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Journal of Atrial Fibrillation Speical Issue Journal of Atrial Fibrillation Speical Issue Dear JAib subscribers, We are honoured to have the opportunity to publish our meeting’s abstract in this special issue of JAFib. This issue includes oral and poster communications accepted and presented during the 13th edition of VeniceArrhythmias 2013, held on October 27-29 in Venice, Italy. All abstracts are divided into categories according to their topics: mechanisms and genetics of cardiac arrhythmias, sick sinus syndrome & atrioventricular / intraventricular conduction disturbances, ventricular arrhythmias and sudden cardiac death, surface ECG & 24-hour holter monitoring in the evolution of cardiac arrhythmias, cardiac arrhythmias: pediatric and miscellaneous issues, vasovagal syncope: diagnostic and therapeutic issues, AF: cardioversion & anti-thrombotic issues, catheter ablation of AF: mapping and ablation techniques, catheter ablation of AF: long-term results, catheter ablation of AF: predictors of success, results of cryoballoon ablation of AF, prevention of SD by ICD, surgery for cardiac arrhythmias, CRT: techniques & imaging aspects, CRT: long-term outcome, transvenous lead extraction, ablation of different cardiac arrhythmias. Among all submitted abstracts, the Abstract Selection Committee chose a total of 131 oral communications and 134 posters. The country of origin of all the presenters along with the number of abstracts is listed below: Algeria 1 Indonesia 2 Argentina 7 Ireland 1 Austria 9 Israel 6 Belgium 1 Italy 26 Bosnia and Herzegovina 1 Japan 32 Brazil 5 Kazakhstan 4 Bulgaria 2 Latvia 3 Canada 8 Mexico 4 China 1 Netherlands 6 Czech Republic 4 Pakistan 1 Georgia 2 Poland 18 Germany 15 Portugal 8 Greece 9 Puerto Rico 2 India 1 Romania 1 Please ind below VeniceArrhythmias 2013 Abstract Selection Committee: P. Alboni / Ferrara, Italy J. Kautzner / Prague, Czech Republic E. Aliot / Vandoeuvre-lès-Nancy, C. Kennergren / Gothenburg, Sweden France H. Klein / Rochester, USA C. Antzelevitch / Utica, USA A.D. Krahn / Vancouver, Canada D.G Benditt / Minneapolis, USA M.T. La Rovere / Montescano, Italy E. Bertaglia / Padua, Italy S. Lévy / Marseille, France J.J. Blanc / Brest, France B. Lüderitz / Bonn, Germany G. Breithardt / Münster, Germany M. Lunati / Milan, Italy D. Callans / Philadelphia, USA P. Mabò / Rennes, France D.S. Cannom / Los Angeles, USA M. Mansour / Boston, USA R. Cappato / San Donato Milanese, F.E. Marchlinski / Philadelphia, USA Italy B.J. Maron / Minneapolis, USA R.J. Jr. Damiano / St. Louis, USA S. Mittal / New York, USA J.C. Daubert / Rennes, France C.A. Morillo / Hamilton, Canada R. De Ponti / Varese, Italy A. Moya / Barcelona, Spain L. Di Biase / New York, USA H. Nakagawa / Oklahoma City, USA P. Dorian / Toronto, Canada B. Olshansky / Iowa City, USA S. Dubner / Buenos Aires, Argentina O. Oseroff / Buenos Aires, Argentina A.E. Epstein / Philadelphia, USA E.I. Ovsyshcher / Beer-Sheva, Israel F. Giada / Noale, Italy A. Proclemer / Udine, Italy M.R. Gold / Charleston, USA A. Revishvili / Moscow, Russia www.jaib.com Russia 29 Slovakia 3 Slovenia 1 South Korea 5 Spain 13 Sweden 1 Taiwan 1 Thailand 1 Tunisia 1 Turkey 11 Ukraine 1 UK 1 Uruguay 1 USA 17 R.P. Ricci / Rome, Italy A. Rossillo / Venice-Mestre, Italy E. Saad / Rio de Janeiro, Brazil F. Sacher / Bordeaux, France S. Saksena / New Brunswick, USA I. Savelieva / London, UK M. Scanavacca / Sao Paulo, Brazil M.M. Scheinman / San Francisco, USA D. Shah / Geneva, Switzerland R.S. Sheldon / Calgary, Canada W.K. Shen / Phoenix, USA W.G. Stevenson / Boston, USA R. Sutton / Montecarlo, Monaco C. Tondo / Milan, Italy G. Turitto / New York, USA A.L. Waldo / Cleveland, USA A.A. Wilde / Amsterdam, the Netherlands B.L. Wilkoff / Cleveland, USA October, 2013 | Special Issue Journal of Atrial Fibrillation Speical Issue We would like to take this occasion to thank all colleagues who submitted their abstracts for VeniceArrhythmias 2013. Our appreciation goes also to the members of the Abstract Selection Committee who gave their precious contribution. Finally, our special thanks go to Dr D. Lakkireddy – JAib Associate Editor - who made this special issue possible. We wish you a good reading. Your sincerely, Antonio RAVIELE, MD www.jaib.com Andrea NATALE, MD Sakis THEMISTOCLAKIS, MD October, 2013 | Special Issue Journal of Atrial Fibrillation Speical Issue Contents Special Issue October 2013 ORAL COMMUNICATIONS: 6 Mechanisms And Genetics Of Cardiac Arrhythmias Sick Sinus Syndrome & Atrioventricular / Intraventricular Conduction Disturbances 14 Ventricular Arrhythmias And Sudden Cardiac Death 20 Surface ECG & 24-Hour Holter Monitoring In The Evolution Of Cardiac Arrhythmias 27 Cardiac Arrhythmias: Pediatric And Miscellaneous Issues 35 Vasovagal Syncope: Diagnostic Issues 42 Vasovagal Syncope: Therapeutic Issues 49 AF: Cardioversion & Anti-Thrombotic Issues 55 Catheter Ablation Of AF: Mapping Techniques 63 Catheter Ablation Of AF: Ablation Techniques 68 Results Of Cryoballoon And Laser Ablation Of AF 75 Catheter Ablation Of AF: Long-Term Results (Outcome) 82 Catheter Ablation Of AF: Predictors Of Success 90 Surgery For Cardiac Arrhythmias 98 Prevention Of SD By ICD 104 Transvenous Lead Extraction 113 www.jaib.com October, 2013 | Special Issue Journal of Atrial Fibrillation Speical Issue CRT: Techniques & Imaging Aspects 120 CRT: Clinical Aspects & Optimization 126 CRT: Long-Term Outcome 133 Ablation Of Different Cardiac Arrhythmias 140 POSTER COMMUNICATIONS: 145 Mechanisms And Genetics Of Cardiac Arrhythmias Surface ECG & 24-Hour Holter Monitoring In The Evolution Of Cardiac Arrhythmias 152 Vasovagal Syncope: Diagnostic Issues 164 Vasovagal Syncope: Therapeutic Issues 172 AF: Cardioversion & Anti-Thrombotic Issues 174 Catheter Ablation Of AF: Mapping Techniques 178 Catheter Ablation Of AF: Ablation Techniques 180 Results Of Cryoballoon And Laser Ablation Of AF 185 Cardiac Arrhythmias: Pediatric And Miscellaneous Issues 189 Catheter Ablation Of AF: Long-Term Results (Outcome) 201 Catheter Ablation Of AF: Predictors Of Success 206 Surgery For Cardiac Arrhythmias 211 Prevention Of SD By ICD 212 Pacemaker Therapy & Transvenous Lead Extraction 229 CRT: Techniques & Imaging Aspects 246 CRT: Clinical Aspects & Optimization 258 CRT: Long-Term Outcome 262 Ablation Of Different Cardiac Arrhythmias 265 www.jaib.com October, 2013 | Special Issue Mechanisms And Genetics Of Cardiac Arrhythmias Right Atrial Appendage And Atrial Septal Pacing Induces Left Atrial Electrical Dyssynchrony: Role Of Septal Activation Pattern I. Choudhuri, D. Krum, A. Agarwal, J. Hare, M. Belohlavek, A. Ahmad, M. Pinninti, B. Khandheria Aurora St. Luke’s Medical Center Clinical Cardiac Electrophysiology Milwaukee, WI USA Abstract Introduction: Left atrial (LA) dyssynchrony, deined as LA septal-lateral delay, is felt to improve with septal pacing. Methods: Eight canines underwent sternotomy during general anesthesia. Bipolar plunge electrodes delivered transmyocardially over the septal, anterior, posterior, and lateral LA recorded local activation during pacing just faster than sinus from sinus node, right atrial appendage (RAA), Bachmann’s bundle (BBR) and coronary sinus ostium (CSO). Results: All canines presented in sinus rhythm. Pacing from sinus node synchronously activated the septum at BBR and CSO. The LA was activated from septal to lateral by simultaneously propagating anterior and posterior wavefronts. RAA pacing activated the septum earlier at BBR than CSO, and the anterior LA was activated before the posterior LA. Septal pacing from BBR preexcited the anterior but not posterior LA. Septal pacing from CSO preexcited the posterior but not anterior LA. Conclusion: RAA, BBR and CSO pacing create dispersion of septal activation, with intra-LA activation delay between the anterior and posterior walls, concordant with pattern of septal activation. This dyssynchronous LA activation would not be detected by measuring LA septal to lateral delays. www.jaib.com 6 October, 2013 | Special Issue Journal of Atrial Fibrillation www.jaib.com Speical Issue 7 October, 2013 | Special Issue Left Atrial Activation Sequence During Bifocal Atrial Pacing: New Observations And Insights In An Acute Canine Model I. Choudhuri, D. Krum, A. Agarwal, J. Hare, M. Belohlavek, A. Ahmad, M. Pinninti, B. Khandheria Aurora St. Luke’s Medical Center Clinical Cardiac Electrophysiology Milwaukee, WI USA Abstract Introduction: Left atrial (LA) dyssynchrony, deined as LA septal-lateral delay, is felt to improve with bifocal pacing. Introduction: Eight canines underwent sternotomy during general anesthesia. Bipolar plunge electrodes delivered transmyocardially over the septal, anterior, posterior, and lateral LA recorded local activation during pacing just faster than sinus from sinus node, right atrial appendage (RAA)+Bachmann’s Bundle (BBR), RAA+Coronary Sinus Ostium (CSO) and RAA+Low Lateral Left Atrium (LLL). Results: All canines presented in sinus rhythm. Pacing from sinus node synchronously activated the septum at BBR and CSO, and activated the LA from septal to lateral by simultaneously propagating anterior and posterior wavefronts. RAA+ CSO pacing and RAA+ LLL pacing resulted in multiple wave-fronts anteriorly and posteriorly in the LA with associated activation dispersion. RAA+ BBR pacing produced simultaneously propagating LA anterior and posterior wavefronts, similar to sinus node pacing. Conclusions: In this canine model, pacing induced left atrial conduction delay and activation dispersion, seen with bifocal RAA+CSO and RAA+LLL pacing may be avoided by bifocal pacing from RAA+BBR. Establishing clinical utility requires human studies for validation. www.jaib.com 8 October, 2013 | Special Issue Journal of Atrial Fibrillation www.jaib.com Speical Issue 9 October, 2013 | Special Issue Mechanisms Of Lethal Arrhythmias In A Transgenic Mouse Model With Heart Failure And Sudden Cardiac Death M. Yamazaki, H. Honjo, I. Kodama, Y. Nakagawa, K. Kuwahara, K. Kamiya RIEM, Nagoya University, Nagoya, Japan (M. Yamazaki, H. Honjo, I. Kodama, K. Kamiya) Kyoto University Graduate School of Medicine, Kyoto, Japan (Y. Nakagawa, K. Kuwahara) Abstract Introduction: Transgenic mice expressing a dominant negative form of the neuron-restrictive silencer factor (dnNRSF), which facilitates reactivation of fetal cardiac gene programs, show progressive dilated cardiomyopathy and sudden arrhythmic death. We have investigated mechanisms of lethal ventricular arrhythmias (VT/VFs) in this model. Objectives: Optical action potential signals were recorded from ventricles of Langendorff-perfued hearts of dnNRSF and wild-type mice. Results: The action potential duration (APD) was prolonged and VT/VFs were initiated following early afterdepolarization (EAD)-mediated triggered activities in all (4/4) hearts of dnNRSF mice, while in none (0/4) of wild-type mice. A breakthrough-type focal activation was observed during the initial phase of VT/VFs, while interplay between focal discharges and reentrant activities was involved in the maintenance of sustained VT/VFs. Under constant pacing (n=3), APD was signiicantly prolonged (121±38% at 4 Hz, p<0.05) and conduction velocity was remarkably slowed (66±3%, p<0.05) in dnNRSF compared with wild-type mice. Conclusions: EAD-type triggered activity induced by excessive APD prolongation and functional reentry associated with decreased conduction velocity may be responsible for the initiation and maintenance of VT/VF in failing hearts of dnNRSF mice. www.jaib.com 10 October, 2013 | Special Issue Genetics Of Life Threatening Cardiac Arrhythmias B. Vyas, N. Namboodiri, R.D. Puri, R. Saxena, I. C. Verma PhD scholar, Centre of Medical Genetics, Sir Ganga Ram Hospital, New Delhi, India. 2Associate Professor, Cardiology, Sree Chitra Institute for Medical Sciences and Technology, Trivandrum, Kerala. 3Senior Consultant, Centre of Medical Genetics, Sir Ganga Ram Hospital, New Delhi, India. 4Senior Consultant, Centre of Medical Genetics, Sir Ganga Ram Hospital, New Delhi, India. 5Director and Senior Consultant, Centre of Medical Genetics, Sir Ganga Ram Hospital, New Delhi, India 1 Abstract Introduction: Sudden cardiac deaths caused by cardiac arrhythmias (long QT’s) have a prevalence of about 1:2000-2500 in different populations worldwide. Individuals affected with life threatening arrhythmias typically exhibit episodes of syncope, palpitations, seizures, abnormal ECG pattern. These are autosomal dominant disorders. Mutations identiied in three genes (KCNQ1, KCNH2 and SCN5A) account for majority of the cases. Aim: The aim of the ongoing study is to identify the mutations and SNPs in long QT type 1, 2 and 3 patients by sequencing all the coding exons in three genes. Till now, we have included eighteen patients in our study, Here, we report here two cases clinically diagnosed and molecularly conirmed with Long QT (Type 1 and 3) syndrome. Methods and results: A 12 year old girl with history of hundred episodes of syncope and QT prolongation was referred for evaluation. Mutational analysis identiied a known heterozygous missense mutation (V411M) in the SCN5A gene, encoding the primary cardiac voltage gated sodium channel, Nav 1.5. Second case is 2 year old boy with QTc of 510 ms. Sequencing identiied a known heterozygous in frame 3 bp deletion (S277del), that causes a decrease in the K+ channel activity. Screening of his parents detected this mutation in the asymptomatic father. A polymorphism (H558R) was also identiied in four out of nine patients screened for mutation analysis in SCN5A gene. Functional studies have shown the association of this polymorphism with the prolongation of QT interval. Conclusion: This study allows conirmation of the clinical diagnosis and provides information regarding choice of adopting the appropriate therapeutic and preventive intervention. www.jaib.com 11 October, 2013 October, 2013 | | Special Special Issue Issue Screening Of Hryr2 Mutations In Patients With Ventricular Tachycardia In Kazakhstan: Two Novel Point Mutations A. Akilzhanova1, C. Gülly2, Z. Nurkina1, O. Nuralinov3, B. Abdirova3, S. Dosmagambet3, Z. Zhumadilov1, A. Sharman1, M. Bekbosynova3 Department of Genomic and Personalised Medicine, Center for Life Scienses, Nazarbayev University, Astana, Kazakhstan Organization for Research Infrastructure Center for Medical Research, Medical University of Graz, Graz, Austria 3 National Scientiic Cardiosurgery Center, Astana, Kazakhstan 1 2 Abstract Introduction: Ventricular arrhythmias are the leading cause of morbidity and mortality worldwide, causing sudden cardiac deaths and making this a major public health concern. Methods: We screened two patients with CPVT (OMIM: 604772, Ventricular tachycardia, catecholaminergic polymorphic) and 14 patients with ventricular tachycardia for genetic variants in the mutational hot-spot regions of the human ryanodine receptor gene 2 (hRYR2). The target regions of hRYR2 including the most relevant 45 exons (coding and intronic splice-site regions of the exons) were ampliied by PCR and directly sequenced. This candidate gene approach revealed one novel mutation in a CPVT patient (c.A13892T; p.D4631V) and a novel mutation in one patient with VT (c.G5428C; p.V1810L). Both variants are located at phylogenetically conserved positions and predicted pathogenetic. Three known synonymous SNPs rs3765097, rs2253273 and TMP ESp1 237664067 were detected in the study group. Conclusion: The present study will be helpful in the evaluation of the need for genetic screening and reliable genetic counseling for Kazakhstan patients with arrhythmias for forecasting and prevention of sudden cardiac death. www.jaib.com 12 October, 2013 | Special Issue Hcm And Wpw Syndrome With Life Threatening Arrhythmia In An Adolescent Female: Prkag2 Mutation V. Aggarwal, N. Dobrolet, P. Jayakar, J. Zablah, Z. Ammous, S. Fishberger Department of Pediatric Medical Education, Pediatric Cardiology and Genetics, Miami Children’s Hospital, Miami, Florida, USA Abstract Introduction: V A 14-year-old girl presented with sudden onset of pre-excited atrial ibrillation with a rapid ventricular response. She was hemodynamically stable and was treated with a procainamide bolus which converted the rhythm to sinus. She had a past medical history of hypertrophic cardiomyopathy and WPW syndrome with multiple accessory pathways diagnosed four years back. At that time she underwent successful ablation of a two rapidly conducting accessory pathways in the right antero-lateral and left lateral AV groove. She had a third midseptal to antero-septal pathway; however, this pathway was not ablated at the time, due to the relative proximity to AV node, the limited antegrade conduction properties, and the lack of retrograde conduction. She was treated with atenolol. The patient had a strong family history of heart disease. Her mother had WPW syndrome and HCM and had atrial ibrillation at 12 years of age. She subsequently had placement of an ICD. Her maternal uncle, who was previously healthy, died suddenly at the age of 32 years. Also, her maternal cousin has WPW syndrome. Considering the past history of WPW and evidence of pre-excitation on ECG, she underwent electro-physiological testing. Three accessory pathways (right postero-septal, right lateral and midseptal) were mapped. Both right sided pathways were successfully ablated. The midseptal pathway demonstrated delayed elimination (10 – 15 seconds) with application of radiofrequency energy, though this was soon followed by accelerated junctional rhythm requiring termination of the lesion. Her postoperative course was remarkable for the development of a variety of AV conduction indings. On post-op day 4, she developed sinus rhythm with irst degree AV block and no evidence of ventricular pre-excitation. Two days later, this progressed to compete AV block. The following day, her AV node conduction returned, though there was still no evidence of pre-excitation. On post op day 9, ventricular pre-excitation was once again evident. She underwent implantation of a dual chamber ICD in view of the episode of high grade AV block and history of syncope in the setting of hypertrophic cardiomyopathy. Genetic testing was demonstrated the patient to be heterozygous in the PRKAG2 gene coding for a missense mutation deined as c.1589 A>G. Discussion: Mutations in PRKAG2 gene that regulates the γ2 subunit of the AMP dependent protein kinase have been associated with the development of AV accessory pathways, cardiac hypertrophy and conduction system abnormalities. We describe an adolescent female affected by the disease who experienced multiple life threatening arrhythmias and AV nodal block before placement of an ICD (Implantable cardioverter deibrillator). We aim to reiterate the importance of early recognition of this entity and possible placement of ICD early in the course of management to prevent catastrophic arrhythmias and possible sudden cardiac death. www.jaib.com 13 October, 2013 | Special Issue Sick Sinus Syndrome & Atrioventricular / Intraventricular Conduction Disturbances Arrhythmic Disorders In Anorexia Nervosa M. Yahalom, M. Spitz, L. Sendler, N. Heno, N. Roguin, Y. Turgeman Heart Institute Ha’emek Medical Centre, Afula. Children and Psychiatry, Western Galilee Hospital, Nahariya and Rappaport School of Medicine, Technion, Haifa, Israel Abstract Introduction: Anorexia Nervosa (AN) is a life-threatening condition, with a signiicant risk for death, due to cardiac complications. It is characterized by abnormal eating behavior with the prevalence of 0.5% to 1.0%. It affects predominantly adolescent girls, has the highest mortality rate of all psychiatric disorders, and has been associated with bradycardia, hypotension, mitral valve prolapse and heart failure. The diagnosis of AN can be elusive and more than one half of all cases are undetected. Purpose: to evaluate cardiac indings in AN. Patients and Methods: 23 patients (20 females) with AN were examined in the last 3 years, including ECG, echocardiogram and Holter monitoring. The mean age was 16 years (range 11.5-20), weight loss 13.5 kg (range 6-26), and BMI 15.4 (range 10.9-20). MVP was found in 3, mitral regurgitation (MR) in 4, and mild Aortic stenosis in one. 10 young adults (8 females and 2 males, mean age 15 years), without AN served as a control group. Results: all patients had bradycardia (mean 44/min, range 26-68/min) documented by ECG and Holter monitoring. Findings were sinus and nodal bradycardia, with no evidence of arrhythmias, or QT interval prolongation. No patient needed pacemaker therapy. In the control group the mean slow heart rate was 74/min (range 66-99/min). Conclusion: Bradycardia, in young adults, especially females with weight loss, should raise the possible diagnosis of AN, so it can be treated early and promptly in time. www.jaib.com 14 October, 2013 | Special Issue Sick Sinus Syndrome Induced By Alcohol P.I. Altieri, H.L. Banchs, N. Escobales, M. Crespo Department of Medicine and Physiology, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico Abstract Introduction: Find the effect of alcohol (.1mg/kg) I.V. on the sinus and atrioventricular nodes in mongrel dogs. Methods: The sinus node function was evaluated by the (SART) and the (AVN) by the highest atrial pacing rate at which Wenckebach (W) periodicity developed. 