HOT CRT-The Effective Combination of Conventional Cardiac Resynchronization and His Bundle Pacing.

Background and Objectives: Cardiac Resynchronization Therapy (CRT) has, besides its benefits, various limitations. For instance, atrial fibrillation (AF) has a huge impact on the therapy efficacy. It usually reduces the overall BiV pacing percentage and leads, inevitably, to lack of fusion beats. In many patients with heart failure that could benefit from resynchronization, the QRS morphology is often IVCD and atypical, or non-LBBB, which further diminishes the CRT response. In those cases, we established His pacing combined with LV pacing as a feasible option to reduce the impact of AF on the CRT response and regain partially physiological ventricular activation to improve the electromechanical sequence. Materials and Methods: We implanted two patients with AF, HF, EF < 35%, NYHA II-III and QRS > 150 ms with CRT-D systems modified to HOT-CRT and observed their clinical, ECG and echocardiographic improvements over a follow-up period of three months. Results: In both patients we observed improvements of the initial parameters. We were able to shorten the QRS duration to approx. 120 ms, improve NYHA functional class, increase the EF by approximately 12% and distinctly reduce mitral regurgitation. Conclusion: Since the conventional CRT reaches its limits within this specific patient group, we need to consider alternative pacing sites and the effective combination of them. Our results and respectively other studies that are also mentioned in the current guidelines, support the feasibility of HOT-CRT in the above mentioned patient group.

The clinical utility of direct His-bundle pacing in patients with heart failure and permanent atrial fibrillation.

In patients with significantly impaired left ventricle function permanent atrial fibrillation (AF) often coexists with symptoms of heart failure. Based on various studies, it is assumed that in patients with heart failure in functional class III and IV AF occurs in 40-50% of patients. AF adversely affects cardiac hemodynamics, and its harmfulness increases particularly in the failing heart. The lack of mechanical function of the left atrium, the usually fast ventricular rate and the irregular sequence of ventricular contraction constitute the spectrum of harmful effects of this arrhythmia. Therefore, the only way to address the underlying problem of AF, which is irregular ventricular rhythm, is to pace the ventricles and to slow or block the AV conduction. Classic, right ventricular pacing is contraindicated in this population as it promotes the abovementioned disorders by initiating additional dyssynchrony of left ventricular contraction with reduction of its contractility and aggravation of AF-related mitral regurgitation. The possibility of direct His bundle pacing (DHBP) significantly extended the clinical armamentarium of cardiac pacing. The restoration of the physiological electrical activation could significantly contribute to echocardiographic and clinical improvement. With time and the development of dedicated tools for direct His bundle pacing the success rate of implantations became more than 90% and the acceptable pacing thresholds under 2.0 V (1 ms) could be achieved in most patients. This contributed to the broader clinical application of DHBP in different patient' groups with various pacing indications. The authors of the paper discuss different electrocardiographic and clinical indications for DHBP.

Diagnosis of atrial fibrillation in heart failure patients with implantable cardioverter defibrillator or cardiac resynchronisation therapy.

INTRODUCTION: Implantable cardioverter defibrillators register various types of arrhythmias. Thus they can be exploited to better identify patients with atrial fibrillation episodes and increase the proportion of patients who may benefit from implementation of pharmacological prophylaxis of thromboembolic events, most of which are asymptomatic. The aim of the study was to assess of the frequency, symptoms and predisposing factors for the occurrence of atrial fibrillation episodes in patients with an implanted implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy with defibrillator (CRT-D) based on the analysis of intracardiac electrocardiograms (EGM/IEGM) records. MATERIAL AND METHODS: The study included 174 consecutive outpatients with heart failure, sinus rhythm and an implanted cardioverter defibrillator and cardiac resynchronisation therapy with defibrillator. Follow-up visits with analysis of IEGM records occurred every 3 months. During a mean follow-up of 20 months, 901 visits were carried out. One hundred forty-seven patients had at least 1 year of follow-up. RESULTS: Atrial fibrillation episodes in the study group occurred in 54 (31.0%) patients and 71.4% were asymptomatic. Predisposing factors were: history of paroxysmal atrial fibrillation (37.0% vs. 13.3%, p < 0.001), atrioventricular conduction abnormalities (42.6% vs. 20.0%, p = 0.002), intraventricular conduction abnormalities (59.3% vs. 40.8%, p = 0.02) and more severe mitral regurgitation (7.4% vs. 0.8%, p = 0.04). Chronic renal disease was a risk factor for death in the study group. No stroke occurred during the study. CONCLUSIONS: Episodes of paroxysmal atrial fibrillation in patients with systolic heart failure and implanted cardioverter-defibrillator systems are quite common. The majority of the episodes recorded in the study were asymptomatic.

Excision of a part of the bile duct as an iatrogenic injury typical for laparoscopic cholecystectomy - characteristics, treatment and long-term results, based on own material.

INTRODUCTION: Cholecystectomy is associated with the risk of bile duct injury (BDI). The nature of the injury in laparoscopic cholecystectomy (LC) cases seems to be more serious. AIM: We present an analysis of long-term results of the treatment of patients who underwent operations at our department due to iatrogenic excision of a part of the bile duct (EPBD). MATERIAL AND METHODS: Out of all 120 patients treated for BDI in our department we selected a group of 40 with EPBD. In all cases the corrective operation was hepaticojejunostomy. The median follow-up time was 157 (56-249) months. We evaluated risk factors for EPBD during LC compared to open cholecystectomy (OC). RESULTS: Among bile duct injuries referred to our centre, EPBD occurred more frequently during LC (46.7%) compared to OC (11%), p < 0.001. Injuries located in the hepatic hilum occurred more often in the case of LC (68.6%) than OC (20%), p = 0.056. We did not find a difference in the frequency of EPBD between LC and OC groups depending on the presence of acute or chronic cholecystitis. The narrow common hepatic duct was reported more frequently in the LC (68.6%) vs. OC (20%) group, p = 0.056. Satisfactory long-term reconstructive treatment results were observed in 36 (90%) of 40 patients. CONCLUSIONS: Excision of a part of the bile duct occurs more often during LC than OC. It is often located in the hepatic hilum. Presence of a narrow common hepatic duct is a risk factor for EPBD during LC. Large diameter hepaticojejunostomy is a reconstructive procedure that promises good long-term results.

