Patients submitted to CPVA answered a questionnaire about lifetime history of endurance sport practice. Endurance athletes were defined as those who engaged in >3 h per week of high-intensity exercise for at least the 10 years immediately preceding their AF diagnosis. A series of 182 consecutive patients was included (51 ± 11 years, 65% with paroxysmal AF, 81% men, 42 ± 6 mm mean left atrial diameter); 107 (59%) patients had lone AF, and 42 of them (23% of the study population) were classified as endurance athletes (lone AF sport group). Freedom from arrhythmia after a single CPVA was similar in the lone AF sport group compared with the remaining patients (P = 0.446). Left atrial size and long-standing AF were the only independent predictors for arrhythmia recurrence after ablation.

Circumferential pulmonary vein ablation was as effective in AF secondary to endurance sport practice as in other aetiologies of AF.

Twenty-two consecutive patients, aged 18–85, diagnosed with VVS following a positive head-up tilt-table test were randomized to 40 min of HOT (n = 12) or 10 min of sham training (n = 10) daily for 6 months. Baroreflex sensitivity (BRS) and heart rate variability (HRV) were measured at weeks 0, 1, 4, and 24. Symptom response was assessed by event diaries. Home orthostatic training resulted in increases in up and down slope BRS at week 4 (e^{log difference} = 1.59, 95% CI = 0.84–3.03 and 1.79, 95% CI = 1.00–3.22) and week 24 (e^{log difference} = 1.75, 95% CI = 1.01–3.06 and 1.53, 95% CI = 0.66–2.68) compared with placebo. Relative improvements in low- and high-frequency HRV were also observed in the HOT group compared with placebo at week 4 (e^{log difference} = 3.22, 95% CI = 1.06–9.86 and 3.19, 95% CI = 1.03–10.59) and week 24 (e^{log difference} = 2.11, 95% CI = 0.72–6.17 and 2.13, 95% CI = 0.52–8.79). Fifty percentage of HOT subjects and 20% of control subjects were syncope-free at 6 months.

This was the first placebo-controlled study in orthostatic training which has demonstrated that such a study is indeed feasible. An enhancement in overall autonomic tone is observed with HOT in tandem with a non-significant trend in symptom improvement. A larger, adequately powered, randomized controlled trial of tilt-training is now needed.

In total, 669 consecutive patients with syncope, admitted to 18 electrophysiological cardiac tertiary centres over a mean of 3 months (range 1–10 months), entered a special Internet database called the PL-US (Polish patients with Unexplained Syncope) registry. Detailed demographic and clinical characteristics of the patients, including the results of all diagnostic tests performed, were analysed. Adherence to the guidelines was assessed, based on the published recommendations. The ILR implantation was indicated when (i) all other tests were inconclusive (unexplained syncope) and (ii) syncope associated with injury or presence of organic heart disease or past medical history and ECG suggesting arrhythmic syncope. Syncope of cardiac/arrhythmic origin was the most frequent diagnosis (53%), followed by reflex syncope (33%). Adherence to the guidelines was less than satisfactory—measurement of blood pressure in an upright position, carotid sinus massage, exercise testing, and electrophysiological study were underused, whereas prolonged ECG monitoring and neurological consultations were overused. Unexplained syncope had 58 (9%) patients, and 42 (72%) of them had indication for ILR which accounts for 6% of the whole study population. The calculated need for ILR was 222 implants/million inhabitants/year.

Patients with syncope admitted to the tertiary electrophysiology cardiac centres are a highly selected group of patients with syncope and differ in their characteristics as well as underlying diseases to those managed at general hospitals, outpatient clinics, or special syncope units. In Poland, the adherence to the published guidelines is far from satisfactory. At least 6% of all consecutive patients with syncope are candidates for ILR insertion.

Sixty patients undergoing a PV isolation procedure received intraprocedural rotational angiography and three-dimensional reconstruction of the left atrium (LA) and PVs. For each patient, 33 angiographic projections were independently evaluated [right anterior oblique (RAO) 80° to left anterior oblique (LAO) 80°, in steps of 5°] by two physicians in order to identify the optimal projections of the PV ostia according to the following definition: Sagittal plane: (i) clear identification of both superior and inferior segments of the LA–PV junction and (ii) no overlapping between LA (and/or left atrial appendage) and PV ostium. Frontal plane: (i) clear identification of all four quadrants of the PV ostium and (ii) fluoroscopic angles at which the maximal horizontal ostial diameter is visualized. A successful reconstruction of the LA and all PVs was obtained in 58 (97%) patients. An optimal ostial projection in a sagittal plane was identified for all four PVs. The optimal ostial projection was RAO 5° for the right superior PVs in 57 out of 58 patients (98%), RAO 55° for the right inferior PVs in 54 out of 58 patients (93%), LAO 45° for the left superior PVs in 46 out of 58 patients (80%), and LAO 60° for the left inferior PVs in 48 out of 58 patients (83%). An optimal ostial projection in a frontal plane was identified only for the inferior PVs. The optimal ostial projection was LAO 40° for the right inferior PVs in 55 out of 58 patients (95%) and RAO 45° for the left inferior PVs in 51 out of 58 patients (88%).

If selective angiography is to be used to delineate anatomy and location of the PV ostia to guide PV isolation, different fluoroscopic projections are required for different PVs. The preselected RAO and LAO projections proposed in our study result in optimal angiographic projections of all PV ostia in at least one plane in the majority of patients.