3 groups (G) were evaluated. Results: The alcohol concentration of each (G) were as follows: GI (Low Concentration), .063±.012 mg%; GII (Medium Concentration), .118±.026 mg%; and GIII (High Concentration) .240±.052 mg%. GI showed a 16% lengthening in SART (P<.05); GII, a 22% lengthening <.01); and GIII, a 45% lengthening (P<.005). The average percent reduction in (W) rate was: no change in Group I; 32% in GII (P<.05); and 41% in GIII (P<.005). The reduction in the heart rate was of 5.7% in GI (N.S.), 9.8% in GII is <.01), and 14.4% in GIII (P<.05). Atrial ibrillation developed at the highest concentration of alcohol. Autonomic blockade prevented these changes. Conclusions: Alcohol produced a sick sinus-like syndrome and its arrhythmias. www.jaib.com 15 October, 2013 | Special Issue Clinical Signiicance Of Rapid Atrial Pacing In Patients With Sick Sinus Syndrome M. Yahalom,Y. Turegeman 1 Heart Institute,Ha’emek Medical 2Rappaport School of Medicine, Technion, Haifa, Israel. Abstract Introduction: Sick sinus syndrome (SSS) is one of the major indications of pacemaker implantations. Aim: We evaluated the usefulness of rapid atrial pacing in patients with suspected SSS, regarding the diagnosis and the indication of permanent pacing. Methods: Sinus node recovery time (SNRT) was measured by atrial overdrive pacing in 21 patients with clinical and electrocardiographic evidence of sick sinus syndrome. There were 11 men and 10 women with an age range 52 to 82 years and a mean age of 68±6 years. Seven had sinus bradycardia, 5 had second degree sino-atrial block and 9 had a bradycardia-tachycardia syndrome. Underlying heart disease included ischemic heart disease in 13 patients, dilated cardiomyopathy in 1 and no detectable heart disease in 7 patients. Results: SNRT was measured by pacing the high right atrium at rates ranging from 90 bpm to 170bpm with 10 bpm decrements for 30seconds periods. It was prolonged ( > 450ms ) in 10 patients. The EP study showed that AV conduction was abnormal in 5 patients. The indication for permanent pacemaker was based on clinical criteria only. Permanent pacing was indicated in 10 patients, 4 with prolonged SNRT and 6 with normal values. Among the 11 patients in whom we did not indicate permanent pacing, 4 had prolonged. A dual- chamber pacemaker was implanted in the 5 patients with compromised AV conduction and atrial pacemakers in the remaining 5 patients. Conclusions: Rapid atrial pacing to measure SNRT was not consistent with the clinical and ECG indings of SSS. The indication of permanent pacing should be based on the clinical and evidence of SSS. However it may be of value for studying AV conduction and to select the type of pacing i.e. atrial vs. dual- chamber pacemaker in patients with suspected associated AV conduction disturbances. Further studies are required to conirm this assumption. www.jaib.com 16 October, 2013 | Special Issue Uncommon Etiology Of Heart Block In Adults M. Yahalom,Y. Turegeman Heart Institute, Ha’emek Medical Center, Afula, Israel;Rappaport School of Medicine, Technion, Haifa, Israel Abstract Introduction: A variety of diseases, besides the common Lev-Lenegre’s disease, can cause heart conduction system abnormalities. These include: Acute rheumatic fever, sarcoidosis, connective tissue disorders, neoplasm and bacterial endocarditis. Objectives: The purpose of the study is to raise awareness of these rare conditions. Patients and Methods: We present nine adult patients with various rare causes of heart block, who needed pacemaker therapy (temporary or permanent): I. A 33-year-old female who suffered acute rheumatic fever and transient complete atrio-ventricular block (CAVB). II. A 19-year-old soldier with a history of acute rheumatic carditis, who presented with recurrent syncope. Serial ECG recordings demonstrated inappropriate sinus bradycardia and AV dissociation. III. A 43-year-old female suffering from Wegener granulomatosis, proven by nasal mucosa biopsy and intermittent CAVB. IV. A 68-year-old female, with known metastatic breast cancer with pericardial involvement, presented with syncope and CAVB. V. A 69-year-old female presented with CAVB was diagnosed as having bacterial endocarditis, with abcess formation along the conduction system . VI. A 43-year-old male, presented with Stokes-Adams syndrome. On chest X-ray, CT and Gallium-scan, there was evidence of hilar lymphadenopathy, he was diagnosed with Sarcoidosis. VII. A 42-year-old man presented with intermittent 2:1 AV Block. The patient had been treated with Radiotherapy to the Mediasinum for Lymphoma 25 years previously, and on a CT scan of his chest, there is evidence of heavy calciicactions of the 3 coronary arteries, the root of the Aorta, Aortic valve and Mitral Annulus. VIII. A 49-year-old male, presented with CAVB. This young patient has quadriplegia and syringomyelia, following a road accident, 11 years ago. IX. A 43-year-old female presented with symptomatic congenital CAVB, and was treated with pacemaker therapy. Conclusions: We suggest that patients with these disorders should be followed at regular intervals, thus allowing early detection and treatment of heart conduction disturbances. www.jaib.com 17 October, 2013 | Special Issue Cardiac Resynchronization Therapy With Right Lead In Right Ventricular Outlow Tract. A Long-Term Follow-Up R. Muratalla, D. Lopez, M. Ortiz, R. Robledo Electrophyisiology Department of the National Medical Center “20 de Noviembre”, ISSSTE, Mexico City, Mexico Abstract Introduction: Cardiac resynchronization therapy (CRT) is worldwide accepted therapy for refractory heart failure with NYHA functional class II-IV; however almost all the studies that support this evidence had the right lead in apex instead the outlow tract. The aim of this study is to show our results in a long term follow up in CRT with the right lead in the right ventricular outlow tract (RVOT) instead of right apex. Patients and Methods: We prospectively included all patients referred to our center for CRT; since 1999 to January 2012. We evaluated them before and after the device implantation and in the follow up; with clinical test like functional class and objective test such as 6 minute walking, stress testing with Naughton protocol and with several echocardiographic parameters. We used central tendency meters and T pair test for the statistical analyses. Results: A total of 72 patients (pts) were suitable for inclusion. There were 49 (68%) male pts with a median age of 56 ± 10 years. The dilated pathology was due to ischemic cardiopathy in 37(51%). The co-morbilities were hypertension in 31 (43%), dyslipidemia in 22(30%), smokers in 17 (23%) diabetes in 13 (18%) and Atrial ibrillation in 10 (14%). With CRT 56 (78%) of which 11(15%) had simultaneous V-V pacing (“Y” connection) and with CRT/D 16(22%). The median follow up was 34 months (rank 12-144 months). Table 1: Baseline characteristics Pre-CRT Post-CRT p NYHA Class 2.34 ±0.85 1.6 ±0.8 0.003 6 min walk test (meters) 357 ±89 384±110 0.095 Exercise Testing (METS) 5.4 ±2.1 6.2±2 0.033 Ejection Fraction (%) 25.4 ±7.1 30.7±11.1 0.002 VTDV (ml) 263±78 212±75 <0.001 VTSV (ml) 198±83 163±72 0.012 Conclusions: As far as we know this is the irst long term report of CRT with right ventricular lead in RVOT, without complications and with a good objective response in the stress testing and echocardiographic parameters and in the clinical evaluation such as NYHA class. This lead position could be a better option for the right ventricle pacing. www.jaib.com 18 October, 2013 | Special Issue Relationship Between Inlammatory Cytokines And Electrical Remodelling In Cardiac Resynchronization Therapy D. Zizek, M. Cvijic, B. Antolic, I. Zupan Department of Cardiology, University Medical Centre Ljubljana, Slovenia Abstract Introduction: Cardiac remodelling in advanced heart failure (HF) is associated with increased inlammation, leading to ventricular ibrosis and subsequent impairment of intraventricular conduction. In addition, scar-related anisotropy provides conditions for re-entry ventricular tachyarrhythmias (VTs). The aim of our study was to evaluate the relation between inlammatory cytokines, intrinsic QRS duration (iQRS) and VT occurrence after cardiac resynchronization therapy (CRT). Methods: We prospectively included 55 patients with advanced HF (age 66 ± 10; 37 male (67%); New York Heart Association class II-IV; EF 26.4 ± 6.2%; QRS 162 ± 21ms; 26 ischaemic aetiology (47.3%)) who underwent implantation of a CRT device. Clinical, electrocardiographic and plasma levels of inlammatory parameters (interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor α (TNF-α)) were evaluated before and after 6 months of CRT. Biventricular pacing at 6 months was temporarily inhibited to record iQRS. Reverse electrical remodelling was deined as a decrease in iQRS duration by ≥10 ms. Results: After 6 months of CRT reverse electrical remodelling was accompanied by signiicant reduction of IL-6, IL-10 and TNF-α. Electrical remodelling was identiied in 31 patients (56%). This group of patients demonstrated signiicant decrease of cytokine levels (IL-6: 2.6 ng/L (1.7-4.4) to 2.1 ng/L (1.1-3.3), p=0.028; IL-10: 8.1 ng/L (0.9-17.8) to 4.2 ng/L (1.7-11.3), p=0.020; TNF-α: 7.4 ng/L (5.0-9.9) to 5.6 ng/L (3.27.1), p=0.001); whereas no changes were observed in patients without electrical remodelling. In median follow-up 30 (24-34) months, VTs were registered in 18 patients (32.7%). Patients with electrical remodelling experienced signiicantly less VTs compared to patients without electrical remodelling. Conclusions: Reduction of inlammatory cytokines after CRT could have a pathophysiological role in improvement of intraventricular conduction and consequent amelioration of arrhythmogenic substrate. www.jaib.com 19 October, 2013 | Special Issue Ventricular Arrhythmias And Sudden Cardiac Death Magnesium And Potassium Levels In Critically Ill Patients With Supraventricular And Ventricular Arrhythmias P.I. Altieri, W. González, H.L. Banchs, N. Escobales, M. Crespo Department of Medicine and Physiology, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico Abstract Introduction: Magnesium (Mg++), Potassium (K+) and Calcium (CA+) are crucial electrolytes in maintaining a stable electrophysiological status in critically ill patients (P.) The purpose of this study was to measure the above electrolytes in critically ill P Methods: 28 consecutive P. were analyzed for abnormalities in the electrolytes status. 18 were females and 10 males with a mean age of 62 years. Results: The admission diagnosis in 95% of the cases was congestive heart failure. Levels of these electrolytes and arrhythmias were analyzed. 64% had subnormal values of Mg++ < than 2mg% (1.8 ± .2mg%). 53 % of K+ < than 4.0mg% (3.8 ± .7mg%) and CA++ < 8mg% (7.4 ± .1mg%). Lower values of the 3 (14%) and (42%) of Mg+-K+. The QTC interval was increase (>440msec) in 28%. 25% had Atrial Fibrillation (A.F.) and Ventricular Tachycardia (V.T.). Conclusion: This data shows that Mg++ and K+ deiciency produces A.F. and V.T in critically ill P. www.jaib.com 20 October, 2013 | Special Issue Malignant Arrhythmias In Peripartum Cardiomyopathy M. Yahalom, L. Ilan-Bushari, E. Rosner, M. Jabaren, Y. Turgeman Cardiology Department, Ha’Emek Medical Center, Afula, Israel Abstract Introduction: Peripartum Cardiomyopathy (PPCM) is a rare disorder, deined as the onset of acute heart failure, without demonstrable cause, in the last trimester of pregnancy, or within the irst 6 months after delivery. It is often unrecognized, as symptoms of normal pregnancy mimic those of mild heart failure. PPCM is seldom presented as a cardiac arrest. Objectives: The purpose of our presentation is to raise awareness and suspicion of PPCM, even when symptoms are mild, and to suggest a clinical evaluation of pregnant women, before lethal or disabling events occur. Methods and Results: A healthy 42-yr-old woman with well documented ventricular ibrillation, was admitted to CCU after cardiac arrest and resuscitation at home, 10 days after her 5th child was born. On arrival the patient was unconscious. On examination S3 was detected. An ECG revealed sinus tachycardia of 110bpm, while an echocardiogram demonstrated global reduced left ventricular function. Brain CT and Coronary arteriography were normal. There was no evidence of pulmonary embolism on CT angiography. Serum markers of acute coronary syndrome were negative. Therapy included artiicial respiration and hypothermia. The patient recovered after one week, and an automatic cardiac deibrillator (AICD) was implanted before discharge. This patient resembles another young 28-yr-old woman, who was admitted to CCU eight years ago, in her 38-week 3rd pregnancy, because of palpitations and dyspnea; on examination S3 was detected, with documented non-sustained Ventricular Tachycardia (VT), with LBBB pattern and right axis of QRS, that was successfully treated with Carvedilol and Quinidine (following obstetric consultation). An echocardiogram revealed moderate global reduced left ventricular function. In summary, 2 female patients, out of 12 patients with PPCM (16%), between the years 2000-2011, with the mean age of 34 years (range 24-42) have been diagnosed as suffering of PPCM, that presented with ventricular arrhythmias (one in a malignant form). Conclusion: Our conclusions: PPCM is a rare disease, that, when appears, may have a lethal or disabling presentation. Careful followup should be performed for every pregnant woman, especially in the presence of symptoms, however mild. The question of expanding perinatal care, to meticulous clinical, and electrocardiographic evaluation, should be considered. www.jaib.com 21 October, 2013 | Special Issue The Bacterial Cultures Of Patients Developing Fever After Successful Out Of Hospital CPR N. Teodorovich, C. Shachter, G. Goltzman, M. Kagansky, Z. Vered Department of Cardiology, Asaf Harofeh Hospital and Tel Aviv University, Tel Aviv, Israel Abstract Introduction: After successful out of hospital CPR, patients frequently develop fever after admission and are treated with antibiotics. The objective of this study was to ind objective evidence of infection in these patients. Methods: The data of all patients that were hospitalized in our institution after out of hospital CPR was collected from electronic database. The bacterial cultures obtained in the irst 48 hours were evaluated. Results: A total of 110 patients were included. Eighty ive percent were males, 35% were previously diagnosed with coronary disease. Bacterial cultures were obtained in 52 patients. Thirty seven percent had positive cultures, including contaminants. Of those, 13.5% were blood cultures. Forty ive (41%) of patients survived till the end of the study. There was no correlation between positive cultures and fever, fever and mortality, and positive cultures and mortality. Conclusion: Bacterial infection is an infrequent cause of early in patients hospitalized after out of hospital CPR. Neither fever, nor positive microbial cultures are related to the patients’ outcome. The empiric antibiotic treatment of such patients should be restricted without proven source of infection. www.jaib.com 22 October, 2013 | Special Issue Diagnosis And Follow-Up Of Athletes With Anomalous Origin Of The Left Circumlex Coronary Artery From The Right Aortic Sinus V. Pescatore 1, C. Basso 2, E. Brugin 1, S. Compagno 1, M. Vettori 1, D. Noventa 1, G. hiene 1, F. Giada 1 Cardiovascular Department, Sports Medicine Unit, P.F. Calvi Hospital, Noale-Venice, Italy 2Department of Cardiac, horacic e Vascular Sciences, University of Padua, Padua, Italy 1 Abstract Background: Anomalous origin of coronary arteries (CA) is a cause of sudden death in the athletes. Origin of left circumlex (LCx) CA branch from the right aortic sinus or artery with a retro-aortic course, is the most frequent congenital CA anomaly. However, its clinical signiicance still remains unknown. The aim of the study was to assess the diagnostic value of transthoracic echocardiography (TTE) to diagnose this anomaly and to obtain follow-up data of these athletes. Methods: During pre-participation screening, 11 asymptomatic athletes (aged 13-48 years) were identiied with TTE suspicion of anomalous origin of LCx CA from right aortic sinus (“tubular shape” of the coronary running behind the aorta). The indications for TTE were: hypertension (1), systolic murmur (3), brady-arrhythmias (1), repolarization abnormalities (2), ST-T abnormalities during stress test (1), ventricular or supraventricular arrhythmias (3). To conirm the TTE suspicion, cardiac magnetic resonance (CMR) was performed in 8 and multidetector computed tomography in 3 athletes. Results: The diagnosis of anomalous CA with a retro-aortic course was conirmed in 9/11 athletes (82%). In 8 athletes, all with anomalous origin of LCx CA from right aortic sinus and negative exercise stress test, no clinical events occurred during a mean follow-up of 24 months, despite they continued to participate in competitive sports activities. In the athlete with ST abnormalities during stress test and inducible ischemia at stress CMR with late enhancement, angiography demonstrated an anomalous origin of the right CA from the left aortic sinus running behind the aorta; this patient was disqualiied from sport participation. Conclusion: These data show a good speciicity of TTE in detection of CA anomalies with a retro-aortic course. In the absence of signs of myocardial ischemia, short-term prognosis of athletes with this anomaly seems good. Further diagnostic work-up is mandatory for those athletes with ST-T abnormalities during stress test in order to exclude a major CA anomaly. www.jaib.com 23 October, 2013 | Special Issue Clinical Outcomes Of Young And Master Athletes Disqualiied From Competition Because Of Cardiovascular Conditions V. Pescatore 1, C. Basso 2, E. Brugin1, S. Compagno1, M. Vettori1, B. Reimers3, D. Noventa1, G. hiene2, F. Giada1 Cardiovascular Department, Sports Medicine Unit, P.F. Calvi Hospital, Noale-Venice, Italy 2Department of Cardiac, horacic e Vascular Sciences, University of Padua, Padua, Italy 3Cardiovascular Department, Cardiology, Mirano hospital, Mirano-Venice, Italy 1 Abstract Aim: To analyze the cardiovascular (CV) causes of disqualiication from competitive sports in young (<35 years) and master (≥35 years) athletes consecutively screened at our Sports Medicine Centre in a 10 years time interval and to collect follow-up data. Methods: During the 2001-2010 period, 35627 athletes (young 91%, master 9%) were screened according to Italian Protocol (history, physical examination, 12-lead ECG, exercise stress testing). CV conditions were analyzed on the basis of the reasons for proceeding with further CV examinations. Athletes with CV diseases were treated according to speciic guidelines. Results: Overall, disqualiied athletes were 99 (0.20%), 94 (95%) for a CV causes. They were referred for further examinations because of positive history for CV diseases (18%), heart murmurs or hypertension (9%), 12-lead ECG or stress test abnormalities (73%). Among young athletes 63 (0.19%) were disqualiied for the following CV causes: rhythm and conduction abnormalities (21), bicuspid aortic valve (12), mitral valve prolapse (MVP) with ventricular arrhythmias (VA) (10), arrhythmogenic right ventricular cardiomyopathy (ARVC) (3), hypertrophic cardiomyopathy (HCM) (3), congenital coronary artery anomalies (3), myocarditis (2), dilated cardiomyopathy (1), coronary artery disease (CAD) (1), atrial septal defect (2), Kawasaki disease (1), left ventricular diverticulum (1), hypertension (2), pulmonary hypertension (1). During follow up (63±34 months) clinical course of young athletes with CV diseases was unremarkable. Among master athletes 31(1%) were disqualiied for the following CV causes: MVP with VA (6), CAD (4), hypertension (3), HCM (2), ARVC (1), dilated cardiomyopathy (1), VA in myocardial ibrosis (2), and idiopathic VA (12). During follow-up (76±41 months) there were no deaths but two acute coronary syndromes. Conclusion: CV disqualiication rate was higher in master than young athletes (1% vs 0.19%). Clinical course of athletes with CV diseases was favorable, probably because they were disqualiied from competition and appropriately treated. These data conirm the usefulness of preparticipation screening and the key role of 12-lead ECG and stress test for the identiication of CV disease potentially at risk of sudden death. www.jaib.com 24 October, 2013 | Special Issue Current Global Practice Of Icd Testing: Everyone To His Taste?! D. Bastian1, F. Al Kandari2, M. Sepsi3, F. Lorgat4, A. Naik5, H. Mazzetti6, D. Becker7, R. Sweidan8 on behalf of PANORAMA Investigators Klinikum Nürnberg - Süd, Nürnberg, Germany, 2Kuwait Cardiac Center, Kuwait, 3University Hospital Brno, Brno, Czech Republic, 4Christiaan Barnard Memorial Hospital, Cape Town, South Africa, 5Care Insititute of Medical Sciences, CIMS hospital, Gujarat India, 6Hospital General de Agudos Juan A. Fernández, Buenos Aires, Argentina, 7Medtronic Germany, 8 King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia 1 Abstract Aim: Improved technology, the use for primary prevention of sudden cardiac death and potential risks of deibrillation testing (DT) have caused doubts on the necessity of intraoperative testing with Implantable Cardiac Deibrillators (ICD). Methods: PANORAMA is a long term, multi-center, prospective, non-randomized observational study. We analyzed the current practice of ICD testing at 100 hospitals across 6 geographical regions. In total 2084 subjects were implanted with an ICD (N=1405) or CRT-D (N=679) between 2005 and 2011. Results: Overall 51% devices were implanted without testing. DT ranged from 28% (Middle East) to 71 % (South Africa) and decreased over time. In 29 centers all implanted devices were tested, 38 centers tested <50% including 11 centers not testing. Conclusion: There are signiicant differences between and within global regions in current practice of ICD and CRT-D testing with a large proportion of not tested devices and a general trend to less testing. PANORAMA will follow up the impact of the observed differences on patient’s outcome in the long term. Table 2: Table 1: ICD test by region Total patients 2084 (100%) Eastern Europe 534 (26%) Patients tested 1020 (49%) 54% Primary Prevention tested 554 (45%) CRT-D tested 214 (32%) 42% 42% Multivariate logistic regression with endpoint ICD test and regions / CRT forced to stay in the model Variable Odds ratio (95%CI) VF Induction at Implant (1020 pts) NO VF Induction at Implant (1064 pts) More Testing India 125 (6%) 62% 46% 32% Latin America 211 (10%) 63% 59% 43% Middle East 634 (30%) 28% 29% 15% South Africa 119 (6%) 71% 60% 52% Western Europe 461 (22%) 58% 62% 17% V Lead Position Not Apex 14.9 (10.1-22.0) 300 (66%) 158 (34%) Impl Physician Cardiologist 3.8 (2.7-5.3) 529 (67%) 264 (33%) Region: Latin America 2.4 (1.2- 5.1) 132 (63%) 79 (37%) Region: Eastern Europe 1.8 (1.0-3.2) 286 (54%) 248 (46%) Region: India 1.6 (0.7-3.6) 77 (62%) 48 (38%) 1.6 (0.8-3.3) 84 (71%) 35 (39%) 1.5 (1.1-2.0) 847 (50%) 832 (41%) 1.2 (0.7-2.2) 266 (58%) 195 (48%) 1.01 (1.00-1.02) 33.1 (±13.6) 29.4 (±10.9) Region: South Africa Gender Male Region: Western Europe LVEF(%) Less Testing www.jaib.com 25 Primary Prevention 0.7 (0.5-0.9) 559 (45%) 680 (55%) History of AF 0.6 (0.4-0.8) 186 (44%) 241 (56%) Year of Implantation 0.6 (0.6-0.7) 2008.7 (±1.6) 2009.1 (±1.5) CRT ICD 0.4 (0.3-0.5) 214 (32%) 465 (68%) Region: Middle East 0.1 (0.0-0.2) 175 (28%) 459 (72%) October, 2013 | Special Issue Follow-Up And Safety Of Implantable Cardiac Deibrillator In The Elderly J. Morales, M. Ortiz, M. Cortes, R. Robledo Electrophysiology Department of the National Medical Center “20 de Noviembre”, ISSSTE, Mexico City, Mexico Abstract Introduction: The ICD (implantable cardioverter deibrillator) is a worlwide accepted therapy for preventing ventricular arrhythmias, however in the elderly there is a trend to diminish the amount of devices implanted in part due to other comorbidities that increases the general mortality and in part because of age itself. Nowadays the life expectancy has increase and these patients could have a better quality of life and survival. The aim of this study is to show that is a safety procedure and could be helpfully in this kind of patients without increasing the mortality and the secondary effects of the therapy like inappropriate shocks. Patients and Methods: We retrospectively included all patients 70 years or older send for ICD implantation from june 2002 to september 2011; we collected the data from the iles since the day of the implantation until December 2012. We used central tendency meters for statistical analysis. Results: We included 15 patients (pts) with median age of 74 years old (rank 70-84). There were 93% males. The associated comorbidities were as follows: Ischemic Heart Disease 87%, Hypertension 67%, Smokers 47%, and Diabetes 20%. Only 3 patients had a resynchronization therapy. The ejection fraction was <30% in 5 pts (33.3%), 30-50% in 6 (40%), and >50% in 4 (26.6%). The reason for the implant was secondary prevention in 10 pts (66.6%) of whom only 4 had an appropriate deibrillator therapy at 4, 15 123 and 270 days respectively. The site of the ventricular lead were in apex in 1 pts, middle septum in 2 pts, the other 13 in right ventricular outlow tract. There were no complications during the implant and there are no mortality during follow up. The acute and chronic pacemaker values are list in the following table. Thresolds Atrium Ventricule Sensitivity P wave R wave Impedances (Ohms) Atrium Ventricule Shock Impedances (Ohms) Acute 0.90 2.33 12.87 686 708 47 At 1 year 0 2.35 12.39 629 570 58 At 3 years 0.50 2.12 10.9 678 569 67 0.79 0.78 Conclusions: The ICD implantation in the elderly is a safe procedure at the implant and during follow up; has the same indication than other young patients, and could increase the survival and the quality of life in this rank of age. www.jaib.com 26 October, 2013 | Special Issue Surface ECG & 24-Hour Holter Monitoring In The Evolution Of Cardiac Arrhythmias Examination Of Resting Electrocardiograms Of Patients With Atrioventricular Nodal Reentrant Tachycardia And Its Utilization In Differential Diagnosis Of Common And Uncommon Subtypes O.C. Yontar, A. Erdem, U. Kutuk Bursa Postdoctorate Training and Research Hospital, Bursa, Turkey Abstract Introduction: AVNRT is the most common subgroup of regular SVT. There are two types of AVNRT: common and uncommon. Our aim is to determine particular resting ECG abnormalities in patients with AVNRT and identify if there is a difference between common and uncommon AVNRT in this ield. Methods: Records of Sivas Numune Hospital from January 2010 to October 2012 were retrospectively examined. ST and T wave abnormality on twelve-lead resting ECG were classiied according to location as 1) DII-III and aVF, 2) DI and aVL, 3) V4-6 leads. Negative T wave and/or ≥1 mm ST depressions were accepted as deviations. Results: Common AVNRT patients had abnormality mostly on DII-III and aVF (75%) while uncommon group rather had on DI and aVL (80%) (p=0,000). Linear regression analysis showed that, among all other variables (age, sex, hypertension and diabetes) only ECG abnormality subtype was an independent predictor for discriminating typical from atypical AVNRT. Conclusion: Common AVNRT seems to be associated with II-III-aVF derivations whereas uncommon AVNRT is more likely associated with I and aVL (p=0,000). We suggest that resting ECG is important in decision making for a patient with SVT who is planned for electrophysigical testing. ST and/or T wave deviations on particular ECG derivations may aid for preprocedural planning and preparation of clinicians. Resting twelve lead electrocardiogram of a patient who later Figure 1: diagnosed as common AVNRT. Arrows indicate nonspeciic ST segment depressions especially on leads III and aVF. www.jaib.com Same patient’s twelve lead electrocardiogram during Figure 2: supraventricular tachycardia. Arrows indicate rate-induced typical ST segment depression. 