 of patients (51.9%) VF was the first clinical manifestation of WPW syndrome. A total of 35 VF episodes were identified in 27 patients. The occurence ofVF was preceded by physical activity or emotional stress in 17.1% of cases, by alcohol abuse in 2.9% and by inappropriate intravenous drug administration in 28.6%. In addition, no clear precipitating factor was identified in 40% of VF cases, while informations about activities preceding 11.4% of VF episodes were not available. The follow-up of 5.7 +/- 3.3 years was obtained in all of 27 VF patients. Of the 20 patients who underwent successful AP ablation, all were alive, without syncope or ventricular tachyarrhythmias during long-term follow-up. In 4 of 7 unsuccessfully treated patients, recurrence of supraventricular tachycardia and/or preexcited atrial fibrillation were recorded; one of these patients suddenly died of VF, 6 years after procedure. CONCLUSION: In significant proportion of WPW patients, VF was the first clinical manifestation of WPW syndrome, often precipitated by physical activity, emotional stress or inappropriate drug administration. Successful elimination of AP by percutaneous RF catheter-ablation is highly effective in secondary prevention of life-threatening tachyarrhythmias in patients with ventricular preexcitation.