Clinical information including a standard 12-lead ECG was collected from patient files in consecutive patients treated with CRT from 1997 to 2007. Symptomatic response was defined as improvement in New York Heart Association class (≥1) and echocardiographic response as improvement in left ventricular ejection fraction of ≥5% absolute. We included 659 patients [median age 66 years, 526 (80%) male]. There was a higher all-cause and cardiac mortality in patients with left bundle branch block (LBBB), prolonged PR interval, right-axis deviation combined with LBBB in the pre-implant ECG, and no QRS reduction after CRT. Patients with right bundle branch block and patients with an intermediate QRS duration (150–200 ms) had a higher chance of symptomatic improvement, and patients with normal PR interval and normal axis in LBBB had a higher chance of echocardiographic improvement.

Cardiac resynchronization therapy does not change the predictive value of ECG patterns in heart failure patients with bundle branch block, where LBBB, a prolonged PR, and an abnormal axis in LBBB are signs of a more severe degree of myocardial disease, and therefore a worse outcome. Lack of electrical resynchronization defined as an unchanged or prolonged QRS duration is associated with higher all-cause and cardiac mortality in patients treated with CRT.

We analysed data of the complications related to all CRM device implantations during 1 year (2006) in a tertiary referral university hospital. In 567 device implantations, pacing system upgrade procedures, or lead revisions, 78 complications occurred in 69 (12.2%) patients. Lead dislodgement, pocket haematoma or bleeding, pneumothorax, and infection were the most common accounting for >80% of all complications. The complication rate was more than twice as high in bradycardia pacemaker (PM) implantations performed by cardiology trainees (17.4%) than by experienced cardiologists (7.7%, P = 0.001). When performed by experienced cardiologists, the complication rate was not higher in implantations of more complex devices compared with that of bradycardia PMs. Fifty-two of the 69 patients needed additional surgical procedures. Altogether, the complications required 504 additional treatment days in hospital.

In conclusion, our retrospective 1-year single-centre survey shows that short-term implantation-related complications of contemporary device therapy are still frequent, occur much more frequently by trainees than by cardiologists, require a large number of additional surgical procedures, and substantially prolong the hospital stay.

This retrospective case–control study included 82 patients with persistent AF (PEF). Group 1 (22 patients) comprised cases undergoing AF ablation following attempted PC with bepridil. Group 2 (60 patients) comprised control that underwent AF ablation without bepridil pre-treatment. In Group 1, 15 patients (68%) restored sinus rhythm (SR) with bepridil (SR group) and 7 continued to have AF (AF group). SR group underwent extensive pulmonary vein isolation (EPVI) alone. AF group and Group 2 underwent linear ablation after EPVI, if AF was inducible. At the end of 18 ± 5 months off antiarrhythmic drugs, the AF-free rate was 87% in SR group, 29% in AF group, and 72% in Group 2 (72 vs. 29%, P = 0.02).

Following AF ablation in patients who successfully restored SR with bepridil pre-treatment, AF-free rate was significantly higher than in those who failed to do so. Conversion to SR with bepridil might help select the optimal patients with PEF for catheter ablation.

We retrospectively identified cases of device infection at our institution between 2000 and 2007 by multiple source record review, and active surveillance. Device infection was related to demographics, clinical, and procedural characteristics. Descriptive analysis was performed. From 2000 to 2007, a total of 2029 permanent pacemakers and 1076 biventricular/implantable cardioverter–defibrillators (ICDs) or ICDs were implanted. Thirty-nine cases of confirmed device infections were identified—27 pacemaker and 12 bivent/ICD or ICD infections, giving an infection rate of 1.25%. Median time from implant or revision to presentation was 150 days (range 2915 days, IQR25% 35–IQR75% 731). Ninety percent of patients presented with generator-site infections. The most common organism was methicillin-sensitive Staphylococcus aureus (30.8%), followed by coagulase negative Staphylococcus (20.5%). Complete device extraction occurred in 82%. Of these, none had relapse, and mortality was 7.4% (n = 2/27). With partial removal or conservative therapy (n = 13), relapse occurred in 67% (n = 8/12), with mortality of 8.4% (n = 1/12). Median duration of antibiotics was 42 days (range 47 days, IQR25% 28–IQR75% 42 days). Re-implantation of a new device occurred in 54%, at a median of 28 days (range 73 days, IQR25% 8.5–IQR75% 35 days). Methicillin-Resistant Staphylococcus Aureus infection predicted mortality (P < 0.004, RR 37, 95% CI 5.3–250). Median follow-up was 36 months.

Cardiac device infection is a rare complication, with significant morbidity and mortality. Complete hardware removal with appropriate duration of antimicrobial therapy results in the best outcomes for patients.

Forty-seven patients in sinus rhythm were evaluated within 14 days of CRT implantation. The atrio- (AV) and interventricular (VV) delay intervals were incrementally adjusted and at each setting, NICOM and echocardiographic data were recorded. Left ventricular (LV) volumes and function were assessed by echocardiography at baseline and 3 months. Response to CRT was defined as a reduction in LV end-systolic volume (LVESV) by >15%. In all patients, cardiac output (CO) increased significantly at optimized settings compared with baseline (5.66 ± 1.4 vs. 4.35 ± 1.1 L/min, P < 0.001). A 20% increase in acute CO following CRT predicted LVESV reduction of >15% with a sensitivity of 81% and specificity of 92% (AUC 0.86). The optimum AV delay determined by NICOM was confirmed by echocardiography in 40 of 47 patients (85%, r = 0.89, P < 0.01) and for VV delay in 39 of 47 patients (83%, r = 0.89, P < 0.01).