27 October, 2013 | Special Issue Non-Invasive 3D Phase Mapping Of Atrial Flutter M. Chaykovskaya, E. Fetisova, M. Yakovleva Department Arrhythmology and Electrophysiology, Petrovsky National Rasearch Center of Surgery of Russian Academy of Medical Science, Moscow, Russia Abstract Introduction: FNovel method of cardiac mapping based on numerical reconstructions of data obtained from body surface electrograms. Electrocardiographic imaging (ECGI) includes phase mapping of re-entrant arrhythmia, which was translated from basic science. Reliability of the method required validation. Methods: Three patients (age 56±7, male) underwent ECGI study (including heart and torso CT) and ECG body surface mapping followed by data processing. Based on processing of unipolar electrograms, isochronal maps, using -dU/dt max approach and phase maps (Hilbert transform approach) were created. Results: Both types of maps demonstrated similar pattern of excitation, including counterclockwise rotation around tricuspid annulus. However, compared to activation front on isochronal map, phase jump boundary was moved back by half cycle of atrial lutter. In addition, phase map demonstrated high quality of visualization. Conclusions: New method of re-entrant arrhythmia visualization based on phase mapping was demonstrated. www.jaib.com 28 October, 2013 | Special Issue Twenty-Four-Hour Heart Rate Evaluation For Permanent Atrial Fibrillation Patients Risk Assessment I. Kurcalte, O. Kalejs, R. Erts, A. Kalnins, A. Kalinin, A. Lejnieks Clinic of Cardiovascular disease, Riga Eastern Clinical University Hospital, Riga, Latvia Abstract Introduction: Heart rate (HR), ventricular arrhythmias (VA) and QRS complex width analysis is used for ECG-based noninvasive risk evaluation for permanent atrial ibrillation(PAF) patients. We speculate: impaired circadian HR changeability is associated with higher PAF patients mortality risk. Methods: In cohort of 253 PAF patients (dead - 74 pts, 34(46%) male, mean age(SD) - 78(7.8), alive – 179pts, 79(44%) male, age - 74(10.1) HM records archived in 2007-2010 (follow-up – 47(8.4) month) were analysed. Primary end-point – total mortality. Characteristics of 24-hours HR changes were calculated, analysed using univariate analysis and included in logistic regression(LR) models. ROC curves were obtained to establish optimal cut-off point for continuous characteristics and compare LR models including patient clinical characteristics only, HM data only and combined models including clinical and HM parameters. Results: All calculated 24-hours HR changeability parameters were statistically signiicantly lower in dead patients (table 1). Maximum risk assessment model capability(AUC) was obtained by including 24-hour HR parameters (table 2). Conclusions: PAF patient with lower 24-hours HR changeability are in higher mortality risk. Inclusion of circadian HR characteristics in risk assessment could improve mortality prediction for PAF patients. Table 1: Univariate analysis of 24-hour HR changes. Variable Dead (n=74) Alive (n=179 DeltaHR (bpm) (mean (SD) 98 (25.0) 112 (32.2) DeltaHR< 108bpm (patient (%) 51 (69%) 76 (42%) AveDNHRratio (mean (SD) 1.14 (0.13) 1.26 (0.16) AveDNHRratio <1,13 41 (55%) 46 (25%) AveDNHRdif(bpm) (median[25;75%] 9 [0; 20] 16 [2; 30] AveDNHRdif <9bpm 45 (61%) 47 (26%) MaxMinHRratio (mean (SD) 3.30 (0.74) 3.60 (0.84) MaxMinHRratio <3,11 39 (53%) 51 (28%) Table 2: OR (95%CI) AUC p-value .64 (.57; .71) .001 .697(.629; 764) <.001 .701 (633;.777) <.001 .621 (.547;.695) .008 2.93 (1.65; 5.2) <.001 3.65 (2.07; 6.43) <.001 4.42 (2.50; 7.85) <.001 2.84 (1,62; 4.97) <.001 Sensi-tivity (%) Speci-ity (%) You-den index Accu-racy 69 57 .26 .60 75 55 .30 .69 74 61 .26 .69 53 72 .23 .59 Comparison of risk assessment models. Model AUC (95% CI) p-value Correct prediction % Nagelkerke R square Clinical .744 (.679; .808) <.001 72,7 .199 HR + VA .780 (.714; .846) <.001 81 .321 Clinical + VA analysis .794 (.732; .855) <.001 77.9 .301 Clinical + HR analysis .801 (.744; .859) <.001 77.9 .325 Clinical + HR + VA .839 (.784; .895 <.001 81.4 .408 Abbreviations: SD, standard deviation; bpm, beats per minute; CI, conidence interval; OR, Odds ratio; Max, maximum; Min, minimum; Ave, average; dif, difference; DeltaHR, max min HR difference; D, day; N, night. www.jaib.com 29 October, 2013 | Special Issue Automated Ecg Reading Of Early Repolarization. Prevalence And Prognostic Implications P. Aagaard, E. Shulman, J.D. Fisher, J.N. Gross, S.G. Kim, E.C. Palma, A. Krumerman, K.J. Ferrick Monteiore Medical Center, he University Hospital of Albert Einstein College of Medicine, Bronx, USA Abstract Introduction: Early Repolarization (ER) has recently been associated with an increased risk of sudden cardiac death. ECG machines detect ER using algorithms based on ST-segment elevation, while the ER-pattern associated with SCD is based on J-wave morphology. As automatic readings of ”ER” may raise unwarranted concern and create liability issues, we investigated its prognostic implication in a large racially diverse inner-city population. Methods: An ECG database from a tertiary medical center serving an urban population containing n=900,000 records was interrogated for automated in- and outpatient resting ECGs. Only the irst recorded ECG per individual was included. ECG’s recorded during ACS and in individuals <18 years old were excluded. Outcomes were assessed by searching hospital records and the Social Security Death Index. Results: Baseline characteristics are shown in Table 1. ER prevalence differed signiicantly between racial subgroups (p-ANOVA <0.001) and was more common in African Americans. When controlling for age using regression analysis, there was no signiicant difference in mortality between subjects with vs. without ER regardless of race or gender (p>0.10 for all). Conclusions: Automated ECG reading of “ER” does not portend an increased risk of death regardless of race or gender. Therefore, individuals with such readings should be reassured. Table 1: Baseline characteristics for subjects with vs. without ER www.jaib.com Early repolarization No early repolarization p-value N= (%) 3,021 (1.5) 198,669 (98.5) <0.001 Age (years) 50.9 ± 8.2 60.9 ± 10.1 <0.001 Female (%) 32 58 <0.001 African Americans (n,%) 1,366 (2.1) 62,565 (97.9) <0.001 Caucasians (n,%) 346 (0.1) 39,911 (99.9) <0.001 Hispanics (n,%) 975 (0.1) 68,342 (99.9) <0.001 30 October, 2013 | Special Issue Risk Of Mortality And Ventricular Arrhythmia In Patients Ineligible For T-Wave Alternans Testing - Substudy Of The Twente ICD Cohort Study (TICS) K. Kraaier, M.A.G.M. Olimulder, M.F. Scholten Department of cardiologie, horaxcentrum Twente, Medisch Spectrum Twente, Enschede, he Netherlands Abstract Background: T-Wave Alternans (TWA) is a potential risk marker for selecting implantable cardioverter deibrillator (ICD) recipients. However, a large percentage of ICD candidates is ineligble for testing. We aimed to evaluate the risk of mortality and ventricular arrhythmia in patients ineligible for TWA testing. Methods and results: 269 Patients with ischemic or non-ischemic left ventricular dysfunction and who received an ICD between September 2007 and March 2010 were included in the analysis. TWA was assessed during treadmill testing and classiied as non-negative or negative. TWA was technically not feasible in patients with atrial ibrillation (AF), pacemaker dependency or poor clinical state. In 66 patients (24.5%), TWA testing was not possible. These patients were more frequently male (p=0.01), older (p<0.01), more frequent known with AF (p<0.001) and lower function class (p<0.001). Compared to non-negative and negative tested patients, both mortality (p= 0.01) and appropriate shock therapy (p= 0.01) was signiicantly higher in these ineligible patients. Conclusions: WA testing is not feasible in a large percentage of patients. These ineligible patients experience the highest risk for mortality. www.jaib.com 31 October, 2013 | Special Issue Precordial Qrs Amplitude Ratio Predicts Long-Term Outcome After Catheter Ablation Of Electrical Storm Due To Ventricular Tachycardias In Patients With Arrhythmogenic Right Ventricular Cardiomyopathy A. Müssigbrodt, B. Dinov, L.Fiedler, P. Sommer, T. Gaspar, S. Richter, O. Breithardt, A. Bollmann, D. Husser, C. Piorkowski, G. Hindricks, A. Arya Department of Electrophysiology, University of Leipzig, Heart Center, Leipzig, Germany Abstract Background: Radiofrequency catheter ablation is currently considered as the therapeutic option of choice in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) and recurrent ventricular tachycardia (VT). Objective: To assess the long term outcome of catheter ablation in a large cohort of patients with ARVC with electrical storm due to monomorphic VT. The speciic objective was to assess the relationship between precordial QRS amplitude ratio and outcome of catheter ablation in these patients. Methods and results: Twenty-eight patients (19 men, age 52.3±14.2 years) underwent 48 catheter ablation procedures (range 1 – 6, six epicardial). All the clinical and non-clinical VTs were ablated successfully in 23 (82%) patients (1.7 ablation/patient). During mean followup of 18.7±15.1 months (range 1 – 64 months) 13 patients (46.5%) experienced VT recurrence. Age < 50 years (odds ratio [OR]: 4.9; 95% conidence interval [CI]: 1.3 – 18.2, Cox-Regression-P=0.009) and ∑QRSmvV1-V3/∑QRSmvV1-V6 ≤0.48 (OR: 4.8; 95%CI: 1.1 – 22.3, CoxRegression-P=0.019) but not right ventricular size (P=0.26) and acute ablation outcome (unadjusted-P=0.03, adjusted-P [for age and QRS amplitude ratio]=0.22) were associated with VT recurrence during follow up. Conclusions: Age < 50 years and ∑QRSmvV1-V3/∑QRSmvV1-V6 ≤0.48 predicts recurrence of VT after successful radiofrequency catheter ablation of VT in patients with ARVC and electrical storm. More aggressive ablation strategies i.e. endocardial and epicardial mapping and ablation, may improve the long term outcome in these patients. www.jaib.com 32 October, 2013 | Special Issue Ekg Artifacts Mimicking Ventricular Tachycardia (Vt) In A Palpitating Woman AS. Salim, M. Yamin, S.A. Nasution Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia Abstract Introduction: Palpitations are one of the most common reasons patients come to internists and cardiologists. Failure to distinguish artifacts from potentially life-threatening arrhythmias might lead to further unnecesarry invasive procedure. Case report: A 40-yo-female came to cardiology clinic because of intermittent palpitation, without precipitating or exaggerating factors. She had no accompanying symptoms nor family history of sudden cardiac death. Her resting EKG was normal and 24-hour Holter showed “run VT” (Figure 1). She demanded more invasive study that failed to demonstrate run VT with programmed extrastimulus on electrophysiology (EP) study. No symptom was experienced afterwards. Discussion: Her Holter showed normal QRS complex within pseudo-VT and unstable baseline before and after the episodes, so most likely these were artifacts mimicking VT. EKG tracing with body movement is needed as speciic muscle movement might intervene. One-third of electrophysiologists failed to identify artifacts mimicking VT and most ordered unecessary invasive procedures. Patient’s tiresless effort asking for further evaluation made us perform EP study showing her “uninduced-arrhytmia”. Conclusions: QRS complex within pseudo-VT and unstable baseline were an useful diagnostic inding to distinguish real VT from artifacts in this patient. Figure 1: Pseudopolymorphic VT in Holter recording during sleeping www.jaib.com 33 October, 2013 | Special Issue Remote Phm Cloud Cluster For Arrhtyhmias Prognosis And Drug Control Eficient Y. Kaganovich , S. Kirillov Assuta Medical Center, Department of Cardiology, Tel-Aviv, Israel; Intelligence prognosis center, Space technology and Telecommunication cluster, Skolkovo, Moscow, Russia Abstract Introduction: Prognostics and Health Management (PHM) is a new IT trend whose purpose is the development of methods, algorithms and computing clusters to identify hidden early predictors of cardiovascular risks. Cloud computing cluster supports ECG ultra-portable recorder. Methods: Using the above-mentioned technology and PHM predictive methods of development of predictors of ventricular tachycardia were studied methods for optimizing drug treatment of arrhythmias in the persistent phase. ECG monitoring was carried out episodically or permanently depending on the ECG dynamics. The minimum time of ECG recording was in different cases from 5 minutes to 10 hours daily. ECG recording length was determined automatically by cloud cluster algorithms. Results: Monitoring was held to ten patients with persistent atrial ibrillation. Change of antiarrhythmic drugs was controlled cloud cluster. Early criteria of drug ineffectiveness were established. It also speciied criteria of eficiency on the basis of modeling the evolution of latent predictors. In some cases, the PHM systems prevent development of life threatening arrhythmias. Conclusions: Thus ECG analysis on base PHM cloud cluster is new possibilities for heart failure management and drug control eficient. www.jaib.com 34 October, 2013 | Special Issue Cardiac Arrhythmias: Pediatric And Miscellaneous Issues Endocardial Pacemaker In Pediatric Populations With Ultra Thin Catheters A. Bochoeyer, R. Rabinovich, A. Rosso, M. Garrido, L. Trentacoste, W. Conejeros, M. Grippo Servicio de Electroisiologia y Marcapasos, Hospital de Niños “Ricardo Gutierrez”, Buenos Aires, Argentina Abstract Introduction: LImplanting a permanent pacemaker (PM) or cardio-deibrillator (ICD) in pediatric patients (pts) or Grown-Up Congenital Heart Disease is a medical and surgical challenge. The weight and size of the pts, the caliber of the veins, the peri-surgical risks, and the need of long-time stimulation required; are all issues that may represent potential risk for the implant and may inluence clinical decisions. In this sense, the strategy of surgical approach as well as the decision of implanting dual-chamber devices, are crucial for prognosis and for adequate cardiac pacing during a long-term follow-up. Material and methods: We describe our experience with implantation of dual chamber PM trough endocardial access in 40 consecutive pts from May 2009 through March 2013. The analysis was retrospective, mean age 13 ± 5 years (5-31). The average weight was 38 ± 13 kg. (Range 16-64 kg.), and 37% (15/40) were women. Either left or right axilar vein punction was performed in 40/40 pts and the device was placed in a retro-pectoral pocket. Results: The indication for dual chamber PM was complete A-V Bock in 28 cases (70%) for congenital in 18 and acquired in 10), severe post-surgery sinus node dysfunction in 5, ICD for VT in 6 pts with Long QT and CPVT, and 1 up-grade to Biventricular pacing in a patient with severe DCM and chronic AF with low heart rate. Ultra-thin 4 French catheters were used in 19 dual chamber PM, and 5.5 French catheters in the other 15 cases. We used 6 French catheters for deibrillation in 6 pts with ICD implantation. The successful implant to dual-chamber devices was achieved in 39/40 pts (97,5%) because in one pts, the LV lead could not be implanted secondary to complete thrombosis of the innominate vein. There were no acute or long-term follow up complications. At the time of latest schedule visits there were not any signiicant increment of stimulation thresholds or malfunction in any case. Conclusion: in this selected population the implantation of endocardial dual-chamber devices through the axilar vein punction was feasible, safely and successful. The use of adequate ultra-thin catheters was a fundamental tool to obtain such results, and those catheters showed proper and stable stimulation capabilities over time. www.jaib.com 35 October, 2013 | Special Issue Twenty Years Of Pediatric Catheter Ablation: Evolution Of Practice J.M. Côté, F. Philippon, J. Champagne, M. Gilbert, F. Molin, L. Blier, I. Nault, J.F. Sarrazin, P. Chetaille, G. O’Hara Department of Cardiology, IUCPQ, Quebec, Canada Abstract Introduction: The Quebec Heart and Lung Institute serves more than 2 million people and represents the only electrophysiologic (EP) center for both children and adults in this population. The purpose of this study was to evaluate our experience with catheter ablation in children over a 20-year period. Results: From 1993 to 2013, 649 EP procedures (85% with ablation) were performed in 591 children with a mean age of 13.3±3.6 years (range 9 months to 17.9 years). Catheter ablation of all AVNRT (n=179) was performed using radiofrequency with recurrence in only 4 patients and no permanent AV block. Concealed or manifest accessory pathways (PW) were documented in 289 procedures. Type N Patients AVNRT Left PW N Procedures Age ≤ 10 years Long-Term Success 176 179 10% 99.5% 162 175 21% 99% Right PW - Postero-septal (PS) - Antero-septal (AS) - Non-septal 95 38 22 35 114 42 30 42 27% 19% 33% 26% 82% 100% 33%* 94% PJRT 22 27 67% 100% Atrial Flutter 12 (CHD = 8) 15 6.7% 8/8 (100%) CHD** Atrial Tachycardia 22 27 18.5% 90% Ventricular Tachycardia 15 21 13% 77% Note: *Ablation attempted by cryotherapy in 12/22 patients. Acute success was achieved in 75%, with a recurrence rate of 44%. **Congenital heart disease with ablation using a 3D mapping system. Recently, in selected postero-septal PW, irrigated catheters have decreased recurrences and failed procedures. There were no major complications including death, AV block, stroke, and tamponade over the whole 20-year period. Conclusion: in this selected population the implantation of endocardial dual-chamber devices through the axilar vein punction was feasible, safely and successful. The use of adequate ultra-thin catheters was a fundamental tool to obtain such results, and those catheters showed proper and stable stimulation capabilities over time. www.jaib.com 36 October, 2013 | Special Issue The Treatment And Long Outcome In Children With Long QT Syndrome B. Pietrucha, M. Pitak, B. Załuska-Pitak, J. Kuźma, J. Oko-Łagan, A. Sulik, A. Pietrucha, A. Rudziński Children Cardiology Department, Children University Hospital, Jagiellonian University Medical College, Cracow, Poland. Department of Coronary Disease, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland Abstract Background and methods: We observed 17 children at the age from 6 months to 17,5 yrs (mean age 10 yrs), 10 girls and 7 boys, with diagnosed long QT syndrome. Patients were divided into 2 groups: Group I – 11 children ( 7 females, 4 males) with symptomatic long QT syndrome ( syncope, dyspnoe); group II – 6 pts (3 girls and 3 boys) with prolongation of QTc segment in ECG but without any clinical symptoms. All patients were in long term follow-up from 19 months till 7 years (mean observation time - 3,5 yrs). Standard 12 leads ECG with assessment of QT interval, corrected QT interval according to Bazzet formula and QTc dispersion were done at the beginning and the end of observation period. 24-hour Holter ECG monitoring with QT evaluation was also performed in all patients. All patients from group I were administered of beta blockers (propranolol or metoprolol) with mean dose 1,2mg/kg. Results: Mean standard ECG QTC duration in pts in group I was signiicantly higher than in group II both in the beginning and in the end of observation period ( 471,82 vs 435 ms and 460,91 vs 423,33 ms). The similar result was observed in Qtc duration in Holter monitoring (535 vs 455 ms; 515,91 vs 452,5 ms.)There were no signiicant differences between QTc duration before and after beta-blocker treatment in group I (471,82 vs 460,91 ms) although frequency and intensity of symptoms in this group of pts was expressively diminished. 