[Measurement dispersion of the QT interval and its significance in different diseases]. / Pomiar dyspersji odstepu QT i jej znaczenie w róznych schorzeniach.

QT dispersion reflects in homogenecity of ventricular repolarization. It is calculated using 12-leads standard synchronized ECG or 24-hours Holter monitoring. The most common used indicators are: QT dispersion (QTd), based on Bazett's formula corrected for heart rate QT dispersion (QTcd) and QT dispersion ratio (QTdR). QT apex and QTd corrected for total number of leads ECG in which QT interval was counted are rare used. Increased QT dispersion is observed among others: following myocardial infarction (MI), coronary heart disease (CAD), hypertension, chronic heart failure (CHF), long QT syndrome, as well as diabetes. Following mentioned diseases increased QT dispersion has prognostic value for sustained ventricular tachycardia. Dispersion of repolarization > or = 80 ms after MI is a risk factor for sudden cardiac death. Following acute MI decrease of QT dispersion after successful thrombolytic therapy is observed and its value > or = 100 ms is regarded as a marker of reperfusion insufficiency. QT dispersion in patients with CAD correlates with extent of ischemia and decreases after coronary angioplasty (PTCA). In recent years beneficial effect of angiotensin-converting enzyme inhibitors and beta-adrenolytic therapy on QT dispersion was described. Actually the improvement of computerised methods in assessment of QT dispersion is observed, but it require further investigations.

[Tachycardia-induced cardiomyopathy]. / Arytmogenna kardiomiopatia rozstrzeniowa.

Dilated cardiomyopathy induces circulatory insufficiency with poor prognosis. Persistent tachyarrhythmias may be the cause of this disease. At particular high risk for heart damage and insufficiency are young people and children. The group of most dangerous arrhythmias consist of: incessant tachycardia in patients with preexcitation syndrome and supraventricular tachyarrhythmias (atrial flutter and fibrillation, ectopic atrial tachycardia) with high rate of ventricles. The result of arrhythmias is dilatation of the heart and thinness of ventricular walls with hemodynamic disorders. The effective therapy of arrhythmias--ablation of the accessory pathway in patients with pre-excitation syndrome or reversion to sinus rhythm (pharmacological or electric cardioversion) in patients with atrial fibrillation and flutter, often leads to normalisation of heart ejection function and diameter. Therefore it exist important question: is dilated cardiomyopathy the cause or consequence of tachyarrhythmias? Causative antiarrhythmic therapy in these second cases gives a possibility to improve the prognosis in patients with such a disease.

[Atrial flutter: causes, electrophysiological characteristics, treatment with radiofrequency catheter ablation]. / Trzepotanie przedsionków--przyczyny, charakterystyka elektrofizjologiczna, leczenie za pomoca ablacji pradem o czestotliwosci radiowej.

Atrial flutter (TP) is one of the most common supraventricular tachyarrhythmias. Because of its influence on hemodynamics of the circulation, prolonged episode of paroxysmal TP can lead in as many as 1/3-1/2 patients to clinical signs of coronary insufficiency, decompensation of the circulatory system, or even such life-threatening states, like cardiac arrest. Patients with preexcitation syndrome, hyperthyroidism, as well as children, whose atrio-ventricular (AV) node can conduct in a 1:1 fashion, are in the group of particularly high risk of complications. Recurrent episodes of TP are also associated with frequent occurrence of thromboembolic events. Based on the electrocardiographic (ECG) pattern TP is divided into common type, with negative "sawtooth" in leads II, III, aVF, and uncommon type, which is characterised by other ECG morphologies. Experimental and clinical data have revealed, that common and some part of uncommon type are due to clockwise or counterclockwise reentry in the right atrium. These forms of TP can be treated with high success-rate with radiofrequency (CR) ablation. Because of difficulties in pharmacological conversion of the arrhythmia to the sinus rhythm and high frequency of recurrences, CR ablation seems to be a high effective method of treatment in patients with common and some forms of uncommon TP.

[Radiofrequency ablation of accessory pathway's atrial insertion site]. / Ablacja pradem o czestotliwosci radiowej ujscia przedsionkowego dodatkowych szlaków przewodzenia.