Non-invasive cardiac output monitoring is a simple, reliable, and portable alternative to echocardiography to program CRT devices.

Low-voltage zone was consistently found at the septal, anterior, and posterior LA in all groups. In Group A, CV through the LVZ was significantly slower compared with the non-LVZ (0.8 ± 0.5 vs. 1.4 ± 0.6 m/s, P = 0.004), but those through the LVZ and non-LVZ were similar in Group B (1.2 ± 0.5 vs. 1.3 ± 0.5 m/s, P = 0.07) and Group C (1.5 ± 0.5 vs. 1.4 ± 0.6 m/s, P = 0.79). The percentage of points showing fractionated or double potentials in the LVZ was significantly more in Group A (76/293 points, 26%) than in Group B (11/185 points, 6%), and Group C (7/135 points, 5%) (P < 0.0001 and P < 0.0001, respectively).

There was a significant slowing of local conduction in the LVZ defined as <0.5 mV and was frequently associated with fractionated or double potentials in patients with AF.

The IPR collected prospectively main epidemiological, clinical, and electrocardiographic data of patients treated by pacemaker (PM) in Italy on the basis of European PM Card. The number of reported PMs in Italy was 30 820 in 2003, 32 047 in 2004, 31 870 in 2005, 31 813 in 2006, and 31 146 in 2007, respectively. The median age was 79 years in all 5 years. Among the atrio-ventricular (AV) conduction defects, third-degree AV block was the most common occurrence. Of the sick sinus syndrome (SSS), sinus node dysfunction involved the majority of cases followed by bradycardia–tachycardia syndrome. Year-over-year percentages among the different indications remained stable. Syncope and dizzy spells were by far the most common symptoms. Dual-chamber pacing showed an increasing utilization in all the examined years.

Italian PM Registry data for the study period reveal a stable pattern of PM utilization and indications. A higher use of dual-chamber pacing in comparison to single-chamber pacing was reported for all indications, despite inconclusive data of the major randomized trials.

We retrospectively analysed multiple variables on pre- and post-ablation ECGs in 238 patients with manifest accessory pathways that had been successfully ablated. A new variable, PR dispersion, was defined as a difference between maximum and minimum PR intervals on a single 12-lead ECG. A logistic regression analysis showed the combination of the following criteria to be powerful in the confirmation of the diagnosis in patients with suspected delta wave: presence of both PR interval ≤120 ms and PR dispersion ≥20 ms, absence of initial positive deflection (septal R wave) in lead augmented voltage right arm (aVR), and horizontal QRS transition in lead V1 or before. A stepwise algorithm was developed based on these criteria. Of the total 476 ECGs, seven patients with pre-excitation and one patient with normal ECG were misdiagnosed using the algorithm. Even though the retrospectively determined sensitivity and specificity of the three stepwise criteria were high (97% and 99%, respectively) a prospective study evaluating the algorithm is needed.

Using a stepwise approach is a very sensitive and specific technique for excluding or confirming ventricular pre-excitation on a 12-lead ECG.

The clinical data of 23 individuals (19 males, age 42.69 ± 14.63) with spontaneous (n = 10) or drug-induced (n = 13) type 1 ECG pattern of BS who underwent programmed ventricular stimulation were analysed. Sustained VT/VF was induced in 17 subjects (74%) and was significantly associated with the presence of spontaneous type 1 ECG of BS (P = 0.012). Among the studied ECG repolarization markers, subjects with inducible VT/VF displayed an increased T_peak–T_end interval in leads V₂ (88.82 ± 15.70 vs. 78.33 ± 4.08 ms, P = 0.02) and V₆ (76.33 ± 10.08 vs. 66.66 ± 5.16 ms, P = 0.04) and a greater T_peak–T_end/QT ratio in lead V₆ (0.214 ± 0.028 vs. 0.180 ± 0.014, P = 0.009) compared with those without arrhythmias. Ventricular tachycardia/fibrillation inducibility was not associated with arrhythmic events during a mean follow-up period of 4.61 ± 2.14 years (P = 0.739).

The T_peak–T_end interval and T_peak–T_end/QT ratio were associated with VT/VF inducibility in BS. The utility of T_peak–T_end/QT ratio as a new marker of arrhythmogenesis in BS requires further studies, including a large number of patients.

Ten seconds bipolar electrograms were classified by visual inspection (VI) during ablation of persistent AF and the result compared with offline manual measurement (MM) by a second blinded operator: Grade 1 uninterrupted fractionated activity (defined as segments ≥70 ms) for ≥70% of recording and uninterrupted ≥1 s; Grade 2 interrupted fractionated activity ≥70% of recording; Grade 3 intermittent fractionated activity 30–70%; Grade 4 discrete (<70 ms) complex electrogram (≥5 direction changes); Grade 5 discrete simple electrograms (≤4 direction changes); Grade 6 scar. Grade by VI and MM for 100 electrograms agreed in 89%. Five hundred electrograms were graded on Carto and NavX by VI to validate AUTO in (i) detection of CFE (grades 1–4 considered CFE), and (ii) assessing degree of fractionation by correlating grade and score by AUTO (data shown as sensitivity, specificity, r): NavX ‘CFE mean’ 92%, 91%, 0.56; Carto ‘interval confidence level’ using factory settings 89%, 62%, –0.72, and other published settings 80%, 74%, –0.65; Carto ‘shortest confidence interval’ 74%, 70%, 0.43; Carto ‘average confidence interval’ 86%, 66%, 0.53.