3 patients (27,3%) from group I were referred to ICD implantation. Conclusions: 1. Beta blockers diminished clinical symptoms in long QT syndrome. 2. Syncope can be evident risk factor of sudden cardiac death in children. 3. Pharmacological treatment could decreased the SCD risk in children with long QT syndrome. www.jaib.com 37 October, 2013 | Special Issue Retrospective Analysis Of Azithromycin On The QT Interval Prolongation In Acute Coronary Syndrome Patients D. Lumban Gaol, M. Winardi, R.J. Saragih, S. Salim, S.A. Nasution Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo National Central Hospital, Jakarta, Indonesia 2 Department of Internal Medicine, Faculty of Medicine, Christian University of Indonesia, Jakarta, Indonesia 1 Abstract Introduction: To evaluate the effect of azithromycin on QT prolongation in acute coronary syndrome (ACS) patients. Methods: We performed a retrospective cohort study of patients with ACS who treated with azithromycin due to pneumonia in 2012. We also explored other risk factors that may cause QT prolongation. Patients divided into group without risk factors (Group 1) and group with risk factors (Group 2). The QTc was calculated using Bazett’s formula on the irst day (QTc1), day 3 (QTc3) and day 5 (QTc5) after administration of azithromycin. We compared QTc prolongation in each group with Wilcoxon signed ranks test. Results: We found 37 patients treated with azythromycin. In Group 1, QTc1 vs QTc3 and QTc1 vs QTc5 were 482±71 ms vs 460±58.1 ms (p = 0.32), and 482±71 ms vs 461±52 ms (p = 0.18), respectively. In Group 2, QTc1 vs QTc3 and QTc1 vs QTc5 were 456±53 ms vs 492±69 ms (p = 0.03), and 456±53 ms vs 494±71 ms (p = 0.03), respectively. Conclusions: Azithromycin signiicantly increase QT interval in ACS patients with risk factors. www.jaib.com 38 October, 2013 | Special Issue Unexpected Finding In An Adult With Ventricular Fibrillation And An Accessory Pathway: Non-Compaction Cardiomyopathy A. Yaksh, D. Haitsma, T. Ramdjan, K. Caliskan, T. Szili-Torok, N.M.S. de Groot Department of Cardiology, Erasmus Medical Center, Rotterdam, he Netherlands Abstract Introduction: A 19-year-old female presented with an out of hospital cardiac arrest caused by ventricular ibrillation (VF) after alcohol intake and immersion into water. After deibrillation, sinus rhythm appeared with pre-excitation in accordance with a right sided posteroseptal accessory pathway. Twenty-four hours after therapeutic hypothermia she regained consciousness without neurological injury. The patient had no cardiac history. The accessory pathway was successfully ablated. Cardiac imaging demonstrated isolated non-compaction cardiomyopathy of the left ventricular myocardium (INVM). Sofar, an accessory pathway has only been described in 2 adult and 4 paediatric INVM patients. However, an adolescent patient with a Wolff-Parkinson-White syndrome and INVM presenting with VF has never been described before. Based on clinical data, it is impossible to determine whether VF was the result of either INVM or atrial ibrillation with fast conduction over the accessory pathway. She received a subcutaneous ICD for secondary prevention. Conclusions: In conclusion, we described a 19-year-old patient who presented with an out of hospital cardiac arrest due to VF in the presence of a right sided postero-septal located accessory pathway. Surprisingly, we also found an INVM. www.jaib.com 39 October, 2013 | Special Issue Interactive Teaching System Combining Two Arrhythma Simulators T. Haber, F. Holzer, J. Härtig, M. Heinke, J. Melichercik, B. Ismer Peter Osypka Institute for Pacing and Ablation at Ofenburg University of Applied Science, Ofenburg, Germany MediClin Heart Center Lahr/Baden, Germany Abstract Introduction: In-vitro training in implantable deibrillator and pacemaker measurements and programming can be done using heart rhythm simulators. Unfortunately, commercial systems provide only limited sets of arrhythmias and electrode problems. Objectives: To combine the features of two heart rhythm simulators, ARSI-4 and Intersim II, into a master-slave teaching system. Methods: Special implant connection modules were developed to provide deibrillators, pacemakers and CRT systems with right atrial, right and left ventricular electrode electrograms simulated by either the commercial ARSI-4 or the Intersim II heart rhythm simulator. Explanted deibrillators and pacemakers were assembled into an isolating box and supplied with external power. After completing their power on reset procedure they were reused for training purposes. To enable remote patient monitoring, seven workstations were equipped with Carelink and Homemonitoring. Results and conclusions: Special implant connection modules are neccessary to combine full features of two commercial heart rhythm simulators into a teaching system with Carelink and Homemonitoring. Thus, interactive in-vitro training in antibradycardic, antitachycardic and cardiac resynchronization therapy can be performed by simulating problems and their solutions in a wide range of the clinical routine. www.jaib.com 40 October, 2013 | Special Issue Feasibility, Eficacy And Safety Of Percutaneous Retrieval Of A Leadless Cardiac Pacemaker In An In Vivo Ovine Model J. Sperzel, A. Khairkahan, D. Ligon Kerckhof Clinic, Department of Cardiology, Bad Nauheim, Germany Abstract Objectives: TLeadless pacemaker technology is an emerging method to deliver pacing therapy to the right ventricle offering the beneit of elimination of the surgical pocket and lead. In this study, we examine the feasibility, safety and effectiveness of retrieval of a leadless cardiac pacemaker (LCP) in an in vivo ovine model. Methods: SThe LCP was successfully retrieved in all 10 subjects. Implant duration before retrieval was 159-161 days (>5 months). The mean time from retrieval catheter insertion into the 18F introducer and mating to the LCP docking button was 1 min 48 sec (range: 13 sec-3 min 58 sec). The average time from retrieval catheter insertion into the 18F introducer to removal of the LCP and retrieval catheter from the 18F introducer was 2 min 35 sec (range: 1 min to 4 min 4 sec). The average delivery time for re-implantation from delivery catheter insertion to removal from the 18F introducer after implant was 2 min 42 sec (range: 2 min to 3 min). There were no embolizations or dislodgements either during the initial 10-subject retrieval cohort or the subsequent series of 5 re-implanted LCP’s. There were no perforations or extrusions of the LCP helix into the pericardial space and the pericardial sac contained normal amounts of serous luid. Conclusions: We demonstrate i) the feasibility of retrieval of a leadless pacemaker, ii) eficacy of retrieval and, iii) safety of a novel leadless cardiac pacemaker retrieved from the RV apex. www.jaib.com 41 October, 2013 | Special Issue Vasovagal Syncope: Diagnostic Issues Familial Neurally Mediated Syncope I. Choudhuri, D. Krum, A. Agarwal, J. Hare, M. Belohlavek, A. Ahmad, M. Pinninti, B. Khandheria Aurora St. Luke’s Medical Center Clinical Cardiac Electrophysiology Milwaukee, WI USA Abstract Introduction: Compared to tachyarrhythmias, little information is available regarding familial bradyarrhythmias. Cases report: Case 1: A 52-year-old woman (proband) was referred because of repeated syncope. At the time of electrophysiological study 5.4sec pause by sinus arrest with chest discomfort was documented. After permanent pacemaker (PPM) implantation, she did not suffer from syncope at all. Case 2: A 27-year-old man (proband’s son) experienced fainting and syncope for few years. He experienced these symptoms especially during bating or hot days. 2 months after implantable loop recorder (ILR) implantation, he suffered from syncope during bathing and he was almost drowned. 10.2sec pause related with sinus arrest was recorded. He did not have any syncope after PPM implantation. Case 3: A 25-year-old woman (proband’s daughter) had repeated fainting and syncope following nausea. Baseline systolic BP was around 90mmHg. Head-up tilt test revealed no obvious abnormality except mild decreasing BP (<10mmHg). Because ILR did not record any ECG abnormalities even during spontaneous fainting, she is treated medically. Conclusions: Though any genetic abnormalities were not detected in this family, familial neurally mediated syncope is mostly suspected. www.jaib.com 42 October, 2013 | Special Issue Evaluation Of Clinical Usefulness Of Standardized, QuestionnaireBased History Evaluation In The Diagnosis Of Syncope A.Z. Pietrucha, I. Bzukala, M. Wnuk, W. Piwowarska. J. Nessler Coronary Disease Department, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland Abstract Introduction and objectives: The aim of our study was evaluation of clinical usefulness of standardized, questionnaire-based history evaluation in the diagnosis of syncope in patients admitted to Syncopal Unit. Methods: We observed 920 consecutive pts. with syncope (552 women, 60%, aged 12-89 yrs., median of age 41 yrs.), diagnosed in our Syncopal Unit of our Department during last 3 years. In all patients a of standardized questionnaire for history evaluation (SQfHE) was used during initial evaluation together with physical examination, ECG evaluation , orthostatic BP measurement and carotid sinus massage in pts. over 40 years of age. This questionnaire included question regarding circumstances of syncopal episodes, evaluation of prodroms and syncope course according to last ESC guidelines for diagnosis and treatment of syncope. Calgary Syncope Symptom Score (CSSS) proposed by Sheldon as well as OESIL Score (OS) were implemented into SQfHE. If CSSS was -2 or more relex syncope was diagnosed or suspected – if concomitant disorders were presented. If OS was higher than 0 - additional diagnosis was performed. Results: Based on initial evaluation diagnosis of syncope was done in 42,4% of pts., Suspected diagnosis of syncope was made in further 39,6% of pts. Only 18 % of patient had no established the reason of syncope based on initial evaluation. Hospitalization rate, longer than 1 day was 8,2%. Conclusions: 1. Standardized, questionnaire-based history evaluation is very useful in the diagnosis of patients with syncope admitted to Syncopal Unit. 2. Standardized, questionnaire-based history evaluation allow to make diagnosis, based only on initial evaluation in over 40% of patients 3. The ratio of undiagnosed syncope based on initial evaluation was only 18% – in these patients the additional diagnosis was performed 4. Standardized, questionnaire-based history evaluation is also useful in limitation of hospitalization rate needed for diagnosis of patients with syncope www.jaib.com 43 October, 2013 | Special Issue Analysis Of Baroreceptor Sensitivity During Head-Up Tilt Test In Patients With Vasovagal Syncope A.Z. Pietrucha, I. Bzukala, J Jedrzejczyk-Spaho, M. Wnuk, W. Piwowarska. J. Nessler Coronary Disease Department, Institute of Cardiology, Medical School of Jagiellonian University, John Paul II Hospital, Cracow, Poland Abstract Introduction and objectives: The aim of study was an analysis of baroreceptor sensitivity during head-up tilt test (HUTT) in patients with vaso-vagal syncope. Patients and methods: Study population: we observed 240 pts. (78 men, 162 women) aged 18-56 yrs (median of age: 23 yrs) with vasovagal syncope (VVS) referred to head-up tilt test (HUTT). Cardio- and neurogenic reasons of syncope were previously excluded in all pts. All pts underwent HUTT performed according standard Westminster protocol. Continuous non-invasive monitoring of heart rate (HR) and blood pressure (beat-to beat) was performed using NEXFIN analyser. Based on registered HR and blood pressure values the baroreceptor sensitivity index was calculated both for systolic (BRS-S) and diastolic (BRS-D) blood pressure. We analyse values of baroreceptor sensitivity indexes between pts. with and without HUTT-induced syncope as well as between different types of vasovagal response. Results: Signiicant reduction of baroreceptor sensitivity index for systolic blood pressure was observed I patients with positive HUTT in relation to non-fainters (8,6 vs. 21,4 ms/mmHg; p<0,015) whereas there was no signiicant differences regarding baroreceptor sensitivity index for diastolic blood pressure (15,3 vs. 15,6 ms/mmHg, p=0,85). There were no signiicant trend thru higher values of BRS-S in patients with cardiodepressive VVS. Conclusions: 1. Induction of vasovagal syncope during head-up tilt test was concerned with signiicant reduction of baroreceptor sensitivity calculated for systolic blood pressure. 2. Impairment of baroreceptor sensitivity seems to play an important role in the patomechanism of vasovagal syncope www.jaib.com 44 October, 2013 | Special Issue Misdiagnosis Of Neurally-Mediated Syncope Revealed By Prolonged ECG Monitoring. An Analysis From The Third International Study On Syncope Of Uncertain Etiology (Issue-3) A. Ungar, P. Sgobino, V. Russo, E. Vitale, R. Sutton, D. Melissano, X. Beiras, N. Bottoni, H.H. Ebert, M.M. Gulizia, M. Iorida, A. Moya, D. Andresen, N. Grovale, M. Brignole Ospedale di Careggi, Florence, Italy Abstract Objectives: According to the guidelines of the European Society of Cardiology a likely diagnosis of neurally mediated syncope (NMS) can be made when the patients have a consistent history and competing diagnosis are excluded. In the present study we validated the initial diagnosis of NMS by means of implantable loop recorder (ILR) documentation. Methods and results: In the Third International Study on Syncope of Uncertain Etiology (ISSUE-3) registry, 504 NMS patients ≥40 years who had suffered, in the prior 2 years, ≥3 syncopal episodes received a ILR and were followed-up for a mean of 15±11 months. A diagnosis was achieved in 187 of them with an estimated diagnostic yield of 31% (95% CI 27-36) at 1 year, 40% (95% CI 36-45) at 2 years and 47% (95% CI 40-53) at 3 years. NMS was conirmed in 162 (87%) patients (asystolic in 99 and likely hypotensive in 63) and was ruled out in other 25 (13%) who had an intrinsic cardiac arrhythmic cause (atrial tachyarrhythmias [#9], long pause at termination of tachyarrhythmia [#7], persistent bradycardia [#3], ventricular tachycardia [#2]) or a non-arrhythmic loss of consciousness (non-syncopal [#3], orthostatic hypotension [#1]). No clinical baseline feature was able to predict an intrinsic cardiac cause with the exception of a more frequent nonsyncopal atrial tachyarrhythmias on clinical history which was present in 38 % of cardiac vs 5% of NMS patients (p=0.001). Treatment: pacemaker in 108 (101 NMS and 7 cardiac), education and counterpressure maneuvers in 61 NMS, catheter ablation in 6 cardiac, ICD in 2 cardiac, other treatments in 5 cardiac patients. Among established NMS patients, pacemaker therapy was more effective then no pacemaker therapy in preventing syncopal recurrence (26% vs 54% at 21 months of follow-up, p=0.01). Conclusions: The accuracy of the diagnosis of NMS made at initial evaluation is 87%. A small not irrelevant number of patients have a different diagnosis, especially an intrinsic arrhythmic cause. Pacemaker therapy is effective in patients with NMS established by ILR documentation ILR implantation 509 NMS at initial evaluation Follow-up: 15±11 months 187 (37%) Diagnosis after ECG documentation NMS confirmed 162 (87%) Asystolic NMS (type 1) 99 (53%) Treatment www.jaib.com - Pacemaker: 98 - CPM: 1 NMS excluded 25 (13%) Hypotensive NMS (type 2,3) 63 (34%) - CPM: 40 - Pacemaker: 3 - Education: 20 45 Intrinsic cardiac arrhythmias 21 (11%) Non-arrhythmic T-LOC 4 (2%) - Pacemaker: 7 - Cath. ablation: 6 - ICD: 2 - Others: 5 October, 2013 | Special Issue Additional Diagnostic Value Of Implantable Loop Recorder In Patients With Initial Diagnosis Of Non-Syncopal Transient Loss Of Consciousness M. Rafanelli, R. Maggi, A. Ceccoiglio, D. Solari, M. Brignole, A. Ungar 1- Centro Aritmologico, Dipartimento di Cardiologia, Ospedali del Tigullio, Lavagna, Italy 2- Syncope Unit, Cardiologia e Medicina Geriatrica, AOU Careggi and University of Florence, Italy Abstract Objectives: Non-syncopal transient loss of consciousness (T-LOC) resemble syncope and differential diagnosis may be challenging. Implantable loop recorder (ILR) is useful but it has never been systematically assessed. Methods and results: 57 patients received an ILR, who had had 4.6±2.3 episodes of T-LOC to distinguishing epilepsy from syncope (#28) or fall from syncope (#29). During 20±13 months of follow-up, 33 patients (57%) had an ILR-documented event. An arrhythmia was documented in 15 (26%) patients: asystole in 7 patients with suspicion of epilepsy and in 5 patients with fall; atrial tachyarrhythmia in 1 and 2 patients respectively. ILR excluded an arrhythmia in 18 patients, supporting the diagnosis of epilepsy in 6 (11%), non-accidental fall in 10 (18%) patients and hypotensive syncope in 2 (3%). A diagnosis remained unexplained in 24 (42%) patients. Therapy: antiepileptic drugs in 6 (10%), pacemaker in 11 (19%), antiarrhythmic drugs in 4 (7%), reduction of hypotensive drugs in 1 patient (2%). No speciic therapy in 11 patients (18%). Conclusions: ILR provides a diagnostic value in “dificult” patients with initial diagnosis of non syncopal T-LOC. www.jaib.com 46 October, 2013 | Special Issue 10-Year Experience In ILR M. Fernandes, V. Sanins, V.H. Pereira, J. Português, S. Ribeiro, B. Rodrigues, A. Alves, I. Quelhas, A. Lourenço Cardiology department, Centro Hospitalar do Alto Ave, Guimarães, Portugal Abstract Introduction: implantable loop recorders permitted to clarify the syncope aetiology with negative when basic exams are inconclusive. They are especially useful when the cause of syncope is related to transitory bradycardia or sinus arrest with sporadic symptoms. The authors aimed to evaluate the inluence of cardiovascular risk factors and previous electrocardiogram (ECG) conduction disturbances in indication to implant deinitive pacemaker in patients with syncope and dizziness who implanted an ILR. Methods: we evaluated 63 patients with an ILR implanted between 2002 and 2012. The mean age was 62.3 years old and 22% were diabetic, 59% had hypertension, 2% were current smokers and 41% had elevated blood lipids. The ECG previous to ILR, presented with irst degree auricular-ventricular block in 13.2% of patients, complete left bundle branch block in 7.3%, right bundle branch block in 5.5% and left anterior fascicular block in 9.1%. Results: ILR allowed the diagnosis of the aetiology of syncope in one third of patients, and the causes identiied were sinus node dysfunction (70%), complete AVB (20%) and supraventricular tachycardia, including atrial ibrillation (10%). It also permitted to exclude dysrithmic events as cause of syncope in 33% of patients, as event reorder was activated and no ECG disturbance was found. A pacemaker was implanted in 30% of patients, about 20 months after ILR. Of the patients who needed pacing, 42% were diabetic and we also found that more than half of the diabetic patients needed a pacemaker according to current guidelines (p<0.05).No relationship was found with other risk factors. Curiously, previous conduction disturbances did not predict the indication to pacemaker placement, as one expected. Conclusions: with this study we realized the relevance of ILR use, allowing us to diagnose disrítmica events in 30% of patients and excluding this diagnosis in another 32%. It also alerted us to the need of a low threshold when suspecting sinus node disease. We also concluded that diabetes predicts better the indication to pacemaker placement than previous conduction disturbances in these selected patients. This could be explained by the dysautonomic dysfunction often seen in diabetics. www.jaib.com 47 October, 2013 | Special Issue Eficacy Of Electrical Velocimetry (EV) For The Diagnostic Of The Progressive Orthostatic Hypotension (POH) C. Podoleanu, A. Varga, A. Magdas, D. Podoleanu, A. Incze, E. Carasca Cardiology Dept., 4th Medical Clinic, University of Medicine and Pharmacy Targu Miures, Romania Abstract Introduction: ito study the eficacy of the method of EV as alternative to continuous blood pressure (BP) monitoring by more sophisticated and expensive devices using an original algorithm and standard ECG electrodes without continuous BP recordingMethods: we evaluated 63 patients with an ILR implanted between 2002 and 2012. The mean age was 62.3 years old and 22% were diabetic, 59% had hypertension, 2% were current smokers and 41% had elevated blood lipids. The ECG previous to ILR, presented with irst degree auricular-ventricular block in 13.2% of patients, complete left bundle branch block in 7.3%, right bundle branch block in 5.5% and left anterior fascicular block in 9.1%. Methods: I72 patients referred for syncope of unknown etiology underwent tilt testing (TT) with nitroglycerine challenge. SVR, CO, SV and HR were recorded beat-to-beat by Aesculon-Osypka monitor using 4 standard ECG electrodes. Non-invasive BP was measured manually. Results: wPOH was found in 12 patients and NTG was used in 3 of them. TT was negative in 15 patients. The SVR (dyns/cm5 /m2) decreased progressively: 1873± 521 initially, 1201± 225(p=0,01) at symptom onset and 901±170 (p<0,01) at the end of test. There was concordance with the BP behavior. Maximum heart rate in POH patients was 98±31 vs. 121±21 (p=0,01). The decrease of SVR was predictive of a positive respons Conclusions: EV correctly identiied the hemodynamic pattern of the POH syndrome. Correlation with other techniques are needed for further assessment www.jaib.com 48 October, 2013 | Special Issue Vasovagal Syncope: Therapeutic Issues Syncope Clinic: First One Year Experience And Problems In Japan T. Furukawa, M. Nakajima, Y. Takagi E. Nakano, M. Takano, S. Nishio, T. Harada, Y. Akashi, F. Miyake Division of Cardiology, Department of Internal Medicine, St. Marianna University, School of Medicine, Kawasaki, Japan Abstract Introduction: We would like to report the experience and problems of The Syncope Unit in Japan. Methods: we enrolled consecutive patients referred to our Syncope Clinic for one year. Results: 54 patients (35 males, age 59) referred due to syncope unknown origins. Their median number of syncope was two. During 30±27 days, 63% of all (34 patients) were diagnosed. The most common origin is relex syncope (11 panties). Nine patients (17%) rejected further examinations. The others were in process. We performed specialized examination to selected patients as follow: electrophysiological studies for 11 patients (20%), tilt table tests for 15 (27%) and coronary angiography for 9 (17%). Indications of implantable loop recorders were in 11 (20%) for recurrence syncopal episodes at high risk. However, 72 % of them were rejected for the implantations. About treatments, we performed 9 pacemaker implantations, 1 implantable cardioverter-diibrillatior implantation and 2 radiofrequency catheter ablation procedures. Conclusion: We documented the current practice of syncope management in a specialized facility in Japan. Several major problems were detected. The most common problem is rejections of future managements. www.jaib.com 49 October, 2013 | Special Issue Evaluation Of Baroreceptor Sensitivity Changes During The Treatment Of Vasovagal Sensitivity By Tilt Training A.Z. Pietrucha, I. Bzukala, M. Wnuk, J. Jedrzejczyk-Spaho, J. Nessler Coronary Disease Department, Institute of Cardiology, Medical School of Jagiellonian University, John Paul II Hospital, Cracow, Poland Abstract Objectives: The aim of study was an analysis of baroreceptor sensitivity Changes of baroreceptor sensitivity during the treatment of with vasovagal syncope with tilt training. Study population: we observed 75 pts. (23 men, 1162 women) aged 18-42 yrs (median of age: 21 yrs) with vasovagal syncope (VVS) conirmed by head-up tilt test (HUTT) and referred to non-pharmacological treatment by tilt training. Methods: All pts underwent HUTT performed according Italian protocol. After positive HUTT result patient were referred to classical tilt training proposed by Ector – repeated tilting until achieving two consecutive negative responses. Continuous non-invasive monitoring of heart rate (HR) and blood pressure (beat-to beat) was performed using NEXFIN analyser. Based on registered HR and blood pressure values the baroreceptor sensitivity index (iBRS) was calculated separately for supine and for tilting during the following training sessions. Results: Signiicant reduction of iBRS during tilt across the training cycle was observed in all patients (2,5 vs. 9,8 ms/mmHg p<0,01), whereas there was no changes regarding supine values of iBRS through the training. Conclusions: 1. Modiication of baroreceptor sensitivity during the tilting seems to be important mechanism responsible for antysyncopal effect of tilt training. 