The impact of selected factors on parameters of weight loss after sleeve gastrectomy.

INTRODUCTION: The effectiveness of sleeve gastrectomy has been confirmed in many studies. The impact of individual factors on the parameters of weight loss is still not clear. AIM: To identify important factors affecting the parameters of weight loss after sleeve gastrectomy. MATERIAL AND METHODS: The impact of prognostic factors and postoperative care components on body mass index (BMI) and percentage excess weight loss (%EWL) was assessed in a group of 100 consecutive patients who underwent laparoscopic sleeve gastrectomy. RESULTS: The baseline BMI and body mass in patients with BMI < 30 kg/m2 and BMI ≥ 30 kg/m2 12 months after surgery were, respectively, 39.7 ±3.2 vs. 45.9 ±4.6 kg/m2, p < 0.0001, and 114.4 ±16.8 vs. 130.3 ±18.5 kg, p < 0.0001. In the group with EWL < 50%, the average age was 47.1 ±7.7 vs. 40.6 ±10.8 in the group with EWL ≥ 50%, p = 0.0025. In the group of patients with preoperative weight loss, %EWL was 61.4 ±17.2 vs. 53.3 ±19.3% in the group with no weight loss, p = 0.0496. Body mass index of the patients who started physical activities was 30.6 ±4.2 kg/m2 vs. 34.0 ±5.6 kg/m2 in the patients with no physical activity, p = 0.0013, and %EWL was 63.4 ±14.6 vs. 47.0 ±19.9%, p < 0.0001, respectively. In the case of patients regularly consulted by a dietician BMI was 30.6 ±4.2 kg/m2 vs. 35.1 ±5.5 kg/m2 in the group without systematic consultations, p < 0.0001, and %EWL was 63.1 ±15.1% vs. 42.3 ±18.2%, p < 0.0001. CONCLUSIONS: Lower baseline body weight parameters, younger age, preoperative weight loss, starting systematic physical activities and constant care of a dietician were conducive to achieving better results of surgery, as assessed on the basis of changes in BMI and %EWL.

Laparoscopic abdominoperineal resection of the rectum - how is it done; initial results.

UNLABELLED: The abdominoperineal resection of the rectum is a classical operation performed in case of patients diagnosed with rectal cancer. The development of laparoscopic techniques in recent years, introduced yet another method of treatment, considering patients with rectal cancer- laparoscopic abdominoperineal resection of the rectum. The aim of the study was to present initial treatment results considering the above-mentioned patients. MATERIAL AND METHODS: The study group comprised 25 patients (16 male and 9 female) diagnosed with low-rectal cancer, subjected to surgery by means of the above-mentioned method. Mean patient age amounted to 66 years. Three (12%) patients required conversion to classical surgery (laparotomy), while one patient required reoperation, due to presacral vascular bleeding. Complications were observed in 10 (40%) patients. Average hospitalization was 7 days. In case of all patients the radial margin was negative, and mean number of removed lymph nodes amounted to 9.6. Mortality was not observed during the perioperative period. Due to the initial character of the study analysis (mean observation period in case of 68% of patients was shorter than 2 years), oncological results were not subject to evaluation. CONCLUSIONS: Laparoscopic abdominoperineal resections are considered as technically difficult operations, requiring significant experience of the operating team. However, they enable the patient to take advantage of the many assets of minimally invasive surgery, with comparable rates of postoperative complications.

Prospective evaluation of pain control and quality of life in patients with chronic pancreatitis following bilateral thoracoscopic splanchnicectomy.

BACKGROUND: Abdominal pain in chronic pancreatitis (CP) is the most common symptom with a highly unfavorable impact on the quality of life. It has been shown that bilateral thoracoscopic splanchnicectomy (BTS) may produce marked pain relief for the majority of patients. The aim of this study was to evaluate the effectiveness of BTS in pain control and quality-of-life improvement in patients with a severe form of CP. METHODS: Between April 2000 and April 2009, a total of 30 patients qualified for BTS due to CP-related pain. Their age ranged from 28 to 60 years. A 12-month follow-up period was planned for all the patients enrolled. To evaluate effectiveness of BTS, an 11-point Numeric Rating Scale (NRS) and the Quality of Life Questionnaire C-30 (QLQ-C30) in its basic form, developed by European Organization for Research and Treatment of Cancer, were used. An NRS value between 0 and 3 was considered a positive postoperative pain control result. RESULTS: The bilateral splanchnicectomy procedure was performed successfully in 27 of 30 qualified patients. A positive effect based on decreased pain (p < 0.05) at 12 months was achieved in 24 patients (80 %). The initial change in quality of life was not significant but it gradually improved with time (preop vs. 12 months QLQ-C30 score, p < 0.001). CONCLUSIONS: This study showed that BTS is safe and efficacious for pain alleviation in patients with severe CP. It may significantly increase the chances of a long-lasting, life-changing improvement in the quality of life.