Grading CFE by VI is accurate and correlates with AUTO.

We assessed a series of 46 patients (61 ± 10 years, 64% male) with idiopathic dilated cardiomyopathy undergoing resynchronization therapy combined with a defibrillator in primary prevention and the potential relationship between baseline characteristics and the onset of ventricular arrhythmic events. Of the 46 patients included, eight (17%) presented episodes of ventricular tachycardia/fibrillation during follow-up (19 ± 12 months). There were no baseline differences among these patients, except the proportion of males (57.9 vs. 100%, P = 0.02) and QRS width (162 ± 24 vs. 189 ± 26 ms, P = 0.008), which was the only independent predictor of arrhythmic events (OR 1.42, 95% CI 1.12–1.68; P = 0.03).

In patients with idiopathic dilated cardiomyopathy undergoing resynchronization therapy combined with a defibrillator, baseline QRS is an independent predictor of arrhythmic events.

Fifty-two patients underwent CRT implantation according to standard techniques and clinical indications. The RV–LV interlead electrical delay measured during spontaneous rhythm and the difference between the pacing-induced (p) RV–LV interlead electrical delays measured during RV and LV pacing were defined intraoperatively using the electrical depolarizations registered at the ventricular leads on the device programmer. At 6 months, a reduction of LV end-systolic volume ≥15% was used to define CRT responders. Responders (62%), when compared with non-responders, showed a higher proportion of ischaemic aetiology (P = 0.007) and a lower value of pRV–LV interlead electrical delay (22.1 ± 18.4 vs. 46.3 ± 15.0 ms, P = 0.0001). At multivariate analysis, the pRV–LV interlead electrical delay was the only independent predictor of response to CRT (P = 0.001). For such a parameter, the receiving operating characteristic curve analysis identified a cut-off value of 42 ms corresponding with the highest accuracy: sensitivity 90.6%; specificity 70%; positive and negative predictive value 83% and 82%, respectively. Conversely, no difference was ascertained between responders and non-responders when RV–LV interlead electrical delay was measured during spontaneous rhythm (76.1 ± 28.5 vs. 89.6 ± 21.2, P = 0.078).

Intraprocedural measuring of paced RV–LV interlead electrical delay obtained during RV and LV pacing predicts mid-term CRT response.

Left ventricular function and synchrony (M-mode, speckle tracking) were evaluated during mid-term follow-up in 32 children with complete non-surgical (n = 15) or surgical (n = 17) atrioventricular block (structural heart disease in 21/32) paced from LV apex (n = 19), right ventricular (RV) apex (n = 7), and RV free wall (n = 6), respectively. Data are in the following order: LV apical, RV apical, and RV free wall pacing. Septal to posterior wall motion delay (SPWMD) = median 0, 69, and 136 ms (P < 0.001), septal to lateral mechanical delay = 54 ± 29, 73 ± 24, and 129 ± 70 ms (P = 0.001), apical to basal mechanical delay = 96 ± 37, 106 ± 50, and 79 ± 18 ms (P NS), and LV ejection fraction (LVEF) = 57 ± 9, 49 ± 12, and 33 ± 10% (P < 0.001), respectively. Left ventricular ejection fraction correlated negatively with SPWMD (R² = 0.454, P < 0.001) and septal to lateral mechanical delay (R² = 0.320, P < 0.001) but not with apical to basal mechanical delay. Right ventricular free wall pacing (P = 0.014) and SPWMD (P = 0.044) were negative multivariable predictors of LVEF.

Compared with other sites, LV apical pacing preserves septal to lateral LV synchrony and systolic function and may be the preferred epicardial pacing site in the young.

Optimization of AV and VV intervals was performed a month after CRT device implantation in 26 patients with heart failure, first by echocardiography then by QuickOpt. The left ventricular outflow tract (LVOT) velocity–time integral (VTI) was measured after optimization by each method. Agreement between the optimization methods was assessed by the Bland–Altman analysis and correlation by Pearson's correlation coefficient. There was good correlation between the LVOT VTI following optimization by both methods (R² = 0.77, P < 0.001). However, agreement between the two methods was poor, with 15 of 26 and 10 of 26 patients having a >20 ms difference in the optimal AV and VV interval values, respectively. Left ventricular outflow tract VTI was significantly better (22 of 26 patients; P < 0.001) in patients optimized by echocardiography than by QuickOpt.

There is a poor agreement in optimal AV and VV intervals determined by echocardiography and QuickOpt, with echocardiographic optimization giving a superior haemodynamic outcome.

Between February 2001 and October 2003, 229 consecutive patients affected by drug-refractory paroxysmal or persistent AF underwent a single radiofrequency catheter ablation procedure (anatomical approach in 146 patients and electrophysiologically guided approach in 83 patients). Of these patients, 177 (mean age 59.1 ± 10.5 years, 57.6% with paroxysmal AF) were free from any atrial arrhythmia recurrence after 12 months. These 177 patients were subsequently followed up for at least another 24 months, by means of electrocardiogram and 24 h Holter monitoring. After a mean follow-up of 49.7 ± 13.3 months (range 36–83 months), 58.2% of the patients were free from any atrial arrhythmia recurrence (39.5% without antiarrhythmic drugs). The actuarial atrial arrhythmia recurrence rate was 13.0% at 2 years, 21.8% at 3 years, 35.0% at 4 years, 46.8% at 5 years, and 54.6% at 6 years. Atrial arrhythmia-free survival was similar in patients with paroxysmal or persistent AF, with and without antiarrhythmic drugs during the follow-up, who underwent electrophysiologically guided pulmonary vein (PV) isolation or anatomical PV ablation.