2. The monitoring of tilt related baroreceptor sensitivity may be marker of effectiveness of treatment of vasovagal syncope by tilt training. www.jaib.com 50 October, 2013 | Special Issue Limited Utility Of Physical Counter-Pressure Maneuvres In Preventing Syncopal Recurrence In Patients Older Than 40 YEARS With Recurrent Neurally-Mediated Syncope. An Analysis From The Third International Study On Syncope Of Uncertain Etiology (Issue-3) C. Romeo1, E. Vitale2, T. Kus3, A. Moya4, W. Wieling5, S. Giuli6, A. Gentili6, R. Sutton7 on behalf of the International Study on Syncope of Uncertain Etiology3 (ISSUE-3) Investigators Ospedale di Bolzano, Bolzano, Italy (MT,CR) 2Ospedale SS.Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (EV) Hospital du Sacre-Coeur de Montreal, Canada (TK) 4Hospital Universitario Vall d´Hebron, Barcelona, Spain (AM) 5 Academisch Medisch Centrum, Amsterdam (WW) 6Medtronic Italia, Italy (SG,AG) 7. St.Mary´s Hospital, Imperial College Healthcare NHS Trust, London, UK (RS) 1 3 Abstract Aims: Physical counter-pressure maneuvers are effective in young patients with vasovagal syncope and recognizable prodromal symptoms. Aim of this study was to investigate their effectiveness in patients ≥40 years with severe neurally mediated syncope (NMS) enrolled in the Third International Study on Syncope of Uncertain Etiology (ISSUE-3). Methods and results: In the ISSUE-3 study, 63 out of 162 patients had a diagnosis of hypotensive NMS (type 2,3 and 4A) documented by implantable loop recorder (ILR); of these, 40 were instructed to perform isometric leg and arm physical counter-pressure maneuver (PCM) therapy. Their mean age was 62±13 years; 71% of patients had a history of some episodes without prodrome. A group of 45 untreated patients acted as controls. During follow-up, syncope recurred in 15 PC patients (39%) and in 24 control patients (53%). At 21 months, the estimated product-limit syncope recurrence rates were 42% (95%CI 29-62) and 64% (95%CI 48-80) respectively (p=0.30). Conclusions: 1.The beneit of PC maneuvers was limited in ISSUE-3 patients affected by hypotensive NMS. The likely factors that hampered effectiveness of PC therapy were older age and absence of suficiently long recognizable prodromal symptoms in the ISSUE-3 population. www.jaib.com 51 October, 2013 | Special Issue Diagnostic Yield Of Tilt Table Test To Predict Recurrences Of Neurally-Mediated Relex Syncope In Patients Treated Using A Pacemaker M. Tomaino, C. Romeo, P. Sgobino, J. Rottensteiner, A. Beccarello, A. Kaneppele Department of Cardiology, Central Hospital of Bolzano, Bolzano, Italy Abstract Aim: To verify the diagnostic value of tilt table test (TTT) to predict the eficacy of cardiac pacing (PM) for preventing recurrences of neurally mediated relex syncope in a selected group of patients with severe clinical presentation and cardio-inhibitory activity documented by implantable loop recorder. Methods: In this observational and retrospective study we wanted to observe the results of TTT in two groups of treated patients using a PM: with and without recurrences. Results: We analysed 21 patients. During an average follow-up period of 23+10 months the recurrence of syncope occurred in 5 patients (22%). 16 patients (78%) had not recurrences. In the group with recurrences TTT was positive in 3 out of four patients in whom the TTT was performed (75%). Among the 16 patients without recurrences TTT was performed in 12 of those and was positive only in 2 cases (16,6%). Conclusions: A positive TTT response in selected patients treated with PM is more likely correlated with a higher frequency of recurrences of syncope, while a negative response seems to predict the success of the pacing therapy. www.jaib.com 52 October, 2013 | Special Issue Dual Chamber Pacemaker (With Rate Drop Response Algorithm) In Patients With Severe Clinical Presentation Of NeurallyMediated Syncope Selected By Implantable Loop Recorder M. Tomaino, C. Romeo, P. Donolato, P. Sgobino, A. Beccarello, J. Rottensteiner, A. Kaneppele Department of Cardiology, Central Hospital of Bolzano, Bolzano, Italy Abstract Aim: To assess the eficacy of cardiac pacing in a selected group of patients with severe clinical presentation of certain or suspected neurally-mediated relex syncope (NMS), age > 40 years and evidence of a cardio-inhibitory activity (CI) documented by Implantable Loop Recorder (ILR). Methods: We selected, using the ILR, patients with a CI mechanism and treated them implanting a dual chamber PM with rate drop response (RDR) algorithm. Other patients were sent to “training” sessions of learning the Isometric Counterpressure Maneuvers (ICPM. Results: We analysed 71 patients (period 2007-2012). 21 patients received a PM (mean age 68+13 years). After an average follow-up period of 23+12 months, among the treated patients recurrences occurred in 5 patients (24%). 16 patients (76%) had no recurrences. There was an improvement of the quality of life in all treated patients. Conclusions: PM implantation is justiied only in well selected patients. Dual chamber PM with RDR algorithm is eficient for preventing recurrences and improve the quality of life. In some cases it could be necessary to perform a “hybrid” therapy (PM + ICPM). www.jaib.com 53 October, 2013 | Special Issue The Beneit Of Pacemaker Therapy In Patients With NeurallyMediated Syncope And Documented Asystole Is Greater When Tilt Test Is Negative. An Analysis From The Third International Study On Syncope Of Uncertain Etiology (Issue-3) M. Brignole, P. Donateo, M. Tomaino, R. Massa, M. Iori, X. Beiras, A.Moya, T.Kus, JC Deharo, S.Giuli, A.Gentili, R.Sutton Imperial Hospital, London, UK Abstract Aims: The Third International Study on Syncope of Uncertain Etiology (ISSUE-3) showed that dual-chamber permanent pacing is effective in reducing recurrence of syncope in patients ≥40 years with severe asystolic neurally mediated syncope (NMS). Nevertheless, patients receiving pacing therapy had an estimated syncopal recurrence of 25% at 2 years. Aim of this study was to investigate the role of tilt testing (TT) response in predicting syncopal recurrence. Methods and results: In the ISSUE-3 registry, 162 out of 504 patients had a diagnosis of NMS documented by implantable loop recorder (ILR). TT was positive in 76 and negative in 60 (not performed in 26). An asystolic response (type 2B: VASIS classiication) predicted asystole during a spontaneous NMS on ILR (type 1 of the ISSUE classiication) with a positive predictive value of 86%. The corresponding values were 48% in patients with non-asystolic TT and 58% in patients with negative TT (p=0.001). Fifty-two patients (26 TT + and 26 TT –) with asystolic, type 1 NMS were treated with a pacemaker. Syncope recurred in 8 TT+ and in 1 TT– patients. At 21 months, the estimated product-limit syncope recurrence rates were 55% and 5% respectively (p=0.004). TT+ recurrence rate was similar to that of 45 untreated patients (control group) which was 64%, p=0.75 (Figure 1). The recurrence rate was similar among 14 patients with asystolic and 12 non-asystolic responses during TT, p=0.53). Conclusions: Cardiac pacing is very effective in NMS patients who have the documentation of an asystolic pause during a spontaneous event and a negative TT; conversely, there is no evidence of eficacy in patients with a positive TT. Although an asystolic response during TT predicts an asystolic spontaneous NMS, the pacing beneit is similar to that of non-asystolic responses. Freedom from syncopal recurrence 1.00 PM, TT – 0.90 0.80 log rank: p=0.004 0.70 0.60 0.50 PM, TT + 0.40 No PM 0.30 0.20 0.10 0.00 0 Number at risk PM TT+ 26 PM TT- 26 NO THER 45 www.jaib.com 3 6 9 14 19 35 10 19 31 9 15 22 12 Months 8 11 22 54 15 18 21 6 10 18 4 9 14 3 9 9 October, 2013 | Special Issue AF: Cardioversion & Anti-Thrombotic Issues Conversion Of Acute Atrial Fibrillation With Propafenone Or Vernakalant D. Conde, J.P. Costabel, M. Aragon, M.F. Lambardi, M. Trivi, A. Giniger Emergency Department, Cardiovascular Institute of Buenos Aires, Buenos Aires, Argentina Abstract Introduction: Intravenous vernakalant has effectively converted acute Atrial Fibrillation (AF) to Sinus Rhythm (SR) and demonstrated eficacy superior to placebo and amiodarone. The objective of this study is compare the eficacy and safety of intravenous vernakalant and oral loading dose of propafenone for conversion of acute (AF). Methods: A total of 40 adult patients with acute AF (less than 48 hours duration) without heart disease were enrolled. Patients received, intravenous vernakalant (n=20), or an oral loading dose of propafenone with 600 mg (n=20). Eficacy end point was the time to conversion from acute AF to SR. Results: The mean time to conversion from AF to SR in patients who received propafenone was 166 (120-300) minutes and 9 (6-18) minutes in patients who received vernakalant (p < 0.0001). The mean hospitalization time was 416 (336.7-740.5) minutes in propafenone group and 238 (189.7-277.7) minutes in vernakalant group (p < 0.0001). There were no serious adverse events. Conclusion: Vernakalant demonstrated a shorter time to conversion from AF to SR than propafenone and a shorter hospitalization time. Both were safe and well tolerate. Table 1 Demographic and Baseline Characteristics Baseline characteristics Propfenone Vernakalant Male - % 63 58 Age –yrs mean SD 62 (54-66) 67 (56-69,5) Diabetes - % 5 5,8 Hypertesion - % 42 64 Smokers - % 30 33 Previous AF % 78 76 Previous Ablation of AF % 5 11 Beta-blockers % 20 30 Amiodarone % 0 10 Propafenone/Flecainide % 5 0 Anticoagulation % 0 0 www.jaib.com 55 October, 2013 | Special Issue Pharmacological Management Of Recent-Onset Atrial Fibrillation In Acute Setting: An Open-Label Cohort Study A. Bonora *, F. Beltrame °, G. Taioli #, G. Zerman*, P. Castiglioni *, R. Codogni#, E. Sanzone *, E. Franchi °, D. Girelli #, C. Pistorelli * *Department of Emergency and Intensive herapy °Department of Cardiology #Department of Internal Medicine, School of Emergency Medicine University of Verona, Verona, Italy Abstract Aim: To compare eficacy and safety of amiodarone, propafenone and lecainide in treating recent-onset AF in acute setting. Methods: Out of patients observed from January 2009 to December 2011 for recent-onset AF in our Emergency Department, we considered only those with irst attempt at cardioversion and without clinical conditions forcing pharmacological strategy. Depending on physician’s choice, patients received a bolus of amiodarone 4 mg/kg or propafenone 2 mg/kg or lecainide 2 mg/kg,. Results: A number of 302 patients with homogenous baseline characteristics (157 males, 145 females, mean age 60.4 years) were considered in this study. At the end of 12-hours observation period, conversion to sinus rhythm was achieved in 51.5% of patients in amiodarone, 76.2% in propafenone and 89.1% in lecainide group (lecainide and propafenone vs amiodarone p<0.0001). Median time to cardioversion was signiicantly shorter in lecainide and propafenone than in amiodarone group (p<0.0001). We reported an overall very low incidence of adverse events. Need for hospitalization resulted higher in amiodarone group (p<0.001). Conclusions: Flecainide and propafenone resulted more effective and as safe than amiodarone in acute management of AF. www.jaib.com 56 October, 2013 | Special Issue Pharmacological Management Of Recent-Onset Atrial Fibrillation In Acute Setting: An Open-Label Cohort Study A. Bonora *, F. Beltrame °, G. Taioli #, G. Zerman*, P. Castiglioni *, R. Codogni#, E. Sanzone *, E. Franchi °, D. Girelli #, C. Pistorelli * *Department of Emergency and Intensive herapy °Department of Cardiology #Department of Internal Medicine, School of Emergency Medicine University of Verona, Verona, Italy Abstract Aim: To compare eficacy and safety of amiodarone, propafenone and lecainide in treating recent-onset AF in acute setting. Methods: Out of patients observed from January 2009 to December 2011 for recent-onset AF in our Emergency Department, we considered only those with irst attempt at cardioversion and without clinical conditions forcing pharmacological strategy. Depending on physician’s choice, patients received a bolus of amiodarone 4 mg/kg or propafenone 2 mg/kg or lecainide 2 mg/kg,. Results: A number of 302 patients with homogenous baseline characteristics (157 males, 145 females, mean age 60.4 years) were considered in this study. At the end of 12-hours observation period, conversion to sinus rhythm was achieved in 51.5% of patients in amiodarone, 76.2% in propafenone and 89.1% in lecainide group (lecainide and propafenone vs amiodarone p<0.0001). Median time to cardioversion was signiicantly shorter in lecainide and propafenone than in amiodarone group (p<0.0001). We reported an overall very low incidence of adverse events. Need for hospitalization resulted higher in amiodarone group (p<0.001). Conclusions: Flecainide and propafenone resulted more effective and as safe than amiodarone in acute management of AF. www.jaib.com 57 October, 2013 | Special Issue Clinical Characteristics And Outcomes Of Patients With NonValvular Atrial Fibrillation Who Undergo Multiple Direct-Current Cardioversion Procedures A. García-Fernández, F. Marín-Ortuño, J.G. Martínez-Martínez, A, Ibáñez-Criado, J.L. Ibáñez-Criado, V. RoldánSchilling, M. Valdés,, F. Sogorb-Garri Arrhtyhmia Unit, Cardiology Department, general Hospital of Alicante, Spain. Cardiology Department, Hospital Virgen de la Arrixaca, Murcia, Spain. Haematology Department, Hospital Morales Meseguer, Murcia, Spain Abstract Introduction: Although immediate success rates of DC cardioversion (CV) in NVAF patients are known to be very high, recurrence is the usual pattern, being many patients submitted to multiple procedures. We aimed to determine if clinical proile and long-term outcome are different in these patients. Methods: We studied 326 patients who underwent 456 DC CV (form January 2008 to August 2011). We compared clinical characteristics, thromboembolic risk (CHA2DS2-VASc score), long-term maintenance of sinus rhythm and event rates (embolism, major bleeding and death) in both two groups of patients: Group 1 (≤2 CV) and Group 2 (≥3 CV). Results: Patients in Group 2 (N=21) were younger (61.1±12.0 vs 66.9±10.9 years, p=0.02) and had less thromboembolic risk (CHA2DS2VASc: 2.14±1.52 vs 2.86±1.59, p=0.04) than patients in Group 1 (N=305). During a median follow up of 740 [327-1224] days, the proportion of patients in sinus rhythm and the event rates were similar in both groups (23.4% vs 35.0%, p:0.57). Conclusions: AF patients who undergo multiple CV procedures tend to be younger and have less thromboembolic risk. The proportion of maintenance of sinus rhythm and the rate of events are similar in both groups. Baseline characteristics of patients in Group 1 (≤2 CV) and in Group Table 1 2 (≥3 CV). Patient Group 1 (N=305) Group 2 (N=21) p Male (%) 210 (68.9) 18 (87.5) 0.1 Age (years) 66.9±10.9 61.1±12.0 0.02 Idiopathic AF(%) 27 (9) 3 (14.3) 0.41 Hypertension (%) 246 (80.9) 15 (71.4) 0.53 Diabetes (%) 83 (27.4) 5(23.8) 0.72 Heart failure (%) 78 (25.7) 7 (33.3) 0.72 Previous embolism (%) 19 (6.3) 1 (4.8) 0.78 Heart disease (%) 121 (40.2) 7 (33) 0.53 CHA2DS2-VASc score 2.86±1.59 2.14±1.52 0.04 Proportion of patients in sinus rhythm at end of follow-up and event Table 2 rate. Patient www.jaib.com Group 1 (N=305) Group 2 (N=21) p Sinus rhythm (%) 71 (23.4) 7 (35.0) 0.57 Embolic events (%) 18(6) 3 (15) 0.11 Major bleeding (%) 9 (3) 0 (0) 0.43 Death (%) 19 (6.3) 0 (0) 0.24 58 October, 2013 | Special Issue Utility Of The CHADS2 And CHA2DS2-Vasc Scores To Predict Embolic Risk After Direct-Current Cardioversion In Non-Valvular Atrial Fibrillation A. García-Fernández, F. Marín-Ortuño, V. Roldán-Schilling, J.G. Martínez-Martínez, A, Ibáñez-Criado, J.L. IbáñezCriado, , M. Valdés,, F. Sogorb-Garri Arrhtyhmia Unit, Cardiology Department, general Hospital of Alicante, Spain. Cardiology Department, Hospital Virgen de la Arrixaca, Murcia, Spain. Haematology Department, Hospital Morales Meseguer, Murcia, Spain Abstract Introduction: The usefulness of the CHADS2 and CHA2DS2-VASc scores to predict thromboembolism in non-valvular AF has been well validated, but their predictive value after electrical cardioversion has not been thoroughly investigated. The aim of this study is to analyze the role of both scores to predict thromboembolic risk in a real-world cohort of patients with AF who undergo DC cardioversion. Methods: T We included 326 consecutive patients who underwent 456 programmed cardioversions between January 2008 and August 2011. We calculated the association between both scales and the development of all embolic events during follow-up. Results: TDuring a median follow-up of 740 (327-1224) days, there were 20 embolic events (4.38%), (2 fatal), with an annual rate of embolism of 2.16%. We found a signiicant association between both risk scales and the incidence of embolic events (CHADS2: HR=1.77; 95%CI: 1.25-2.51; p=0.001); (CHA2DS2-VASc: HR=1.68; 95%CI: 1.29-2.19; p<0.001). Conclusions: During a median follow-up of 740 (327-1224) days, there were 20 embolic events (4.38%), (2 fatal), with an annual rate of embolism of 2.16%. We found a signiicant association between both risk scales and the incidence of embolic events (CHADS2: HR=1.77; 95%CI: 1.25-2.51; p=0.001); (CHA2DS2-VASc: HR=1.68; 95%CI: 1.29-2.19; p<0.001). Annual rate of embolic events depending on CHADS2 AND CHA2DS2Table 2 VASc scores. Baseline characteristics of patients in Table 1 Group 1 (≤2 CV) and in Group 2 (≥3 CV). CHADS2 score Annual embolic rate (%) No Yes Total 0 0.89 54 1 55 1 0.83 171 3 174 2 2.36 119 6 125 3 3.55 64 5 69 4 8.10 25 5 30 85 (26.2) 5 0 2 0 2 20 (6.2) 6 0 1 0 1 Patient N=326 Male 228 (69.9) Age 68 [61-74] Idiopathic AF 30 (9.3) Hypertension 261 (80.3) Diabetes 88 (27.2) Heart failure Previous thromboembolism 128 (39.8) CHA2DS2-VASc Score Coronary heart disease 62 (19.3) 0 0 25 0 25 Dilated cardiomyopathy 21 (6.5) 1 0.63 76 1 77 Valvular (mild or moderate) 25 (7.8) 2 1.15 124 3 127 Congenital 6 (1.9) 3 1.61 88 3 91 Hypertrophic 12 (3.7) Channelopathy 2 (0.6) Heart disease Vascular disease 72 (22.1) DC cardioversion N=460 Success 400 (87) Recurrence 323 (80.7) www.jaib.com 59 4 2.61 71 4 75 5 6.53 26 4 30 6 7.25 23 4 27 7 24.5 1 1 2 8 0 1 0 1 October, 2013 | Special Issue Warfarin Dosing Algorithm Is Safe And Effective In The Elderly A. Salacata, S. Keavey Great Lakes Heart Center of Alpena, Alpena, MI, USA Abstract Introduction: The risk of stroke associated with atrial ibrillation (AF) is greatest in the elderly. However, in this age group, systemic anticoagulation (SA) is often underused due to fear of bleeding complications. This fear persists inspite of the introduction of newer anticoagulants. Ironically, in this age group, warfarin may be the safer anticoagulant despite their greater sensitivity to the drug and greater risk of complications. Dosing algorithms for W have been developed to reduce the risks of SA, the effectives in the elderly is not known. We had previously demonstrated that W dosing based on ACCP recommendations (ADR) was effective. The effect of age on the effectiveness and safety of this regimen is the subject of this study. Methods: From our anticoagulation practice we then identiied 61 consecutive patients with chronic AF whose medical regimen was otherwise stable. Their INR and clinical histories were then abstracted. They were then stratiied according to age into 45-60, 60-79, and greater than 80 years. The times in therapeutic (TTR), as well as time in sub therapeutic (SUB) and supra therapeutic (SUP) ranges for each group were then calculated and compared using ANOVA. Results: Majority of patients were drawn from those over 60 years of age. Using ADR the rates of effective anticoagulation was comparable among the different age groups. Likewise, safety as relected in the time SUB or SUP was the same for all groups. Conclusions: A warfarin dosing regimen based on current ACCP guidelines results in similar rates of effective anticoagulation in all age groups, including octogenarians. The safety proile was likewise comparable across the different age groups. Baseline characteristics of patients in Group 1 (≤2 CV) and in Group Table 1 2 (≥3 CV). www.jaib.com 45-60 60-79 >80 Mean Age 50.1+/-9.5 71+/-6.3 85.9+/-4.8 p TTR 0.54 0.67 0.66 ns SUB 0.25 0.16 0.23 ns SUP 0.21 0.17 0.11 ns 60 October, 2013 | Special Issue Analysis Of Problems In Oral Anticoagulants Real Clinical Practice By Patients With Atrial Fibrillation A. Strelnieks, B. Lurina, O. Litunenko, M. Vikmane, S. Sakne, G. Rancane, A. Lejnieks, A. Erglis, O. Kalejs Riga Stradins University, Riga East Clinical University Hospital, Paul Straduns Clinical University Hospital, latvian centre of Cardiology, Riga, Latvia Abstract Introduction: Old generation oral anticoagulants (OAC) have been irst line medication for prevention of thrombembolic events by patients with non-valvular atrial ibrillation (AF) for a long time, although the usage of vitamin K antagonists cause a lot of problems for patients and physicians. Novel OAC promise to solve those problems, however their implementation in practice is undergoing slowly in Latvia. Aim, materials and methods: The aim of this study was to analyse main problems of OAC clinical usage by patients with non-valvular AF and by professionals treating them. The study enrolled 254 patients with nonvalvular AF under OAC therapy at two Clinical University Hospitals, Riga, Latvia. Problems associated with OAC side effects and interactions, awareness of patients, complexity of OAC usage were analyzed from patients perspective. Second study group included 245 medical practitioner with clinical experience in treatment and care of non-valvular AF patients applying OAC. Dificulties during the choice of OAC and the beginning of the therapy, patient care and communication were analyzed from the physicians point of view. Results: In patients group were 76,8% users of vitamin K antagonists (VKA) and 23,2% users of novel OAC (NOAC). In VKA group were 31,8% patients prior cardioversion in compare to 86.4% in NOAC group (p<0,001). According to CHA2DS2-VASc scale median in VKA group was score of 3 [95% CI 2-4], in NOAC group score of 2,5 [95% CI 2-4]. Statistically signiicant higher incidence of side effects and blleding were by VKA users 33.1% vs 3.3% (p<0.001) in NOAK group. No major bleeding were observed in NOAK group, but 17 cases in VKA group.. Less than a half of patients followed the interaction of active substances with OAC in both groups, besides patients were less informed about this aspect in compare to OAC side effects and INR controls in VKA group. By VKA users more than 50% had dificulties to adjust OAC dose and to keep the INR between 2,0 and 3,0. 