Brought into clinical practice in 80, method of radiofrequency catheter ablation (RFCA) enabled possibility of causative treatment in patients with preexcitation syndrome. RFCA may be performed utilizing various techniques, choice of one of them depends on experience and preference of the operator. Aim of the study was assessment of efficacy and safety of RFCA targeting accessory pathway's atrial insertion site with help of unipolar signals from ablation-catheter with regard to various localizations of accessory pathways. Material and method studied population consisted of consecutive 149 patients with symptomatic, drug-resistant WPW-syndrome, which were admitted to our Center for electrophysiologic study and RFCA. From the studied population two groups were subdivided: patients with left-sided (group I, n = 112) and right-sided (group II, n = 37) accessory pathway. Every patient underwent electrophysiological study with use of four diagnostic electrodes and after preexcitation was confirmed RFCA was undertaken. In case of left-sided accessory pathway transseptal puncture was performed. Analyzed parameters were: total duration, fluoroscopy-time, number of current-applications during RFCA, as well as success-rate, complications and recurrences after successful ablation. Patient in both groups did not differ significantly with respect to age and sex. Success-rate was insignificantly higher in gr.I (92.8%) than in gr.II (86.5%), as was RFCA-duration (136.4 min versus 123.6 min). We found significant differences in fluoroscopy-time, which was longer in gr.I (37.2 min versus 28.4 min, p < 0.05). Complications occurred in 1 patient in each group. RFCA aiming at accessory pathway's atrial insertion site with use of unipolar tracings from ablation-catheter is safe and effective method of treatment in WPW-patients.

[Use of intravascular ultrasonography (IVUS) for diagnosis and treatment of coronary artery disease--case report]. / Zastosowanie ultrasonografii wewnatrznaczyniowej (IVUS) w diagnostyce i leczeniu choroby niedokrwiennej serca--opis przypadku.

One of the additional methods of coronary artery assessment is intravascular ultrasound (IVUS). Contrary to coronary angiography this relatively new technic provides new information including precise calculations of stenosis degree, morphology of atheromatous plaque and differentiation of its structure. Coronary angiography was performed in 54 years old male patient with unstable angina, revealing 99% stenosis in distal RCA. Discrepancy between clinical presentation and angiographic findings and exercise test resulted in performing IVUS of LAD. Angiographically clear LM and LAD were found to be narrowed 52% and 58% on IVUS. Subsequent CABG resulted in symptoms withdrawal and increase of physical tolerance. Exercise test after CABG did not reveal ischaemia in area of LCA at 10 METs. IVUS is found to be an important technic in assessment of silent or ambiguous lesions and in many cases allows to choose the optimal method of treatment of coronary artery disease.

[Dispersion of the QT interval in unstable angina pectoris]. / Dyspersja odstepu QT w niestabilnej chorobie wiencowej.

UNLABELLED: Increased dispersion of the QT interval is a risk factor of sudden cardiac death. In unstable angina pectoris (UA) a few authors described QT dispersion. The aim of the study was to assess QT dispersion in patients with UA in comparison to the healthy subjects and analysis QT dispersion according to the presence during in-hospital stay significant cardiac events like: death due to cardiological causes, myocardial infarction and urgent revascularization. Study group consisted of 54 patients with UA in a class IIIB of Braunwald classification (18 women, 36 men, mean age: 58.2 +/- 9.6 years). In 40 patients after pharmacological treatment stabilization in the first three days of hospitalization was achieved and during in-hospital stay significant cardiac events were not observed--group I. In 14 patients during in-hospital stay significant cardiac events were present, including 5 death due to cardiological causes--group II. During first two days of hospitalization coronary angiography was performed in all patients. The control group comprised 25 healthy subjects (8 women, 17 men, mean age 56.4 +/- 6.1 years). On admission to the hospital in all patients and in control group, using standard 12-leads ECG, following parameters were calculated: QT dispersion (QTd), corrected QT dispersion based on Bazett's formula (QTcd) and QT dispersion ratio (QTdR). In the study group as well as in group I and II values of QTd, QTcd and QTdR were significantly higher than in healthy subjects. In group I all the QT parameters were significantly lower than in group II (QTd: 56.8 +/- 11.2 vs 68.6 +/- 16.6 ms, p = 0.002). The highest value of QT dispersion was found in patients who died during in-hospital stay and it was significantly higher than in survivors (86.0 +/- 13.4 vs 57.1 +/- +/- 10.6 ms, p = 0.004). A cut-off value for QTdR > or = 9% identified patients with high risk of sudden cardiac death. CONCLUSIONS: QT dispersion analysis in unstable angina pectoris allows to distinguish patients according to the risk of sudden cardiac death. Patients with high risk of sudden cardiac death identify the best QTdR.