Even patients in whom catheter ablation prevents AF recurrence for 1 year should not be considered ‘cured’, since >40% of them will suffer AF recurrence over a long-term clinical follow-up.

This study included 867 patients (age 54 ± 5, 57% females) who underwent 24 h ambulatory electrocardiographic (ECG) recording (Holter) in the period from 1998 to 2000. We examined the unadjusted and multivariable-adjusted associations between resting HR with factors involved in ventricular arrhythmogenesis [ventricular late potentials (LPs) detected by signal-averaged ECG, heart rate variability (HRV), and premature ventricular complexes (PVCs)]. Linear regression models were used for continuous outcomes and logistic regression analysis was used for categorical outcomes. The multivariable models included first age and sex, then history of hypertension, diabetes, hypercholesterolaemia, CHD, heart failure, left ventricular ejection fraction (LVEF), smoking, body mass index, the use of anti-arrhythmic drugs, and ST-depression in the 24 h ambulatory ECG recording (Holter) were included in the final models. In the unadjusted and multivariable-adjusted analysis, high resting HR was significantly associated with positive ventricular LPs, depressed HRV indices, and increased prevalence of PVCs/24 h independently from demographic and clinical variables including LVEF, history of CHD, and the presence of ST-depression in Holter (P-value <0.05 in all comparisons and models).

High resting HR is independently associated with ventricular arrhythmogenesis, the major cause of SCD. These findings could partially explain the reported association between increased HR and SCD.

In this retrospective analysis 674 consecutive patients (464 male, mean age 57.3 ± 10.8 years) with AF (84.8%, paroxysmal) treated with CPVA ablation between May 2005 and August 2007 using a manually controlled steerable sheath (Agilis^® St. Jude Medical Inc., St. Paul, MN, USA), were included. The endpoint of the ablation was the completion of predefined lesions (CPVA for paroxysmal, and CPVA+mitral isthmus and roof line ablation for persistent AF). Seven day Holter recordings were done immediately, 3, 6, and 12 month after ablation. AF longer than 30 s was considered as recurrence. The success was defined as lack of recurrence during 7-day Holter recordings done 3, 6, and 12 months after ablation. Early recurrence was defined as recurrence during the first 7-day Holter recording immediately after ablation. Forty-five and 20.8% of the patients received antiarrhythmic medications for the first 3 and 6 months after ablation procedure, respectively. After 6 months all antiarrhythmics were discontinued. About 51.5% experienced early recurrence. Twelve months success rate was 75.7% (paroxysmal: 75.7%, persistent: 75.0%, P = 1.0). Using multivariate analysis left atrial (LA) diameter ≥50 mm was the predictor of early recurrence {Hazard Ratio (HR) [95% confidence interval (CI)] = 5.1 (2.0–12.9)}. LA Diameter ≥50 mm [HR (95% CI) = 4.6 (2.6–9.1)]; early recurrence [HR (95% CI) = 4.3 (2.0–9.1)]; and arterial hypertension [HR (95% CI) = 4.6 (2.6–9.1)] were predictors of late recurrence.

In our patients' cohort, a single catheter ablation procedure based on CPVA using steerable sheath for catheter navigation resulted in a 1 year success rate of 75.7% [without (91.0%) and with (58.6%) early recurrence, respectively, P = 0.0001]. Among those patients who are at high risk for recurrence after CPVA other ablation endpoints rather than completion of predefined lesions might be necessary to increase the success rate.

We prospectively enrolled 39 patients (31 male; age 59 ± 11 years) elected to circumferential PV isolation with CBA for highly symptomatic paroxysmal AF. A total of 149 PVs were evidenced. Adenosine testing after CBA induced a left atrium–PV reconnection only in 7 (4.6%) of PV.

Our study showed a low rate of transient PV reconnection after adenosine infusion following successful PV isolation with CBA. However, larger studies will be needed in order to confirm our findings and the prognostic value of adenosine testing after successful PV isolation obtained with CBA.

The haemodynamic profiles of 42 consecutive patients non-responsive to passive HUT and glyceryl trinitrate (GTN) provocation (‘non-responders’) and, contemporaneously, 41 consecutive patients responsive to passive HUT and GTN provocation (‘responders’) were assigned oscillation-positive or oscillation-negative depending on the presence or absence of a characteristic oscillation in systolic blood pressure which varied by ≥30 mmHg (peak-to-trough). All the non-responders proceeded to an isoprenaline (Iso) challenge test. Of the 42 non-responders, 27 patients were Iso tilt-positive; all of these patients were assigned oscillation-positive. The other 15 non-responders were Iso tilt-negative; of these 9 were assigned oscillation-positive and 6 were assigned oscillation-negative. Of the 41 responder patients, 33 were assigned oscillation-positive, whereas 8 were assigned oscillation-negative. Overall, the presence of oscillations as a diagnostic predictor for vasovagal syncope had a sensitivity of 88% (positive predictive value of 87%) and a specificity of 40% (negative predictive value of 43%).

In patients non-responsive to passive HUT and GTN provocation, the presence of an oscillating systolic blood pressure varying ≥30 mmHg may still indicate a diagnosis of vasovagal syncope, possibly obviating the need for Iso testing.