31,8% had problems with INR controls while 90,6% were regulary undergoing INR control, mostly one to two times a month. In physicians group there were 13,9% cardiologists, 20,8% doctors-internists, 23,8% general practitioners, 8,9% doctors of other specialities, 32,7% resident physicians. 48,5% did use NOAC in their practice, mostly prescribing them rarely/rather rarely, but 81,3% of physicians who did not prescribe/prescribed NOAC rarely were willing to do it more often. High costs and not suficient clinical experience were mentioned as main problems for NOAC. According to physicians the main problems for VKA are lack of understanding and cooperation from patients, poor INR control and dificulties in dose adjustment. 82% of doctors did explain interaction of active substances with OAC to their patients. Before the beginning of OAC therapy physicians mostly (>50%) considered thrombembolic events in medical history, the age of patient, vascular diseases, patients’ compliance and inancial situation. In practice doctors most often face noncompliance, dificulties to control coagulation parameters and to keep them in therapeutic range. Conclusions: Clinical usage of OAC for AF patients is more complicated in VKA group due to side effects, complexity of use and lack of information. NOAC are more safety and with signiicantly less side effects in comparison with VKA.Physicians ind use of NOAC less problematic and they would be ready to use NOAC in practice more often if the inansial issues were solved. Before the beginning of OAC therapy thrombembolic and bleeding risk factors are not considered enough, physicians and patients preferring social aspects of drug use. www.jaib.com 61 October, 2013 | Special Issue Novel Oral Anticoagulants In Patients Undergoing Catheter Ablation For Atrial Fibrillation D. Bastian, K. Goehl Division of Cardiology and Electrophysiology, Medizinische Klinik 8, Klinikum Nürnberg Süd, Nuremberg, Germany Abstract Introduction: Limited data are available demonstrating the safety of novel oral anticoagulants (NOAC) in patients undergoing pulmonary vein isolation (PVI) for atrial ibrillation (AF). Methods: Overall 308 consecutive patients were pretreated four weeks either by uninterrupted vitamin K antagonists (VKA) or NOAC (dabigatran n=35, rivaroxaban n=40; only a single dose withheld the morning of the PVI). Post ablation the NOAC therapy was continued immediately after sheath removal. VKA- treated patients with INR <2.0 received enoxaparin bridging until therapeutic INR (2.0-3.0) was reached. Bleeding and embolic complications were classiied according to the 2012 HRS/EHRA/ECAS Expert Consensus Statement on AF ablation. Results: The total incidence of bleeding complication was signiicantly reduced for patients treated with NOAC (tab. 1). Especially vascular access complications occurred more often under VKA treatment plus Heparin bridging. There were no cases of tamponade and no embolic events in either group. Conclusions: CPeriinterventional anticoagulation with NOAC was safe and feasible and did not increase embolic or bleeding complications compared to uninterrupted VKA treatment. Further data from randomized controlled trials are needed to prove the safety of this approach. Table 1 www.jaib.com Periinterventional bleeding and embolic complications 62 October, 2013 | Special Issue Catheter Ablation Of AF: Mapping Techniques Noninvasive Electrocardiographic Imaging And Catheter Ablation Of Persistent Atrial Fibrillation: Initial Experience A. Revishvili, O. Sopov, E. Labartkava, T. Dzhordzhikia, V. Kalinin Bakulev Scientiic Center for Cardiovascular Surgery, Moscow, Russia Abstract Introduction: Recent achievements in noninvasive electrocardiographic (ECG) imaging allowed its extensive use in diagnostics and treatment of different arrhythmias. This study aimed to identify sources of initiation and maintenance of atrial ibrillation (AF) by means of surface ECG based mapping technology combined with CT scan or MRI and to evaluate results of ablation guided by these maps. Methods: We applied noninvasive mapping using 240-lead ECG combined with CT scan or MRI based anatomy (Amycard LCC) to 10 patients (6 male/4 female) with persistent AF (mean continuous AF duration 4±2 months). Windows with spontaneous pauses during AF were selected for mapping before procedure. We evaluated electrical activity in the left, right atrium and atrial septum using speciic algorithm. In 9 patients radiofrequency (RF) ablation was made at the sites of sustained circular electrical activity (rotors) followed by antral pulmonary veins (PV) isolation. One patient underwent Maze IV procedure due to thrombus in left atrial appendage. Results: During evaluation of electrical activity in the left and right atrium we found from 2 to 4 simultaneously coexisting rotors. RF application in this areas resulted in alteration of frequency or direction of electrical activity registered at CS or Lasso catheters. Targeted ablation terminated AF and maintained sinus rhythm in 7 patients (70%). Mean RF application time was 26±18 minutes. In 3 patients (30%) we registered prolongation of arrhythmia cycle length but its termination was achieved only after pharmacological or electrical cardioversion. Conclusion: Initial experience with noninvasive ECG imaging using 3D-4D mapping system combined with CT scan or MRI shows its clinical utility, feasibility to provide noninvasive characteristics of arrhythmogenic areas and to increase effectiveness of interventional AF treatment. www.jaib.com 63 October, 2013 | Special Issue Rotors And Focal Sources Are Stable In Location For Thousands Of Cycles In Patients With Persistent Or Paroxysmal Atrial Fibrillation With Or Without Prior Ablation S.M. Narayan, R. Sehra, D.E. Krummen, K. Shivkumar, J.M. Miller, V. Swarup San Diego VA Medical Center, Topera Medical, UCLA Medical Center, Indiana University Medical Center, Arizona Heart Institute, USA Abstract Introduction: Independent groups now show that paroxysmal and atrial ibrillation (AF) is sustained by rotors or focal impulses that are stable when mapped using Focal Impulse and Rotor Mapping (FIRM), where FIRM-guided ablation substantially improves patient outcomes. We hypothesized that sources would be stable across a wide range of AF patient populations. Methods: In a multicenter prospective clinical trial we mapped AF in 210 patients (28% paroxysmal) using 64 pole electrode baskets in both atria, with AF analyzed using phase mapping (RhythmViewTM, Topera Inc). FIRM-Guided ablation was performed in n=132 consecutive patients (n=33 paroxysmal, LA diameter 54±10 mm; n=73 irst ablation) by targeting each source for abolition prior to pulmonary vein isolation. Results: Sources were identiied in 129/130 mapped patients (99.2%), for 2.6±1.2 sources/patient (all cases) and 2.7±1.2 sources/ patient (1st ablation cases). Sources were distributed in RA/LA 64/36% (all cases) and 65/35% (1st ablation). On FIRM mapping, sources were stable (see igure) for 5961±9650 cycles (all cases), and 5906±7499 cycles (1st ablation; p=0.96). Stability was equivalent between patients with paroxysmal or persistent AF (p>0.50), or right and left atrium (p>0.50). Conclusions: Rotors and Focal sources for human AF present evidence for a consistent mechanism across patients, in which paroxysmal or persistent AF differ primarily in the number and locations of sources. These results provide the irst mechanistic explanation for why localized ablation can terminate AF, and further motivate source-based AF ablation. www.jaib.com 64 October, 2013 | Special Issue Identiication Of Left Atrium Ganglionated Plexi By Dense Epicardial Mapping As Ablation Targets For The Treatment Of Concomitant Atrial Fibrillation Y. Kondo, M. Ueda, M. Watanabe, M. Ishimura, T. Kajiyama, N. Hashiguchi, T. Kanaeda, M. Nakano, Y. Hiranuma, T. Ishizaka, G. Matsumiya, Y. Kobayashi Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan Abstract Introduction and objectives: To identify the location of the left atrial ganglionated plexi (GPs) based on dense epicardial mapping during in patients with concomitant atrial ibrillation. Methods: Sixteen patients (68 ± 10 years; 11 males (69%))with heart failure and concomitant atrial ibrillation (duration 55 ± 86 months) underwent intraoperative epicardial electrophysiological mapping and a GP ablation using the maze procedure. Twenty-four site, highfrequency stimulation (1000/min; 18 V) was performed by placing tweezers directly onto the potential GP sites on the left atrial epicardium. Results: Active GPs were found in 13 (81%) of the 16 patients, and 12 (92%) of 13 patients had active GPs between the right pulmonary veins and the interatrial groove. For those patients with active locations, a 7-day event-loop recording demonstrated that 12 (92%) out of 13 patients were maintained in sinus rhythm 3 months after the operation. Conclusions: Dense epicardial mapping in the potential GP areas identiied active GP locations in a high percentage of patients. GPs between the pulmonary veins and interatrial groove have a high potential as ablation targets for treatment of concomitant atrial ibrillation. www.jaib.com 65 October, 2013 | Special Issue Radiofrequency Ablation Approach In Paroxysmal Atrial Fibrillation Patients Using Either Mathematical Scanning Or Clinical Approach A. Ardashev1, M. Mazurov2, I. Kaluzhny2, E. Zhelyakov1, Yu. Belenkov 3 Federal Scientiic and Clinical Center of FMBA, 2Moscow University of Economics, Statistics and Mathematics, 3Lomonosov State University Moscow, Russia 1 Abstract Introduction and objectives: 1) to compare clinical results of linear ablation vs. PVI approach in patients with paroxysmal AF and 2) to estimate theoretical probability of 4-waves re-entry to eliminate as a results of simulation the both ablative techniques in 2D mathematical modeling of left atrium (LA). Methods: Study was conducted on 20 pts (6 women, 51.4±13.6 years of age) with paroxysmal AF underwent index RFA. The irst group consisted of 10 pts (3 women, 51.1±11.9 years of age, history of arrhythmia – 3.2±1.2 years) in whom ablation strategy consisted of LASSO technique PVI. The second group concluded of 10 pts (3 women, 51.1±12.9 years of age, history of arrhythmia – 3.1±1.1 years) in whom ablation strategy consisted of wide-area circumferential lines application using CARTO-system. As the irst step numeric reconstruction of the autowave process in excitable tissues of the LA and the simulation of AF was performed using Fitzhugh-Nagumo. A special scanning method was used for calculating characteristics of autowave processes in a 2D mathematical model of the LA. As the second step simulation of circular (corresponding to LASSO approach) and linear ablation (corresponding to 3D approach) were performed. Results: 7 pts of the irst group vs 4 pts of the second group had early recurrences of arrhythmia. AAD free effectiveness in the irst/second groups was 80%/20% at 12 months respectively (р=0.003). There was no elimination of 4-waves re-entry around PVs after period equaling to re-entry period while circular LASSO-like ablation pattern was used. In contrast, linear ablation patterns suppress arrhythmias caused in 2D mathematical modeling of LA. Conclusions: Mathematical scanning approach using linear ablation to simulate clinical impact suppressed 4-waves re-entry more effectively comparing to PVI-only modeling. Our clinical results are consistent with ablation formatting data obtained by means of 4-waves re-entry simulation in 2D mathematical modeling of the LA. www.jaib.com 66 October, 2013 | Special Issue Ganglionated Plexi Ablation Directed By High-Frequency Stimulation And Complex Fractionated Atrial Electrograms For Paroxysmal Atrial Fibrillation A. Strelnikov, D. Losik, S. Bayaramova, E. Pokushalov, A. Romanov, S. Artyomenko, N. Shirokova, A. Turov, A. Karaskov Arrhythmia Department, Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia Abstract Introduction and objectives: The effectiveness of ganglionated plexi (GP) ablation in patients with AF is ambiguous. Some researchers had already suggested that additional identiication of complex fractionated atrial electrograms (CFAE) around the areas with a positive reaction to high-frequency stimulation (HFS) might improve the accuracy of GPs boundaries location, then enhancing the success rate of ablation. The purpose of this study was to assess the safety and eficacy of GP ablation directed by HFS and CFAE in patients with paroxysmal AF (PAF). Methods and results: Sixty-two patients with paroxysmal AF (age 57±8 years) underwent ganglionated plexi (GP) ablation. Ablation targets were the sites where vagal relexes were evoked by HFS and additional extended ablation CFAE area around the areas where vagal relexes were evoked. At 12 months, 71% of patients were free of symptomatic AF. At 3 months after ablation the rMSSD and HF were signiicantly lower in patients without AF recurrence (p<0.0001 and p=0.004). The LF/HF ratio was signiicantly higher in patients without AF recurrence (p=0.02). Conclusions: Enhanced GP ablation directed by high-frequency stimulation and complex fractionated atrial Electrograms can be safely performed and enables maintenance of sinus rhythm in majority of patients with PAF for a 12-month period. Denervation of the intrinsic cardiac autonomic nervous system may be the preferable target of catheter ablation of atrial ibrillation. www.jaib.com 67 October, 2013 | Special Issue Catheter Ablation Of AF: Ablation Techniques Radiation Dose Is Signiicantly Reduced By Use Of Contact Force Sensing Catheter During Circumferential Pulmonary Vein Isolation K.A. Walsh, G.J. Fahy Cardiology Department, Cardiorenal Centre, Cork University Hospital, Wilton, Cork City, Ireland Abstract Purpose: Circumferential pulmonary vein isolation (CPVI) for treatment of atrial ibrillation involves signiicant radiation dose, ablation time and procedure time. We assessed the impact on these parameters of a radiofrequency ablation catheter (RFC) allowing contact force sensing (CFS) during CPVI. Methods: Consecutive patients undergoing irst CPVI under conscious sedation guided by Lasso®, CartoSound™, CartoMerge™ (MRI) and Fast Anatomical Mapping using the Carto 3 system (Biosense Webster Inc., Diamond Bar, CA) and steerable sheath (Agilis™NxT, St Jude Medical Inc., St Paul, MN) were included in this single centre, single operator study. RFC without CFS (Navistar™, Biosense Webster, Inc.) was used in the irst 18 patients (Group 1). RFC with CFS (SmartTouch™, Biosense Webster, Inc.) was used in the subsequent 30 patients (Group 2). Ablation was applied at contact force > 9 g. The Mann Whitney U test was used to detect differences in radiation dose and luoroscopy, ablation and procedure times. Results: See Table. All pulmonary veins were isolated in all patients. Conclusion: Contact force sensing allows signiicant reduction of radiation dose but does not shorten procedure time. Age (Years) Gender (male) Fluoroscopy Time (mins) X Ray Dose (cGy/cm2) Procedure Time (mins) Ablation Time (mins) Paroxysmal (%) Group 1 Navistar™ (n=18) 52±12 13 22.24 range (8.83-47.02) 1782 range (334-6342) 180 range (120-450) 46 range (25-86) 72.22 Group 2 SmartTouch™ (n=30) 57±9 22 6.92 range (1.17-27.33 473.25 range (74.2-3734) 203, range (120-345) 56 range (37-109) 63.34 P value NS NS <0.001 <0.001 0.26 (NS) 0.017 NS www.jaib.com 68 October, 2013 | Special Issue Prospective Evaluation Of A Novel Catheter Tracking System Aimed At Reducing Fluoroscopy Exposure: Preliminary Results Of The Atrial Fibrillation Ablation Cohort P.G. Guerra, H. Nguyen hanh, P. Khairy, M. Dubuc, M. Talajic, B. hibault, L. Rivard, D. Roy, K. Dyrda, J. Andrade, N. Maillet, J. Gonzalez, L. Macle Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Canada Abstract Background: Catheter ablation for treatment of AF is associated with signiicant luoroscopy exposure. Recently, a novel sensor-based electromagnetic catheter tracking system (MediGuide [MG] Positioning System) was introduced. We prospectively evaluated the impact of the MG system on luoroscopy times during pulmonary vein isolation (PVI) procedures for paroxysmal AF. Methods: The MG system was recently installed in 1 of our 3 EP labs. A prospective registry evaluating luoroscopy duration and radiation exposure was initiated in February 2013, which includes all AF ablation procedures with or without MG, using irrigated radiofrequency (RF) energy. To assess the impact of MG on luoroscopy times, we classiied the procedure into the following steps: 1) positioning of CS catheter, 2) transseptal access, 3) creation of left atrial geometry, 4) PVI. For patients undergoing procedures with MG, luoroscopy cineloop acquisition was performed in PA and LAO views at the beginning of the intervention, which were then used for non-luoroscopic catheter tracking and positioning of CS and ablation catheters. In all patients, a circular mapping catheter and 3D mapping system was used and the procedural endpoint was deined as electrical PVI. Results: During the irst 2 months of the registry, 14 patients undergoing AF ablation procedures were included, 7 with and 7 without MG. The mean age was 60.5±9.3 years and 71% were male. Electrical PVI was successfully achieved in all procedures and no complications were observed. The mean procedural duration was 138.1±17.4 min with MG vs 131.7±46.2 min without MG (p=0.09). The mean RF delivery time was 50.7±20.7 min with MG vs 39.3±14.7 min without MG (p=0.74). Details of luoroscopy duration and radiation exposure are summarized in the Table. Conclusions: Initial results using a novel non-luoroscopic catheter tracking system for PVI procedures in patients with AF indicate a signiicant reduction (i.e., 48%) in the total luoroscopy duration. The ongoing prospective registry should better deine the procedural steps associated with the greatest reduction in luoroscopy exposure. Fluoroscopy time (min) MediGuide No MediGuide p value CS catheter positioning 1.0±1.6 1.1±0.7 0.14 Transseptal access 2.7±0.8 5.2±5.2 0.10 Creation of left atrium geometry 2.6±1.3 7.4±5.6 *0.0099 Pulmonary vein isolation www.jaib.com 7.3±4.4 11.8±5.6 0.10 Total luoroscopy duration (min) 14.3±4.3 29.2±14.7 *0.0012 Radiation exposure (microGy.m2) 2143±970 3760±3449 0.45 69 October, 2013 | Special Issue Ice In Catheter Ablation. It's Better To See What You Are Doing AO.V. Sapelnikov, A.S. Partigulova, P.V. Mezenstev, D.I. Cherkashin, A.B.Toporinskiy, I.R. Grishin, A.V. Chapurnikh, R.S. Akchurin Cardiology Research Center, Dpt. of Cardiovascular Surgery, Moscow, Russia Clinical Hospital No1 Dpt. Of President's Afairs, Moscow, Russia Hospital of Ministry of Internal Afairs, Moscow, Russia Abstract Introduction: Intracardiac Echo (ICE) is relatively new imaging method and it is not widespread currently, especially in Russia. Materials and methods: We analyzed the results of 44 AF-ablation procedures with Intracardiac Echo (ICE) convoy (1st group), and compared them with 35 control patients without ICE (2nd group). 32 AFlut-procedures (3rd group), and compared them with 20 patients (4th group). 