[The assessment and clinical significance of heart rate variability]. / Metody oceny i znaczenie kliniczne zmiennosci rytmu zatokowego.

Heart rate variability (HRV) is a phenomenon to generation through the sinus node consecutive impulses in the different succession. HRV is regarded as a marker of autonomic nervous system tone of the heart. To assess HRV following methods: time domain, frequency domain and non-linear analysis are known. Time domain parameters correlate with frequency domain parameters. Some parameters can be used substitution, particularly reflect parasympathetic activity: rMSSD, pNN50 and HF. In clinical practice the most useful is time domain analysis based on 24-hours ecg Holter monitoring. Among time domain parameters the most significant prognostic value has SDNN. Decreased HRV following many diseases has been described. Significant prognostic value of decreased HRV after myocardial infarction (MI) and in patients with chronic heart failure (CHF) has been proved. Decreased HRV after MI is independent as well as ejection fraction (EF) sudden cardiac death risk factor. In patients with SDNN value below 50 ms high risk of cardiac death is observed. SDNN should be estimated on 7th day of MI to evaluate patients with high risk of sudden cardiac death. In patients after MI with ventricular tachycardia (VT) before VT decreased HRV is described. During MI beneficial influence of infarct-related artery patency on HRV is observed. HRV correlates with EF and infarct site too. HRV in patients with CHF correlates with EF and functional severity of CHF. Correlation between decreased HRV and increased mortality in CHF has been shown. In diabetic patients decreased HRV is observed. Following diabetes examination of HRV is useful to estimate early phase of autonomic neuropathy. Increase HRV parameters is observed in the course of beta-adrenolytic and converting enzyme inhibition treatment. In other diseases, including heart transplantation prognostic value of HRV and its clinical significance are still investigated.

[Right ventricular infarction]. / Zawal prawej komory serca.

Right ventricle infarction (RVI) is not a rare clinical entity. It complicates approximately half of inferolateral myocardial infarctions. Under the term RVI we can find mild, asymptomatic dysfunction of right ventricle and cardiogenic shock as well. RVI is associated with increased mortality and its presence obliged us to qualify patient to a high risk group. Diagnosis is based on clinical signs, electrocardiographic findings, hemodynamic measurements and echographic evaluations. The proper treatment of RVI requires support of right ventricle preload with fluid administration, maintainance of atrio-ventricular synchrony, reduction of right ventricle afterload. Early reperfusion with fibrinolytic therapy and coronary angioplasty should be regarded as the prior methods of treatment RVI. Patients who survive RVI have complete resolution of hemodynamic abnormalities with restoration of proper right ventricle function.

[Radiofrequency catheter ablation of two accessory pathways in patients with WPW Syndrome]. / Ablacja pradem o czestotliwosci radiowej dwóch dróg dodatkowych u chorego z zespolem preekscytacji.

In 10-30% patients with WPW syndrome more than one accessory pathway in electrophysiology study is observed. These patients make a group of higher atrial fibrillation and coming next ventricle fibrillation risk. We present the 39 years old patient with symptomatic WPW syndrome, without preexcitation signs in ECG at rest. In medical history--palpitations was observed from childhood with one episode of atrial fibrillation with high ventricle response required cardioversion. Electrophysiology study: without preexcitation signs at rest, two ortodromic AV reentrant tachycardias were induced--200 and 166/min. Two accessory pathways were diagnosed, left lateral and left midseptal. Radiofrequency catheter ablation of both accessory pathways was made during tachycardia, first lateral, next septal. In six month follow-up the patient was asymptomatic.

[Arrhythmogenic dysplasia of the right heart ventricle]. / Arytmogenna dysplazja prawej komory serca.