Contact electro-anatomical mapping was performed in 15 heart failure (HF) patients with left bundle branch block and echocardiographically optimized CRT (seven ischaemic aetiology, 64 ± 8 years, three women, New York Heart Association class 3 ± 0.4, LV ejection fraction 25 ± 5%). Left ventricular activation maps were performed in sinus rhythm (SR), during DDD right ventricular apical (RVA) and optimized Biv pacing. Fusion with intrinsic rhythm during pacing was considered when LV septal activation was produced at least partially by intrinsic depolarization, when compared with LV activation map during SR. Patients were considered responders to CRT if they had ≥10% reduction in LV end-systolic volume (LVESV) after 6 months of CRT. During SR, the LV breakthrough was mid-septal (n = 12), basal septum (n = 2), and apical (n = 1). During RVA pacing, LV breakthrough shifted apical in all patients. Right ventricular apical/Biv pacing proved fusion with intrinsic depolarization in 8 of 15 patients. The PR interval was shorter in patients with fusion RVA/Biv pacing (164 ± 24 vs. 234 ± 55 ms, P = 0.006). There was a trend for shorter LV activation time (LV_at) in patients with fusion during RVA pacing (87 ± 33 vs. 113 ± 21 ms, P = 0.08) as well as during optimized Biv pacing (83 ± 18 vs. 104 ± 24 ms, P = 0.07), although LV_at was similar in SR (100 ± 22 vs. 106 ± 20, P = NS). In patients with fusion, 6 months responder rate was significantly higher (100 vs. 28.5%, P < 0.007) as was the degree of LVESV reduction (39 ± 17 vs. 1.0 ± 14%, P < 0.001).

Biventricular pacing with fusion may substantially increase the structural responder rate probably by shortening LV_at.

Twenty-five patients with dual-chamber pacemakers and sick sinus syndrome were evaluated. Echocardiographic examinations included standard and tissue-Doppler echocardiography at bilateral mitral annulus margins under either the intrinsic atrio-ventricular sequential conduction (ventricular sensing; VS) mode or right ventricular apical pacing (VP) mode. Under either mode, we accelerated the pacing rate at an increment of 15 b.p.m. step-by-step from 60 to 90/min. The tissue-Doppler echocardiography of mitral annulus showed that under the VS status, accelerating atrial pacing rate from 60 to 90 b.p.m. enhanced A'-wave velocity (P less double equals 0.002), whereas no significant change of LV ejection fraction (LVEF) and E'-wave velocity were noted. Under the VP status, acceleration of pacing rates exerted no effect on the LVEF, E'-, and A'-wave (P = NS). While shifting the pacemaker mode from VS to VP, the E'-wave velocity (P less double equals 0.002) and E'/A' ratio decreased significantly (P less double equals 0.001). The A'-wave velocity also increased significantly during shifting to VP mode at 60 b.p.m. (P less double equals 0.004).

At fixed pacing rates, shifting from VS to VP mode impaired LV diastolic function immediately with preserved LV contractility. The acceleration of heart rate impaired LV diastolic function under VS mode.

A case–control study (1:1) was conducted with a total of 72 patients: 36 cases (depressed LVEF) and 36 controls (normal LVEF). Patients were matched by left atrial diameter (LAD), the presence of arterial hypertension, and other variables that might influence the results (age, gender and paroxysmal vs. persistent AF). There were no statistical differences in the variables used to perform the matching. Patients with depressed LVEF had higher LV end diastolic diameter (55.6 ± 6.2 vs. 52.4 ± 5.5, P = 0.03), higher LV end systolic diameter (40.3 ± 6.9 vs. 32.6 ± 4.3, P < 0.001), lower LVEF (41.4 ± 8.0 vs. 63.1 ± 5.5, P < 0.001) and were more likely to have structural heart disease. After a mean follow-up of 16 ± 13 months, survival analysis for AF recurrences showed no differences between patients with depressed vs. normal LVEF (50.0 vs. 55.6%, log rank = 0.82). Cox regression analysis revealed LAD to be the only variable correlated to recurrence [OR 1.11 (1.01–1.22), P = 0.03]. Analysis at 6 months showed a significant increase in LVEF (43.23 ± 7.61 to 51.12 ± 13.53%, P = 0.01) for the case group.

LV systolic dysfunction by itself is not a predictor of outcome after AF ablation. LAD independently correlates with outcome in patients with low or normal LVEF.

Successful S-PVI or C-PVI with a basket catheter was achieved in 120 consecutive PAF patients. Serial 24 Holter-recordings were obtained before, immediately, and 1, 3, 6, 12 months after the PVI to analyse the heart rate variability (HRV). Nineteen patients were excluded from analysis because of additional ablation for recurrent PAF after successful PVI. Among the residual 101 patients, 33 had PAF recurrences (S-PVI = 44.0%, C-PVI = 21.6%) at 1 year of follow-up. The root mean square of successive differences and high-frequency power reflecting parasympathetic nervous activity were significantly lower in patients with and without PAF recurrences after C-PVI and patients without PAF recurrences after S-PVI than patients with PAF recurrences after S-PVI (P < 0.005–0.0001). However, there were no significant differences in any HRV parameters in the immediate aftermath of PVI among the patients without PAF recurrences after S-PVI and those with and without PAF recurrences after C-PVI.

Although additional radiofrequency ablation for AM may be recommended after S-PVI to reduce PAF recurrences, it should be carefully determined after C-PVI.