10 F AcuNav sensors (Siemens) together with Vivid q ultrasound machine (GE), closed and open irrigated ablation catheters (Boston Scientiic) have been used. Results: The average luoroscopy time in 1st group was 36±12 min, and 57±16 min in 2nd one. We observed 4 complicated cases in patients without ICE: puncture of the aorta, which required surgery; penetration of contrast into the pericardium cavity during transseptal puncture; and 2 hemopericardiums. The ICE group we observed 1 hemopericardium after pumping during left veins isolation. We successfully completed the procedure using ICE. Also we observed phenomenon of silent pumping and several complicated cases of transseptal puncture. In one case we utilized ICE to evaluate LAA in patient with the diverticulum of the esophagus directly before the procedure. In total AFlut we signiicantly reduced a luoroscopy time, up to fully ICE-guided ablation in 5 patients. Conclusions: ICE allows to perform transseptal puncture safely and to monitor complications, especially for those starting practicing AFablation; helps to reduce time of luoroscopy signiicantly and to navigate inside the left atrium, as well as to evaluate contact of ablating catheter with left atrial wall; ICE is indispensable instrument in cases of impossibility of TEE using; in AFlut ablation ICE helps rapidly to achieve isthmus-block especially in cases with complicated anatomy, and almost to exclude a luoroscopy time; ICE does not require a specialist and is more convenient for both a surgeon and a patient. www.jaib.com 70 October, 2013 | Special Issue Complete Isolation Of The Left Atrial Posterior Wall (Box Lesion) To Treat Longstanding Persistent Atrial Fibrillation E.B. Saad, C. Slater, L.A. Inacio Jr., L.E. Camanho Center for Atrial Fibrillation Hospital Pró-Cardíaco, Rio de Janeiro, Brazil Abstract Introduction: Pulmonary vein isolation (PVI) is associated with high recurrence rates in longstanding persistent atrial ibrillation (LPAF), possibly due to rotors in the posterior wall (LAPW). The objective is to describe the results of complete isolation of the LAPP on top if PVI. Methods: Twenty ive pts (mean age 65±12 y, 72% male, mean AF duration 16±3 months) underwent circunferential PVI after which two connecting ablation lines on the roof and the infero-posterior LA were performed to completely isolate the LAPW (Box Lesion). LAPW isolation was proved by eletrogram elimination, lack of capture during pacing and Adenosine infusion. Results: After 12±2 months of follow-up, 19/25 pt (76%) were AF-free (19% off AADs) after a single procedure. Five pts (20%) had recurrences in the form of atrial lutter and were successfully ablated at the mitral isthmus, without recovery of conduction in the LAPW. Conclusions: Complete isolation of the LAPW using the Box Lesion technique is associated with high sucess rates in pts with LPAF. Most recurrences occur as macroreentrant lutters outside of the ablated area (mitral isthmus). www.jaib.com 71 October, 2013 | Special Issue Ganglionated Plexi Ablation Combined With Pulmonary Vein Isolation Improves Outcome Of Catheter Ablation In Patients With Longstanding Persistent Atrial Fibrillation: A Prospective Randomized Comparison S. Bayramova, D. Losik, A. Strelnikov, A. Romanov, E. Pokushalov, S. Artyomenko, N.Shirokova, A. Karaskov Arrhythmia Department And EP Laboratory, State Research Institute Of Circulation Pathology, Novosibirsk, Russia Abstract Introduction: Pulmonary vein isolation (PVI) is an established strategy for paroxysmal atrial ibrillation (AF) but seemed to be less effective in patients with persistent AF. Some researchers had already suggested that additional ganglionated plexi (GP) ablation might improve the success rate. The aim of our study was to assess the maintenance of sinus rhythm (SR) in patients with longstanding persistent AF at least 3 years using 2 different ablation strategies, PVI plus linear lesions (LL) versus PVI plus GP ablation. Methods: Two hundred sixty four consecutive patients with longstanding persistent AF were randomly assigned to 2 different ablation schemes: PVI plus LL (n=132) and PVI plus GP ablation (n=132). Primary end point was to assess the maintenance of SR after procedures in a long-term follow-up of at least 3 years. Results: All cases underwent the procedure successfully. PVI was achieved in all cases. With a single procedure at the 12-month follow-up, 47% of patients treated with PVI plus LL were in SR, whereas at the 3-year follow-up, 34% maintained SR; using the PVI plus GP with a single procedure at the 12-month follow-up 54% of patients were in SR (p=0.068), whereas at the 3-year follow-up, 49% remained in SR (p=0.021). Atrial lutter was more frequent in the group of PVI plus LL than in PVI plus GP ablation group (11% versus 4%, P=0.036). After a second procedure, the long-term overall success rate was 52% with PVI plus LL and 68% with PVI plus GP ablation (p=0.018). Conclusions: The difference between PVI plus LL and PVI plus GP ablation strategy is not statistically signiicant at 12 months in patients with longstanding persistent AF, whereas the difference becomes statistically signiicant in the longterm follow-up because of the higher number of recurrences in the PVI plus LL group. www.jaib.com 72 October, 2013 | Special Issue Atrial Fibrillation Ablation Using Magnetic Navigation: Comparison With Conventional Approach During Long-Term Follow-Up P. Adragão, F. Moscoso Costa, D. Cavaco, P. Santos, S. Carvalho, G. Cardoso, P. Carmo, K. Santos, L. Parreira, F. Morgado, M. Mendes Hospital West Lisbon, Hospital Santa Cruz, Department of Cardiology, Lisbon, Portugal Abstract Background: Percutaneous bilateral pulmonary vein isolation is recommended for symptomatic drug refractory atrial ibrillation (AF). Different robotic devices are available for this procedure although the long term eficacy is not well established. The goal of this observational prospective study is to evaluate the eficacy of pulmonary vein isolation using magnetic navigation comparing to a non robotic conventional ablation. Methods: We studied the 1140 consecutive patients admitted to irst AF ablation (same medical team in two centers, one using only magnetic navigation and the other manual approach), 57 ± 11 years old, 71.5% male, 30.1% hypertensive, 70.5% Paroxysmal AF, left atrium volume 97.4±34.7ml. 3D mapping systems (CARTO for magnetic navigation and CARTO or NAV-X for manual approach) and circular Lasso catheter were used in all patients. Follow up included clinical evaluation (with ECG or 24h Holter recording by protocol and driven by symptoms) and phone interview. Success was classiied in 3 classes: 1 - free of AF (no clinical or documented AF); 2 - clinical AF (AF symptoms not documented by ECG or 24h Holter recording lasting longer than 30sec); 3 - documented AF (ECG and 24h Holter recording lasting more than 30 sec). Results: Ablation was performed with magnetic navigation in 540pts (47.4%). There were no differences regarding type of AF at presentation (76.5% robotic vs 67.6% conventional, p=NS) but patients in the magnetic navigation group had higher prevalence of hypertension (36.9% vs 16.9%; p<0.001). Magnetic navigation procedure lasted longer (189.3 ± 41.3 min vs 153.5 ± 58.4min, p<0.001) but needing lower luoroscopy time (15 ± 12 min vs 28 ± 17 min; p<0.001). During an average follow up of 32.2±21.6 months, documented recurrence rates were lower in the magnetic navigation group (18.6% vs 32.1%, p=0.003). There was no difference regarding antiarrhythmic drug treatment (57.8% vs 55.3%, NS). In multivariate analysis, matching for follow up and clinical variables, Left atrial volume (OR 1.01; 95%CI 1.0011.016;p=0.038) was the strongest predictor of recurrence and magnetic navigation was related to a lower recurrence rate (OR 0.55; 95%CI 0.31 – 0.98;p=0.04). Conclusions: In our registry of patients submitted to pulmonary vein isolation, magnetic navigation with Stereotaxis® used lower luoroscopy times and was non inferior during long term follow up when compared to manual approach. www.jaib.com 73 October, 2013 | Special Issue Renal Denervation And Pulmonary Vein Isolation In Patients With Drug Resistant Hypertension And Symptomatic Atrial Fibrillation S. Bayramova, D. Losik, A. Strelnikov, E. Pokushalov, A. Romanov, S. Artyomenko, A. Turov, N. Shirokova, A. Karaskov Arrhythmia Department and Electrophysiology Laboratory, State Research Institute of Circulation Pathology, Novosibirsk, Russia Abstract Introduction: Hypertension is a risk factor for developing and maintaining atrial ibrillation (AF). Treating hypertension with renal denervation in drug-resistant patients might not only contribute to a decrease in blood pressure, but also to a decrease in AF recurrences in patients with paroxysmal (P) AF or persistent (Pers) AF. The aim of this prospective, single-center, randomized pilot study was the assessment of the impact of renal denervation and pulmonary vein isolation (PVI) in patients with history of AF and drug-restistant hypertension. Methods: Patients with history of symptomatic PAF and/or PersAF and drug-resistant hypertension were enrolled in this study. Patients were randomized to pulmonary vein isolation (PVI) only or PVI + Renal denervation. All patients were followed-up for 1 year to assess maintenance of sinus rhythm and to monitor changes in blood pressure. Results: We enrolled 27 patients with symptomatic AF and drug-resistant hypertension: 14 randomized to PVI only and 13 to PVI + renal denervation. At 12 months FU the reductions in systolic and diastolic blood pressure were successfully and signiicantly maintained (P<0.001) in patients treated with PVI + renal denervation. On the contrary, no signiicant change in blood pressure was observed in the PVI only group. Nine (69%) of the 13 patients treated with PVI + renal denervation were AF-free at the 12-month post-ablation FU, versus 4 (29%) of the 14 patients in the PVI only group (Log- Rank test, p=0.033). Conclusions: Renal ablation is effective in reducing systolic and diastolic blood pressure in patients with drug-resistant hypertension and history of atrial ibrillation. The beneit is maintained at 1 year after the procedure and it has an independent and positive impact on atrial ibrillation recurrences. www.jaib.com 74 October, 2013 | Special Issue Results Of Cryoballoon And Laser Ablation Of AF Characteristics Of The Left Atrium-Pulmonary Vein Reconductions In The Clinical Recurrences Of Paroxysmal Atrial Fibrillation In Patients Initially Treated With The Cryoballoon Catheter Technique J.M. Paylos, C. Ferrero, J.R. Conesa, M. Rayo, A. Morales, V.G.Tello Arrhythmia Unit and Electrophysiology Lab. Moncloa Hospital European University of Madrid, Madrid, Spain Abstract Introduction: Cryo-balloon catheter ablation technique (CB) has demonstrated been useful to treat patients with paroxysmal atrial ibrillation (PAF). We analyzed the anatomo-electrophysiological characteristics of the residual gaps in 4 segments (Sup. Inf. Ant. Post.) of the veins (PV) showed in the irst procedure (FP) and their correlation with the clinical recurrence of PAF and the locations of the LA-PV reconductions demonstrated in a second procedure (REDO). Methods: We analyzed 278 PV from 72 patients initially treated with CB, Artic Front Cryocath 28 mm and mapped with a 20 poles circular catheter at the LA-PV junction level. Complete electrical isolation with bidirectional block (BB) and after adenosine was demonstrated in all PV (100%) at the FP with a mean temperature occlusion reached ≥ -50ºC. Results: A total of 36 PV (13%) reconducted in the FP with a different segment location; all inally abolished by focal RF applications. In a follow-up of 777±454 days, 10 patients (13.8 %) had clinical recurrences, 8 (11%) at 4, and 1 (1.4%) at 10, 1 (1.4%) at 40 months respectively after the FP, and 8 (80%) were REDO. No signiicant (NS) differences were found related with the LA or PV size in the recurrence group versus no recurrence. From the 31 PV of the 8 REDO patients: 16 reconducted (51.6%): LSPV 6 cases (75%), LIPV 3 (37.5%), RSPV 2 (25%), RIPV 4 (50%) and 1 (12.5%) common trunk (CT) respectively. Four REDO patients (50%) showed reconduction in the FP in a different segment location, and one in all segments. Conclusion: Cryo-energy applications with CB doesn’t produce a homogeneous circumferential lesion in all PV, which is probably related to several factors, including: 1) Small LA-CB contact area at the PV-LA junction level. 2) LA and PV wall thickness and size. 3) The histological characteristics of the cryo-induced tissue lesion, resulting in aleatory reconductions in any segment of the vein not related with the residual conduction location showed in the FP. The highest conduction rate was found at the LSPV. As all clinical recurrences occurred late, we probably might expect a higher reconduction rate in a more long-term follow-up. www.jaib.com 75 October, 2013 | Special Issue Journal of Atrial Fibrillation Speical Issue CLINICAL RECURRENCES NO RECURRENCES 52±12 N.S. 46 range (25-86) 72.22 (Mean / Diameters) (Mean / Diameters) L.A. (mm) P.V. (mm) L.A. (mm) P.V. (mm) AP 37±6 SI 18±3 18±4 LAT 49±10 AP 19±6 - SI 53±7 - - AP 37±6 SI 20±4 LAT 48±8 AP SI 55±7 - RECONDUCTION FIRST PROCEDURE PV REDO BASAL SEGMENTS AFTER ADENOSINE PROCEDURE SEGMENTS S I SEGMENTS A S I A S I A P LS - - - 1 1 - 3 3 2 1 LI 1 - 1 1 1 3 2 1 1 2 RS - - 3 - - 1 1 2 1 1 RI 1 2 1 6 1 2 4 2 3 2 CT - - - - - - 1 1 - - www.jaib.com 76 October, 2013 | Special Issue Extrapulmonary Muscular Connections As A Potential Cause Of Left-Atrium-Pulmonary Vein Reconductions After Apparently Complete Electrical Pulmonary Veins Isolation In Patients Treated For Atrial Fibrillation With The Cryoballoon Technique J.M. Paylos, C. Ferrero, J.R. Conesa, A. Morales, M. Rayo, M.A. Gómez, V.G. Tello Arrhythmia Unit and Electrophysiology Lab. Moncloa Hospital European University of Madrid, Madrid, Spain Abstract Introduction Cryo-balloon technique (CB) for electrical isolation of pulmonary veins (PV) from the left atrium (LA) is a useful tool to treat patients with atrial ibrillation (AF). Limitations include the impossibility to eliminate extrapulmonary muscular connections (EMC), potential cause of PV-LA reconduction. We analyzed the incidence of EMC in our patients treated with the CB. Methods: A total of 326 PV from 84 patients with paroxysmal atrial ibrillation (PAF) (72), and persistent (AFP) (12) were treated with the big 28 mm CB, and acute electrical isolation achieve. A 20 poles circular-catheter mapping (CC) was used for cartography, and checking for bidirectional block (BB) performed. Antral pacing at the PV-LA junction level, and LA at distal CS was performed in a sequential manner from all the 20 poles of the CC at 3 different CL (600, 500, 400 mS), repeated after adenosine and pacing distal into the vein. Results: A Conclusions: The only not evidence of PV electrical activity after CB ablation, neither the demonstration of BB at the antral level is not enough to assure complete PV-LA isolation, and pacing distal PV from the 20 poles of the CC is mandatory to perform, to rule out such a potential cause of PV reconduction. EMC cannot be eliminated by the CB, representing by themselves a signiicant percentage of potential reconduction in patients with PAF (11%) and 17% (AFP), which ones, by the contrary, once identiied, can be easily eliminated by RF focal applications. www.jaib.com 77 October, 2013 | Special Issue Technical Evolution Of Cryoballoon Pulmonary Vein Isolation In Patients With Paroxysmal Atrial Fibrillation – First Experience With The New Artic Front Advance© Cryoballoon A. Kypta, T. Lambert, K. Saleh, C. Steinwender, S. Hoenig Cardiovascular Division, City Hospital Linz, Europe, Academic Teaching Hospital of the University of Vienna and Innsbruck, Austria Abstract Objectives: The purpose of this study was to investigate possible differences in procedural parameters and clinical follow-up between the new Arctic Front Advance© Cryoballoon (Medtronic) and the already established Artic Front© Cryoballoon (Medtronic) used for pulmonary vein isolation (PVI) in a paroxysmal atrial ibrillation (PAF) population. Methods: Between 2010 and 03/2013, we performed PVI with cryoballoons in 186 patients with PAF (143 with the Arctic Front© and 43 with the new Arctic Front Advance© Cryoballoon, respectively). Both devices were used according to the recommendations of the manufacturer with a freeze time of 300 sec for the Artic Front© and 240 sec for the Artic Front Advance©, respectively and a minimum of 2 freezes for each PV. In order to eliminate data from the learning curve with a single-shot balloon-catheter, we excluded the irst 30 patients ablated with the Arctic Front© from retrospective analysis. In consequence, we compared procedure- and luoroscopy times, the need for touch-up ablations as well as the incidence of phrenic nerve palsy between 113 Artic Front© - and 43 Artic Front Advance©-patients. Clinical follow-up consisted of 48-hour ECG monitoring at 3, 6, and 12 months after ablation plus additional ECGs recorded during episodes of suspicious symptoms. Freedom from atrial arrhythmias ≥ 30 seconds was counted as clinical success. Results: Signiicant reduction of procedure time (mean 163 ± 49min for the Arctic Front© vs. mean 110 ± 30 min for the Arctic Front Advance©, p<0.001) and luoroscopy exposure (mean 36 ± 16 min for the Arctic Front© vs. 21 ± 5 min for the Arctic Front Advance©, p<0.001) could be observed. The need for touch-up ablations was 7/113 (6%) and 2/43 (5%) for the Artic Front© and the Artic Front Advance©, respectively (p=ns). Phrenic nerve palsy occurred in 4/113 (4%) of the Arctic Front©-patients and in no Arctic Front Advance©patient (p=ns). Clinical 3-month eficacy was similar in both groups with freedom from AF: 84/113 patients (74%) in the Arctic Front©-group and 33/43 (77%) patients in the Arctic Front Advance© group, respectively (p=ns). Conclusions: Compared to the Artic Front© cryoballoon, the new Arctic Front Advance© cryoballoon could signiicantly reduce the procedure and luoroscopy times of PVI without a reduction of the safety or eficacy of the intervention. Thus, the positive evolution of this catheter could be a key for increasing the number of treated patients by making the intervention easier and faster. EMC cannot be eliminated by the CB, representing by themselves a signiicant percentage of potential reconduction in patients with PAF (11%) and 17% (AFP), which ones, by the contrary, once identiied, can be easily eliminated by RF focal applications. www.jaib.com 78 October, 2013 | Special Issue Coolloop First: A First In Man Study To Test A Novel Circular Cryoablation System In Paroxysmal Atrial Fibrillation M. Stuehlinger, S. Hoenig, K. Spuller, C. Koman, O. Pachinger, C. Steinwender Innsbruck Medical University, Department of Internal Medicine III, Cardiology, Innsbruck, Austria and General Hospital (AKH) of Linz, Linz, Austria Abstract Purpose: Pulmonary vein (PV) isolation has become the mainstay of catheter treatment of atrial ibrillation (AF). For an optimal procedural success, wide and complete linear lesions around the PVs are necessary. For this purpose, the CoolLoop circular cryoablation catheter (AFreeze; Innsbruck / Austria) was developed. In this study we evaluated the feasibility and safety of this ablation system for the irst time in humans. Methods: 10 patients (6M/4F; 61.3±9.5y) with symptomatic paroxysmal AF refractory to at least 1 AAD and without signiicant heart disease were included in 2 Austrian centres. The CoolLoop catheter was positioned at each PV antrum by guidance of intracardiac echocardiography (ICE). Subsequently, 2-4 double-freezes were performed for 5 min, respectively. PVI was conirmed with a circular mapping catheter. During cryoablation (CA) of the right PVs, phrenic nerve pacing was used to monitor phrenic nerve function. Results: The CoolLoop catheter (igure) could positioned at all PV antra of all patients. A mean of 5.6±1.8 CA were performed in the LSPV, 5.6±1.6 in the LIPV, 6.3±2.5 in the RSPV and 5.4±1.6 in the RIPV. Mean procedure time was 231.7±48.4min and mean luoroscopy time was 39.3±13.3min. 6/10 LSPV, 6/10 LIPV, 5/10 RSPV and 6/10 RIPV could be isolated exclusively using the novel cryoablation system. 1 patient developed groin hematoma and a brief episode of ST-elevation due to air embolism was observed in another patient. No other clinical complications and no phrenic nerve palsy occurred during 3 months of follow up. Conclusions: Cryoablation for paroxysmal atrial ibrillation using the CoolLoop catheter system is feasible and safe. Clinical medium and long term eficacy still needs to be evaluated and to be compared with other catheters for ablation of AF. www.jaib.com 79 October, 2013 | Special Issue Adenosine Testing After Endoscopic Ablation System (EAS) Pulmonary Vein Ablation For Atrial Fibrillation N. Kumar, Y. Blauw, L. Pison, R. Ter Bekke, K. Vernooy, C. Timmermans, H. Crijns Dept. of CTC- Cardiology, Maastricht University medical centre, Cardiovascular research institute of Maastricht, Maastricht, he Netherlands Abstract Purpose: Adenosine administration after PVI using radiofrequency and cryo ablation reveal acute recovery of the conduction to the PVs and predict AF recurrence. It is considered superior to isoproteronolol. This study aimed to determine whether adenosine can reveal dormant PV sleeves after using EAS. Methods: All AADs were stopped 5 days before the procedure except for patients on Amiodarone. All 11 patients underwent PVI using EAS (CardioFocus Inc., Marlborough, MA, USA). After waiting for 30 minutes, other ablation lesions (Table 1) and sinus rhythm were obtained; bolus of adenosine 15-21 mg was injected followed by rapid saline lush. The subsequent response was assessed for each vein using an insitu lasso catheter. Further ablation (if needed) using EAS was done till no reconduction occurred with repeat adenosine. Results: Acute PV isolation was achieved in all 41 PVs in 11 patients. In 4 patients,6 PVs (2 LSPV, 1 LIPV, 2 RSPV, 1 RIPV) showed dormant PV potentials. Conclusions: Adenosine testing after pulmonary vein isolation using EAS reveals dormant conduction in initially isolated PVs. This testing may improve success rates when EAS is used. Table 1 Patient Characteristics Patients (n) 11 Pulmonary veins (n) 41 Gender (men/women) 8/3 Age (years) 58.9 ± 8.7 (46-71) BMI 29 ± 3.5 Additional CTI ablation (n, %) 1(9.0%) Average procedure time (minutes) 180±44 AF duration (years, mean±SD) 5±4.2 LVEF (%, mean±SD) 58±4 LA volume (cc, mean±SD) 60±9 Number of prior electrical cardioversions (n, %) 1(9%) Number of prior AF ablation patients (n, %) 0(0%) Number of prior pharmacological cardioversions (n, %) 1(9%) Number of prior AFl ablation patient numbers (n, %) 0(0%) Medical History Hypertension (n, %) 4(36.3%) CHF (n, %) 0(0%) Atrial lutter (n, %) 1(9.0%) CAD (n, %) 2(18.1%) Medication Use Amiodarone 1(9.0%) Flecainide 6(55.5%) Sotalol 2(18.1%) Disease Characteristics Paroxysmal/persistent AF (n/n, %/%) www.jaib.com 10/1(90% / 10%) 80 October, 2013 | Special Issue Retrospective Comparison Of The Learning Curves For PVI Between Cardiofocus Laser Balloon & PVAC D.Q. Nguyen*, L. Lichtenberg*, K. Schuettler**, W. Fehske* Dept. of Electrophysiology, Clinic III for Internal Medicine and Cardiology, St. Vinzenz-*: Hospital Cologne, Merheimer Str. 221 - 223, 50733 Cologne, Germany. **: CardioFocus, 500 Nickerson Road, Marlborough, MA 01752, USA 1 Abstract Purpose: The CardioFocus laser balloon (CFLB) with its 30 degree ablation sector takes an intermediate position between a single shot device for PVI as originally designed, and the conventional point-by-point ablation. Advantages are the direct endoscopic view of the ablation area, and the contact force independent application of laser energy. Methods: A retrospective comparison with a PVAC ablation approach for the irst 50 patients (pt) of each technology, i.e. the learning curves will be presented. Results: Mean procedure time for CFLB was 221±42.9 min, for PVAC 188±37.4 min; mean luoroscopy time 38±13.6 min, and 41±10.7 min; Mean procedure time reached the bottom after 20 patients - for CFLB with around 210 min, for PVAC with about 180 min; Mean luoroscopy time for CFLB is continuously declining beyond the 50th pt. with pt 50 at around 30 min, but for PVAC it is reaching a bottom at about 40 min. Acute isolation rates were optimal with 99% (CFLB: 196 out of 198 veins; PVAC 194 out of 196 veins) from the beginning on. Mean freedom from AF/AT after 6 months after a single procedure was 81.4% for CFLB and 78.0% for PVAC measured by 7-day ECG recording. Most importantly, mean clinical recurrence of AF/AT after 6 months improved obviously from 31.2% of the irst third, to 17.6% for the second third, down to 0% for the last third of patients treated by CFLB while there was less clear improvement by PVAC. Conclusions: Two learning curves could be found concerning the time course: one inished after 20 pt. for procedure time (CFLB & PVAC) and luoro time (PVAC), another longer lasting for CFLB’s luoro time and superior outcome. www.jaib.com 81 October, 2013 | Special Issue Catheter Ablation Of AF: Long-Term Results (Outcome) Elimination Of Dormant Pulmonary Vein Conduction Revealed By Adenosine After Their Initial Isolation: Randomized 3-Year FollowUp Study E. Lyan, A. Klukvin, G. Gromyko, F. Tursunova, A. Kazakov, A. Morozov, A. Merkureva, P. Krasnoperov, S. Yashin Cardiac Electrophysiology Department, Pavlov State Medical University, Saint