Arrhythmogenic right ventricular dysplasia (ARVD) is a heart muscle disease in which muscle tissue has been partially replaced by adipose or fibro-adipose tissue. Morphologic changes in the right ventricle and ventricular arrhythmias are characteristic. Pathomorphological changes should be confirmed by NMR or endomyocardial biopsy. Morphological changes ought to be found by ultrasound methods or angiographic examination. ECG exercise test, Holter monitoring, late potentials, total ventricular activation time and programmed stimulation of right ventricle are used to evaluate the risk of sudden death due to ventricular arrhythmias which is the most important problem. Those methods indicate pharmacologic or invasive therapy (RF ablation, implanted cardioverter-defibrillators), and are used to establish the effectiveness of treatment.

[Cardiomyopathy in diabetes. Ultrastructural examinations]. / Uszkodzenie serca w cukrzycy. Badania ultrastrukturalne.

The functional and morphological changes in myocardium of diabetic patients is caused by diabetic macroangiopathy, diabetic microangiopathy, autonomic neuropathy and metabolic disorders. Mechanism of these changes in the course of diabetes is not fully known. To determine whether there are myocardial ultrastructure differences between patients with diabetic cardiomyopathy (normal coronary angiograms) and diabetic patients with coronary artery disease, electron microscopy examination were performed of 70 sections received from seven biopsied patients (1F, 6M), average age 53 years (range: 42-60) with diabetes type II WHO (group A) without clinical evidence of prior coronary artery disease and hypertension, and 100 sections from 10 patients (2F, 8M), average age 54 years (range: 42-65) with diabetes and coronary atherosclerosis. These patients had clinical evidence of heart failure and were submitted to bypass-graft operations (group B). Endomyocardial biopsy tissues were obtained from the right ventricle without complications either during or after the procedure. Obtained biopsy specimens were fixed in 3% glutaraldehyde stabilized with 1M cacodylate buffer at pH 7.4, postfixed in 1% OsO4 on cacodylate buffer. The materials were then dehydrated and embedded in epon. The Irvin-Fischer test for statistical analysis was used. A p value < 0.05 was considered significant. The presence of focal mild loss of myofibrils (+) was statistically more frequent in the patients in A group (p < 0.05). It was found in 86% (6/7) of cases in A group, while in the B group was observed in 20% of (2/10) cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiogenic shock. Coronary angioplasty after failed intravenous thrombolysis]. / Wstrzas kardiogenny. Koronaroplastyka przy niepowodzeniu trombolizy dowiencowej.

Rescue coronary angioplasty (PTCA) was employed as reperfusion strategy after unsuccessful intracoronary infusion of streptokinase in 13 patients with AMI complicated by cardiogenic shock (CS). Reperfusion defined as reestablishment of TIMI 3 degree flow in the infarct related artery and reduction in luminal narrowing to less than 50% was achieved in 8 patients (61.5%). The failure of PTCA was caused by: inability to cross occlusion in 2 patients and recurrent thrombosis despite repeated dilatations resulting in hemodynamic instability requiring cardiopulmonary resuscitations during the procedure in 3 patients. There was no significant differences in mean age, sex, time from onset of symptoms, LVEF, artery involved, extent of coronary disease and incidence of cardiopulmonary resuscitations during the procedures. There where 4 in-hospital deaths among patients with failed PTCA (80%) compared to 25% mortality in reperfused group. We conclude that PTCA is an effective method of achieving reperfusion in patients with CS complicating AMI after failed thrombolysis with intracoronary streptokinase and that it improves in-hospital survival.

[Acute myocardial infarction with shock. Intracoronary thrombolysis]. / Ostry zawal serca ze wstrzasem. Tromboliza dowiencowa.

UNLABELLED: Of 932 pts with acute myocardial infarction (AMI) who underwent reperfusion therapy (RT) by intracoronary streptokinase (IC.STK), 32 pts had cardiogenic shock (CS). Shock was defined as systolic blood pressure (BP) < or = 80 mmHg without inotropic support or BP < or = 90 mmHg with inotropic or balloon counterpulsation support and left ventricular end diastolic pressure < 18 mmHg and clinical symptoms of hypoperfusion. Time from onset of symptoms to initiation of therapy was less than 6 hours. Reperfusion was defined as reestablishment of antegrade TIMI-2 or 3 flow in occluded artery. Comparison revealed no significant differences in sex, age, time after onset of symptoms, artery involved, history of previous AMI, left ventricular ejection fraction and in extent of coronary disease between pts with successful and failed thrombolysis. IC.STK was successful in 12 pts with CS (37.5%) and in 67.2% of pts without CS (p < or = 0.001). Mortality rate in pts with CS was 25% in reperfused and 81.8% among nonreperfused (p = 0.0095). CONCLUSIONS: 1. IC.STK gives a considerably lower rate of reperfusion in pts with AMI complicated by CS. 2. No influence on the frequency of effective reperfusion with respect to the analyzed clinical and angiographical data was found. 3. The high mortality in the group with unsuccessful reperfusion as well as the low effectiveness of the IC STK indicates the necessity to apply more effective methods of reperfusion in pts with AMI complicated by CS.