We assessed 125 patients with isolated LVA or LVD for the prevalence of ECG abnormalities and compared the findings to an age- and gender-matched control group. The 12-lead ECG patterns were evaluated according to commonly used criteria and were classified into three subgroups (distinct, mildly, and minor). Fifty-four of the 125 patients (43.2%) had normal and 71 (56.8%) abnormal ECGs. Mean age was 66 years. Forty-nine (39.2%) were male. Distinct abnormal ECG patterns were more prevalent in patients with LVD (38.2 vs. 15.8%, P = 0.04), and apical location of the anomaly (36.6 vs. 16.6%, P = 0.02). Older age (>66 years) was associated with a trend for a higher prevalence of abnormal ECG pattern (33 vs. 18%, P = 0.06), whereas gender had no influence (32 vs. 16%, P = 0.14). This study also shows that the sensitivity, specificity, positive predictive value and negative predictive value of a 12-lead ECG for the diagnosis of LVA or LVD are low.

This large single-centre study suggests that the prevalence of abnormal ECG patterns in patients with isolated LVA or LVD is as high as 56.8%. However, ECG is not specific and sensitive to be used as a screening tool in such patients.

Consecutive patients in NYHA functional class III or IV despite optimal drug therapy, QRS duration ≥130 ms, left ventricular ejection fraction ≤35%, and left ventricular end-diastolic dimension ≥55 mm were eligible for enrolment. Patients with permanent or persistent atrial fibrillation (AF) were not included in the study. The first follow-up examination was performed 2 weeks after implantation, to optimize atrial sensing and CRT. Subsequent follow-up examinations were carried out 15 and 28 weeks after implantation, to collect the telemetric data. A total of 173 patients (67 ± 11 years, M 116) were enrolled. Complete arrhythmia monitoring data were available from 120 patients over a mean follow-up of 183 ± 23 days. Atrial tachycardia episodes were detected through telemetry in 25 of 120 patients (21%) during at least one follow-up examination. Atrial tachycardia episodes were recorded in 29 and 17% (P = NS) of patients with and without previous history of AF, respectively.

More than 20% of the overall HF patient population treated with CRT suffer PAT episodes. Paroxysmal atrial tachycardia may interfere with response to CRT. Therefore, telemetric data may be relevant to drive the appropriate therapy in each patient.

252 patients admitted for ventricular arrhythmia related to CAD were included: 149 had acute myocardial infarction (MI) (Group I, 59%), 54 had significant chronic obstructive CAD suggestive of an ischaemic arrhythmic trigger (Group II, 21%) and 49 patients had an old MI without residual ischaemia (Group III, 19%). 34% of the patients with scar-related arrhythmias had an LVEF ≥40%. Based on pre-event LVEF evaluation, it can be estimated that less than one quarter of the whole study population had a known chronic MI with severely reduced LVEF. In Group III, the proportion of inferior MI was significantly higher than anterior MI (81 vs. 19%; absolute difference, –62; 95% confidence interval, –45 to –79; P ≤ 0.0001), though median LVEF was higher in inferior MI (0.37 ± 10 vs. 0.29 ± 10; P = 0.0499).

Patients included in defibrillator trials represent only a minority of the patients at risk of sudden cardiac death. By applying the current risk stratification strategy based on LVEF, more than one third of the patients with old MI would not have qualified for a prophylactic defibrillator. Our study also suggests that inferior scars may be more prone to ventricular arrhythmia compared to anterior scars.

The database of the obligatory external quality control program for the years 2003–2006 was evaluated retrospectively. In 72 centres, 17 826 patients undergoing stationary primary pacemaker implantation have been registered. Male patients had more AV blocks when compared with women and less sick sinus syndrome and atrial fibrillation with bradycardia. In patients being 80 years and older, men received significantly more dual-chamber devices than women for the indications: AV block and sick sinus syndrome. In women, atrial pacing thresholds were significantly higher and P-wave amplitudes were significantly lower. Women had, independent from age or pacing system implanted, significantly more acute complications than men, with significant differences for pneumothorax and pocket haematoma.

This large-scale real-life patient cohort of primary stationary pacemaker implantation showed that gender has an impact onto pacemaker implantation, with less favourable outcomes for women.

In 122 ICD patients undergoing generator replacement or surgical lead revision between January 2006 and July 2008, microbiological cultures of generator pockets and extracted leads were consecutively obtained. Patients with clinical evidence of a device infection were excluded. Positive cultures from the generator pocket and leads were found in 40 (33%) patients. The most common bacteria isolated were coagulase negative staphylococci (68%). During a median follow-up time of 203 days after the revision device infection occurred in three [7.5%, confidence interval (CI) 1.6–20.4%] patients with a positive culture vs. two (2.4%, CI 0.3–8.5%) patients with a negative culture (P = 0.33). Time from revision to infection was 108 ± 73 days in patients with positive culture vs. 60 ± 39 days in patients with negative culture (P = 0.50).

A third of ICD patients undergoing generator replacement or lead revision have an asymptomatic bacterial colonization of generator pockets. After revision 7.5% of these patients develop a device infection with the same species of microorganism.

In 81 patients (M:F = 63:18, 59.1 ± 10.5 years old) with AF who underwent CV, clinical, image, and CV findings (energy requirement, immediate recurrence of AF < 15 min), and pre-CV serological markers were evaluated. Results: (i) During 13.1 ± 10.6 months of follow-up, 8.6% (7/81) showed failed CV, 59.26% (48/81) showed AF recurrence, and 32.1% (26/81) remained in sinus rhythm (no recurrence). (ii) Failed CV showed higher plasma levels of transforming growth factor (TGF)-β (P = 0.0260) than those with successful CV. (iii) Patients with AF recurrence were older (60.4 ± 9.0 years old vs. 55.3 ± 12.5years old, P = 0.0220), had a higher incidence of spontaneous echo contrast (SEC; 68.1 vs. 40.0%, P = 0.0106), a lower prescription rate of angiotensin-converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB; 27.0 vs. 50.0%, P = 0.0248) or spironolactone (0.0 vs. 19.2%, P = 0.0007), and lower plasma levels of stromal cell-derived factor (SDF)-1 (P = 0.0105).

Post-CV recurrence commonly occurs in patients with age >60 years, SEC, under-utilization of ACE-I/ARB or spironolactone, and low plasma levels of SDF-1. High plasma level of TGF-β predicts failed CV.

Entrance skin doses were assessed during 16 CRT procedures. Seven of the 16 patients were upgrade of conventional pacemaker to CRT. The patients wore jackets which had 100 radiosensitive indicators placed on the back during the procedures. After the procedure, the patients’ ESDs were calculated from the colour difference of the indicators. Eleven of the 16 patients were implanted devices with a defibrillator, and three patients those without a defibrillator. In the other two, the procedures failed. The average total fluoroscopic time (TFT), total numbers of cine frames, and the maximum ESDs were 56.7 ± 28.0 min, 674 ± 342 frames, and 1.0 ± 0.6 Gy, respectively. Of the 16 patients, six received ESDs exceeding 1 Gy, TFT, total number of cine frames, and the maximum ESD tended to decrease as the operator experience increased.

The patients’ ESDs during CRT procedures can exceed the thresholds for radiation skin injuries due to prolonged fluoroscopic times. Therefore, interventionalists should estimate the doses.

Fifteen patients with lone AF refractory for antiarrhythmic drugs (AADs) underwent PVI by minimal invasive epicardial off-pump monolateral right-sided video-assisted thoracic surgery (VATS) using the UltraCinch with high-intensity focused ultrasound (HIFU). Primary endpoint was successful ablation defined as absence of AF or atrial flutter/tachycardia after 6 months assessed by complaints, 12 lead electrocardiogram, and 96 h Holter monitoring. Secondary endpoints were ablation success at the end of follow-up irrespective of AADs use or re-ablation and complications related to the procedure. Mean age was 47 ± 10 years and 14 (93%) were male. Eleven (73%) had paroxysmal, and 4 (27%) patients had persistent AF. Median AF history was 5 (1–12) years. At 6 months, six (40%) patients had sinus rhythm after one epicardial PVI (four on AADs). After 1.3 ± 0.6 years, four (27%) patients had sinus rhythm after one epicardial PVI (two on AADs) and in six (40%) patients endocardial radiofrequency re-ablation was performed, which was successful in three patients (20%). Two patients (13%) were planned for re-ablation. Three others (20%) refused re-ablation. Two major complications occurred (one late tamponade and one bleeding during surgery, necessitating sternotomy).

Epicardial PVI using monolateral right-sided VATS with the UltraCinch delivering HIFU is feasible, but is associated with substantial complications. Furthermore, the success rate was low. More research is therefore warranted to assess optimal ablation techniques and energy sources to perform PVI.

clinicaltrials.gov Identifier: NCT00448656.

Symptomatic bradyarrhythmia patients implanted with a pacemaker equipped with both algorithms (Adapta DR, Medtronic) were enrolled. The %VPs of the patients during two periods were compared: 1 month operation of either one of the two algorithms for each period. All patients were categorized into subgroups according to the atrioventricular block (AVB) status at baseline: no AVB (nAVB), first-degree AVB (1AVB), second-degree AVB (2AVB), episodic third-degree AVB (e3AVB), and persistent third-degree AVB (p3AVB). Data were available from 127 patients for the analysis. For all patient subgroups, except for p3AVB category, the median %VPs were lower during the MVP operation than those during the Search AV+ (nAVB: 0.2 vs. 0.8%, P < 0.0001; 1AVB: 2.3 vs. 27.4%, P = 0.001; 2AVB: 16.4% vs. 91.9%, P = 0.0052; e3AVB: 37.7% vs. 92.7%, P = 0.0003).

Managed ventricular pacing algorithm, when compared with Search AV+, offers further %VP reduction in patients implanted with a dual-chamber pacemaker, except for patients diagnosed with persistent loss of atrioventricular conduction.

Data used in this analysis came from two CRT studies: Cardiac Resynchronization Therapy Registry Evaluating Patient Response with RENEWAL Family Devices (CRT RENEWAL) (n = 436) and Heart Failure-Heart Rate Variability (HF-HRV) (n = 838). Patients from CRT RENEWAL were used to create a model for risk of death using logistic regression and to create a scoring system that could be used to predict mortality. Results of both the logistic regression and the clinical risk score were validated in a cohort of patients from the HF-HRV study. Diagnostics significantly improved over time post-CRT implant (all P < 0.001) and were correlated with a trend of decreased risk of death. The regression model classified CRT RENEWAL patients into low (2.8%), moderate (6.9%), and high (13.8%) risk of death based on tertiles of their model predicted risk. The clinical risk score classified CRT RENEWAL patients into low (2.8%), moderate (10.1%), and high (13.4%) risk of death based on tertiles of their score. When both the regression model and the clinical risk score were applied to the HF-HRV study, each was able to classify patients into appropriate levels of risk.

Device diagnostics may be used to create models that predict the risk of death.