[Angioplasty of several stenoses including the left main coronary artery in a patient with acute circulatory insufficiency after myocardial infarction]. / Angioplastyka kilku zwezen, w tym pnia lewej tetnicy wiencowej, u chorego z ostra niewydolnoscia krazenia po zawale serca.

A 74 year old man with diabetes and multivessel coronary heart disease involving also left main coronary artery is presented. The patient was admitted to the hospital because of acute myocardial infarction. PTCA of left main coronary artery and other four severe stenoses was attempted. The clinical status after procedure, short-term (after eight months) and long-term (after five years) was much improved.

[Holter monitoring in diagnosis of syncope]. / Monitorowanie holterowskie w diagnostyce omdlen.

Thirty two patient with a history of brief unconsciousness underwent a constant ECG monitoring with Holter's technique for 24-72 hours. Syncope was noted in 16 patients. Cardiac arrhythmia was a cause of unconsciousness in 14 patients whereas no such a pathology was seen in the remaining two patients. No syncope was seen during ECG monitoring in 16 patients. Loss of consciousness was found in the majority of patients monitored for 72 hours. This technique may be valuable in the diagnosis of syncope, especially when it appears during ECG monitoring.

[Invasive treatment of recent myocardial infarction. Evaluation of left ventricular function]. / Leczenie inwazyjne swiezego zawalu serca. Ocena funkcji lewej komory.

Hemodynamic parameters of left ventricular function were assessed in 179 patients with acute myocardial infarction, who were treated with intracoronary thrombolysis during first six hours after the onset of chest pain. Some of them were subjected to coronary angioplasty. Patency of the infarct related artery was controlled between the 2nd and 3rd week after acute myocardial infarction concomitant with evaluation of EF and LVEDP. Reperfusion of the infarct related artery was obtained in 121 patients (67.6%) and also significant increase of EF was observed in those patients. EF rose in patients with a patent coronary artery after 2-3 weeks (not significant) in contrast to patients with obstructed coronary artery in whom there was a fall in EF. The rise of EF was more pronounced in patients with reperfusion reached in 3 hours after the onset of infarct pain and without coronary angioplasty. It was shown that LVEDP is not usefull in estimation of left ventricular function.

[Effect of beta adrenergic blocking drugs on the prognostic value of ST-segment depression during exercise electrocardiogram testing]. / Wplyw leków beta adrenolitycznych na wartosc prognostyczna obnizonego odcinka ST w elektrokardiogramie wysilkowym.

Exercise testing has been shown to be predictive for future cardiac events in patients with established diagnosis of coronary heart disease. Exercise test parameters associated with poor prognosis may be unreliable if patient is receiving beta adrenergic agents. The purpose of this study was: 1) to compare the results of exercise testing performed before and during beta blocking therapy, and 2) to determine the role of beta blockers in the prognostic significance of the ST-segment response recorded during exercise testing. The study population consisted of 518 patients (mean age 52 +/- 7 years) with coronary heart disease. The diagnosis was based on the presence of one of the following three criteria: 1) typical history and significant ST-segment depression on resting or exercise electrocardiogram, 2) history of myocardial infarction, 3) significant coronary angiographic abnormalities. In all patients symptom-limited exercise test was performed before and two weeks after the onset of beta blocker therapy. The data from the first and second tests were estimated for significance of differences between the mean values with following results: maximal heart rate--135 +/- 21 and 123 +/- 19 bpm (p less than 0.001), maximal work load achieved--98 +/- 43 and 109 +/- 44 W (p less than 0.001), maximal systolic blood pressure--171 +/- 28 and 163 +/- 26 mmHg (p less than 0.001). Occurrence of characteristic ST-segment depression was more frequent during the first than during the second test (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)