Petersburg, Russia Abstract Purpose: Study was aimed to evaluate whether additional dormant conduction ablation improves clinical outcomes in patients with atrial ibrillation after pulmonary vein (PV) isolation. Methods: Study included 134 patients with paroxysmal and persistent atrial ibrillation. After PV isolation, 30 minutes observation period was applied, followed by adenosine-test. In case of dormant conduction patients were randomized to 2 groups. Dormant conduction was eliminated by additional ablations in all patients of ATP-Abl group and remained intact in ATP-Control group. Results: Adenosine-test revealed dormant conduction in 33 out of 268 ipsilateral PV pairs (12%) in 31 patients (23%). ATP-Abl group included 14 patients, in whom dormant conduction were eliminated by additional ablations in 15 ipsilateral PV pairs. ATP-Control group included 17 patients, in whom dormant conduction was revealed in 18 ipsilateral PV pairs and left intacted. After 40 months follow-up 6 patients in ATP-Abl group (43%) and 6 patients in ATP-Control group (35%) were free from any arrhythmia, difference didn’t demonstrate statistical signiicance (Log Rank = 0,75; p=0,39). Conclusion: Elimination of dormant PV conduction does not improve long-term clinical outcomes after PV isolation. www.jaib.com 82 October, 2013 | Special Issue Atrial Fibrillation Ablation: Does Recurrence Compromise Symptomatic Improvement? F. Moscoso Costa, D. Cavaco, H. Dores, P. Santos, P. Carmo, G. Cardoso, S. Carvalho, F. Morgado, P. Adragão Hospital West Lisbon, Hospital Santa Cruz, Department of Cardiology, Lisbon, Portugal Abstract Background: Percutaneous bilateral pulmonary vein isolation is recommended for symptomatic drug refractory atrial ibrillation (AF). Although having good short term results, long term eficacy and symptomatic improvement are not well established. Our goal was to evaluate the eficacy of pulmonary vein isolation and effect in quality of life on a large series of patients. Methods: We studied 601 consecutive patients admitted to irst AF ablation in our center, (56±11) years old, 72.9% male, 61.7% Hypertensive, 62.8% Paroxysmal AF, 30.4% Persistent AF, 6.8% Permanent AF) from 01-05-2005 to 31-11-2011. FUp was made by in clinic evaluation (with ECG or 24hours Holter by protocol and driven by symptoms) and by phone interview. Success was classiied in: 1-free of AF (no symptomatic or documented AF); 2-Cinical AF (AF symptoms not documented by ECG or Holter and lasting more than 30 sec); 3-documented AF (lasting longer than 30sec); 4- Permanent AF. EHRA score was used to access quality of life before and after ablation. Results: During a Fup of 1320±576 days, 43.8% of patients were free from symptomatic or documented AF; 45.1% with clinical AF; 36.9% with documented AF and 3% in permanent AF. The procedure was repeated in 20.7% of patients. The most powerful predictor of recurrence was left atrium volume accessed by angio TC (OR 2.23, 95%CI 1.18 – 4.25; p=0.015). Antiarrhythmic therapy was maintained in 40.3% of patients. A signiicant improve in EHRA score result was observed after ablation (average 2.7±0.6 before vs 1.27 ±0.6 after; wilcoxon p<0.001), even in patients with AF recurrence (2.7±0.5 before vs 1.4±0.7 after; p<0.001). Conclusions: In our registry of patients submitted to pulmonary vein isolation, 36.9% of patients had documented recurrence during long term follow up. Although 56.2% of patients had symptomatic or documented recurrence, there was a signiicant improve in AF related symptoms and quality of life after ablation. Left atrial volume accessed by angio-TC was the main predictor of recurrence. www.jaib.com 83 October, 2013 | Special Issue Atrial Fibrillation Ablation. Our First Results O.V. Sapelnikov, P.V. Mezentsev, A.S. Partigulova, I.R. Grishin, R.S Latypov, S.V. Chapyrnikh, R.S Akchurin Cardiology Research Center, Dpt of Cardiovascular Surgery, Moscow, Russia Volyn Hospital no 1 of the President Administration, Moscow, Russia Hospital of the Ministry of Internal Afairs, Moscow, Russia Abstract Background: The number of AF-ablation procedures are rapidly growing, and the results are being actively studied at present. Currently, there are still many unresolved issues that have accumulated as they gain experience. Materials and methods: WFrom 2011 up to 05.2013 we treated 143 patients. We used Chilli II closed irrigated and Blazer Open Irrigated systems (Boston Scientiic), AcuNav ultrasound 10 F sensors (Siemens) in catheter ablation group. 1st group – catheter ablation procedure in paroxysmal AF - 86 2nd group – catheter ablation procedure in persistent AF patients – 57 Results: Mean age was 58 years, left atrial size was 4.0 cm (68.5 ml) without signiicant differences in the groups. In 1st group we’ve got 84.9% of success, including 13 patients with 2nd procedure (average 14 months of follow-up). We made PV-isolation protocol with the following provoking AF by rapid left atrial stimulation. In 2nd group with persistent AF we’ve got totally 68% of patients free from AF in 1 year of follow-up. We extended our protocol to posterior wall isolation, ablation of CFAFs, CS-isolation, trying to get a sinus rhythm during delivering of ablating lesions. We observed 9 complicated cases (6.3%) in groups of patients: puncture of the aorta, which required surgery; penetration of contrast into the pericardium cavity during transseptal puncture without hemopericardium; and 6 hemopericardiums after transseptal puncture and after pumping during left veins isolation. In 5 cases we successfully completed the procedure using ICE. Once we have seen a case of cortical blindness, which recovered after treatment started immediately. Conclusions: AF ablation is very effective and safe even in persistent and permanent AF Sinus rhythm restoration during ablation delivery – is a strong predictor of long-standing sinus rhythm in patients with persistent AF. ICE can prevent complications of transseptal puncture, helps to navigate in left atrium, to monitor complacations and more comfortable both to surgeon and patient than TEE. It should be a routine procedure during AF ablation. www.jaib.com 84 October, 2013 | Special Issue Free Of Antiarrhythmic Drugs Before And After Ablation Of Atrial Fibrillation. Is It Really Possible? A.S. Partigulova, A.V. Chapyrnikh, O.V. Sapelnikov, P.V. Mezentsev, I.R. Grishin, A.B. Toporinskiy, D.I. Cherkashin, M.A. Magomedov, R.S. Latypov, R.S. Akchurin Cardiology Research Center, Dpt of Cardiovascular Surgery, Moscow, Russia Volyn Hospital no 1 of the President Administration, Moscow, Russia Hospital of the Ministry of Internal Afairs, Moscow, Russia Abstract Background: There are still many unsolved issues that have accumulated as our experience is been growing. There is no consensus on the protocol of antiarrhythmic therapy before and after ablation of atrial ibrillation. Materials and methods: From 2012 up to 2013 we treated 63 patients. We used Chilli II closed irrigated and Blazer Open Irrigated systems (Boston Scientiic), AcuNav ultrasound 10 F sensors (Siemens). In some patients (pts) antiarrhythmic treatment (AAT) by amiodarone or 1C class drugs before and for 3 months after ablation have been used. Several patients were treated only by β-blockers after ablation procedure. 1st group – catheter ablation procedure in paroxysmal AF – 42 patients / 12 pts without AAT 2nd group – catheter ablation procedure in persistent AF patients – 21 / 6 pts without AAT Results: Mean age was 56 years, left atrial size was 4.1 cm (70.3 ml) without signiicant differences in the groups. We made PV-isolation protocol with the following provoking AF by rapid left atrial stimulation. We extended our protocol in 2nd group to posterior wall isolation, ablation of CFAFs, CS-isolation, trying to get a sinus rhythm during delivering of ablating lesions. In 1st group we’ve got 85.7% of success, and 76.2% in 2nd one after 3 months of follow up. Patients with recurrent AF in 1st group distributed equally (3x3) among pts with or without AAT. In patients with persistent AF recurrency of arrhythmia prevailed among patients with AAT. Conclusions: AF ablation is very effective and safe even in persistent and permanent AF Clear background without AAT before and after ablation helps us to evaluate true results of AF-treatment, especially in patients with persistent AF. There is no clear dependency of AAT in recurrency of atrial ibrillation after ablation procedure www.jaib.com 85 October, 2013 | Special Issue Long-Term Follow-Up Of Recurrences After The First Ablation Of Atrial Fibrillation E.A. Ivanitskiy, A.P. Tsaregorodtsev, D.A. Shluakov, D.B. Drobot, V.A. Sakovitch Department of Cardiovascular Surgery, Federal Centre of Cardiovascular Surgery, Krasnoyarsk, Russia Abstract Objectives: Analyze and compare all recurrences after the irst ablation of atrial ibrillation in the long term follow up. Materials and methods: FWe studied long term follow up of 61 patients, mean age 54 + 17 years, who had undergone ablation of an atrial ibrillation (AF) including those with paroxysmal, persistent and long standing persistent AF. All these patients had recurrences after the irst procedure. Patients were divided into two groups according to type of arrhythmia before ablation: in the irst group patients had lone AF before the procedure; in the second group patients had AF in combination with atrial lutter. Mean follow up period 18 + 11 months. Results: MIn both groups recurrences in AF only we associated with worse prognosis when compared with recurrences in any atrial lutter. It was possible to maintain sinus rhythm in a group of patients with recurrence in AF (36 patients) after multiple procedures (at least three) in 18 cases 50%. In a group of patients with recurrences in any atrial lutter (25 patients) it was possible to maintain sinus rhythm after multiple procedures (at least two) in 24 patients 96%. The aim of the irst procedure of atrial ibrillation ablation was the antral isolation of all pulmonary veins (PV). In a case of recurrence of AF the aim of procedure was to reisolate of reconnected PV. If all PV were isolated we completed procedure with vagal denervation. After the irst ablation all recurrences were divided into two subgroups in each group: 1)recurrences in AF and 2)recurrences in atrial lutter (typical or atypical). At the end of the study in the irst group of patients with isolated AF before ablation (42 patients) sinus rhythm was present in 26 patients 62%, 9 patients got pacemaker and AV node ablation 21,4% and 6 patients 16,6% were on pharmacological rate control therapy. In a group of patients who presented with AF in combination with atrial lutter before ablation (19 patients) sinus rhythm was maintained in 16 patients 84,2%, 3 patients 15,8% were on pharmacological rate control therapy. Conclusions: Recurrence in any type of macroreentrant supraventricular tachycardia after the irst ablation of atrial ibrillation seems to have the best prognosis on long term results and on sinus rhythm maintenance when compared with AF as a recurrence after ablation. Those patients who have AF in combination with atrial lutter before ablation have best prognosis when compared with patients who have lone AF. www.jaib.com 86 October, 2013 | Special Issue Long-Term Outcomes Of Remote Magnetic Catheter Navigation For Ablation Of Atrial Fibrillation: A Case Control Study E. Koutalas, L. Bertagnolli, P. Sommer, S. Rolf, A. Bollmann, G. Hindricks, A. Arya Department of Arrhythmiology, Herzzentrum Leipzig, Germany Abstract Introduction: This study intended to assess the long term outcome of remote magnetic catheter navigation (RMN) in comparison to manual catheter navigation (MCN) for ablation of atrial ibrillation (AF). Methods: 140 patients (96 men, mean age 58.2±10.2 years; 70 in each group) were included in this case-control study. Patients were matched for age, gender and type of AF. Patients were followed up with 7-day continuous Holter ECG recordings immediately postinterventionally, after 3 and 6 months and on a 6-month basis thereafter. Any atrial arrhythmia episode longer than 30 sec was reported as recurrence. Results: Mean follow up after the index procedure was 28.8±18.9 months. 40% and 59.1% of patients in RMN and MCN groups, respectively, remained free of AF recurrence (p=0.031) (Figure). Conclusions: Fewer patients in RMN group experienced freedom from AF during long term follow up compared to MCN using steerable sheath. Randomized studies are warranted to further clarify this issue. 68.3% 59.1% 59.5% 40.0% Log Rank (Mantel-Cox) P=0.433 67.6% 53.3% 50.0% 24.0% www.jaib.com 87 October, 2013 | Special Issue Ablation Of Paroxysmal And Persistent Atrial Fibrillation: LongTerm Recurrence Rates Via Continuous Subcutaneous Monitoring S. Bayramova, D. Losik, A. Strelnikov, A. Romanov, E. Pokushalov, S. Artyomenko, N. Shirokova, A. Karaskov, S. Mittal, J. Steinberg Arrhythmia Department and Electrophysiology Laboratory, State Research Institute of Circulation Pathology, Novosibirsk, Russia. he Valley Health System and Columbia University, New York, NY, USA Abstract Introduction: Concerns have been raised that over prolonged follow-up, initial responders to ablation of atrial ibrillation (AF) may recur very late post-procedure, even years after. Existing data, however, are limited to symptomatic events or at best, intermittent Holter or event recordings. The aim of this prospective observational study was to comprehensively track recurrence rates over 3 years post-ablation using implantable loop recorders (ILRs). Methods: One hundred twenty nine patients with symptomatic drug refractory AF (45% with persistent AF) were enrolled. All patients underwent circumferential pulmunary vein isolation (PVI) with ILRs inserted for continuous AF monitoring during the 36-month follow-up. AF freedom was deined as AF%<0.5%. Results: Complete PVI was achieved in 100% of cases. With a single procedure at the 12-month follow-up, 76 (59%) of the 129 patients were AF-free: 48 out of 71 (68%) in the paroxysmal AF group and 28 out of 58 (48%) in the persistent AF group. At the 36-month, 43 (33%) of the 129 patients were AF-free: 29 out of 71 (41%) in the paroxysmal AF group and 14 out of 58 (24%) in the persistent AF group. A second procedure was performed in 41 (32%) and a 3rd in 6 (5%) patients. After the inal ablation, 78 (60%) of the 129 patients were AFfree at 36 mos: 56 out of 71 (65%) in the paroxysmal AF group and 32 out of 58 (55%) in the persistent AF group. In the overall population, the AF% dramatically decreased by 6-months, followed by a plateau and a gradual increase after 16 months. 11 patients (21%) of the nonresponders were completely asymptomatic. Progression to longstanding persistent AF was observed in 18 patients (14%). Conclusions: Although ablation is effective in treating AF, there is a signicant attrition rate as assessed through detailed 3-year continuous ILR monitoring. Prior studies underestimated very late recurrences and failed to account for asymptomatic patients. The use of ILRs is a valuable means of identifying responders and non-responders, and can potentially guide therapies. www.jaib.com 88 October, 2013 | Special Issue Does Af Burden Measured By Implantable Loop Recorder During Post-Ablation Blanking Period Predict Response At 12 Month Follow-Up? SD. Losik, A. Strelnikov, S. Bayramova, E. Pokushalov, A. Romanov, S. Artyomenko, A. Turov, N. Shirokova, A. Karaskov Arrhythmia Department and EP Laboratory, State Research Institute of Circulation Pathology, Novosibirsk, Russia Abstract Introduction: The aim of this study was to identify if there is a threshold of AF burden during the irst months post-ablation obtained through continuous subcutaneous monitoring that can identify patients at risk of subsequent AF recurrences. Methods: 613 patients with symptomatic drug refractory AF (17% with persistent AF) were enrolled in this retrospective analysis. All patients underwent circumferential pulmunary vein isolation (PVI) and were implanted with an ILR for collecting data on AF burden during 12-month follow-up. AF freedom (Responders) was deined as AF%<0.5% during follow-up period. A ROC curve analysis was performed to identify the value of AF burden during the irst 2 months post ablation (Blanking Period, BP) that was predictive of late recurrence of AF. Results: After the irst ablation procedure, 396 (65%) of the 613 patients were AF-free at 12-month: 346 out of 508 (68%) in the paroxysmal AF group and 50 out of 105 (47%) in the persistent AF group. Using the ROC curve (Fig 1), the speciicity corresponding to 90% sensitivity was 75%. The corresponding threshold in the AF burden during the blanking period able to identify patients at risk of late recurrences was 7.1%, corresponding to 102h (= 4.25 days) in AF during the 2 months BP. At the multivariate analysis, a threshold in the AF burden <7.1% during BP was still highly signiicant (p<0.0001) and the odds of responders/non-responders was 21.5 (10.8 - 42.9). Conclusions: The BP AF pattern predicted response to catheter ablation. An AF burden ≥7.1% assessed by continuous monitoring was a powerful predictor of subsequent AF recurrence after initial ablation, and thus be an appropriate guide for early re-intervention www.jaib.com 89 October, 2013 | Special Issue Catheter Ablation Of AF: Predictors Of Success Exercise Capacity Test Helps In Selecting Candidates For Aggressive Sinus Rhythm Maintenance Using Catheter ABLATION In Patients With Long-Persistent Atrial Fibrillation M. Okanao, N. Tanaka, K. Su, Y. Morita, M. Kimura, E. Minomino, T. Kato, E. Nakane, S. Miyamoto, T. Izumi, M. Inoko, R. Nohara Heart Center, Kitano Hospital Medical Research Institute, Osaka, Japan Abstract Introduction: The indication of suitability of ablation for long-persistent atrial ibrillation (CAF) remains to be studied. CAF patients, likely less symptomatic, can have lower exercise capacity (EC). Hence we investigated whether EC testing prior to attempting further procedures could be used as a determinant for suitability of sinus rhythm (SR) maintenance in CAF patients. Methods: For 36 consecutive CAF (>1 year) patients, we sought to maintain SR using ablation with anti-arrhythmic drugs. EC was evaluated before procedures and after 6 months SR maintenance. For 32 cases, SR was maintained for 27.4±6.9 months. EC parameters varied before procedures. (Peak VO2. % of predicted: 38% to 124%; median: 80%, VE/VCO2-slope: 14.8 to 41.5; median: 25.9). Patients with better EC had greater stroke volume index, lower pulmonary vascular resistance and better diastolic function. After SR maintenance, the peak VO2 improved to 87% (P<0.01), though percentage changes in VE/VCO2-slope varied (-23.2% to 27.1%; median: 4.2%). However, greater EC improvements were observed in patients with lower EC (Peak VO2: R2=0.41; VE/VCO2-slope: R2=0.61, P<0.01). Conclusion: We conclude CAF patients with lower EC can more beneit from aggressive SR maintenance. www.jaib.com 90 October, 2013 | Special Issue Galectin-3 In Atrial Fibrillation And Ablation M. Gwechenberger, B. Richter, S. Steiner, H. Gössinger Dept. of Cardiology, Medical University of Vienna, Vienna, Austria Abstract Introduction: Atrial ibrillation (AF) is associated with ibrosis. Galectin-3 (Gal3) is a novel biomarker for ibrosis. Aim of the study was to investigate its role in atrial ibrillation. Methods: Thirty consecutive patients ((57.9 ± 1.7 years, 63% males) with pAF who underwent radiofrequency ablation were included. Biomarkers were assessed in blood samples before and 3 months after the ablation.Results: After the irst ablation procedure, 396 (65%) of the 613 patients were AF-free at 12-month: 346 out of 508 (68%) in the paroxysmal AF group and 50 out of 105 (47%) in the persistent AF group. Using the ROC curve (Fig 1), the speciicity corresponding to 90% sensitivity was 75%. The corresponding threshold in the AF burden during the blanking period able to identify patients at risk of late recurrences was 7.1%, corresponding to 102h (= 4.25 days) in AF during the 2 months BP. At the multivariate analysis, a threshold in the AF burden <7.1% during BP was still highly signiicant (p<0.0001) and the odds of responders/non-responders was 21.5 (10.8 - 42.9). Results: The mean Gal3 levels were 9.6+2.6 at baseline and 10.6+2.7 at follow up. Two thirds of the patients demonstrated an increase after the ablation procedure. However, this was not predictive for the longterm outcome. While the baseline level of Gal3 correlated with the atrial diameter (p<0.016), the Gal3 levels at 3 months correlated with the left ventricular ejection fraction (p<0,038) and the presence of structural heart disease (p<0,041). There was no correlation with CRP, IL-6, Matrix metalloproteinase-9 (MMP-9), transforming growth factor-β1 (TGF-β1) and the aminoterminal propeptide of type III procollagen (PIIINP) Conclusions: Galektin-3 correlates with the atrial diameter at baseline and shows an upregulation after the ablation. However this did not predict longterm outcome. www.jaib.com 91 October, 2013 | Special Issue Pulmonary Vein Isolation In Patients With Paroxysmal And NonParoxysmal Atrial Fibrillation: Importance Of Diastolic Function Grading T. Pezawas, T. Binder, R. Ristl, B. Schneider, S. Stojkovic, F. Moser, C. Schukro, H. Schmidinger Department of Cardiology, Medical University of Vienna, Vienna, Austria Abstract Background: Pulmonary vein isolation (PVI) has become an accepted therapy for patients with atrial ibrillation (AF) and the indications have widened to include non-paroxysmal AF-patients. Clinical and echocardiographic parameters should help to identify patients who have the best long-term beneit from PVI. Methods and Results: After baseline clinical and echocardiographic evaluation the follow-up strategy in the irst year and thereafter, if non-sustained AF has been recorded included: 1) Clinical follow up, 12-lead ECG and 24-h ECG every 3 months, 2) trans-telephonic ECGs twice daily and when symptomatic (over 4 weeks) every 3 months, or 3) continuous monitoring via implanted devices. A recurrence was an atrial arrhythmia lasting >30sec. All 340 PVI procedures of 229 consecutive patients were analyzed. On average, 1.5 PVI procedures per patient (range, 1-6 PVI) were performed. The mean age was 58 ± 11 years (73% male) with 109 paroxysmal and 120 non-paroxysmal AF cases. Clinical follow-up with 12-lead ECGs, 24-h ECGs, trans-telephonic ECGs and implanted devices was available in 100%, 63%, 51% and 16% of cases, respectively. The one-year recurrence rate of 59% (range, 24% - 82%) was dependent on grades of diastolic function (normal - dysfunction grade III) in a multivariate analysis model. Patients with normal diastolic function had the lowest recurrence rates of 24% and 49% after 1 and 3 years of follow-up, respectively (p<.0001). Conclusions: PVI in unselected AF-patients is a palliative strategy with high recurrence rates obtained by close monitoring. Grading of diastolic function can identify AF-patients who beneit most from PVI. www.jaib.com 92 October, 2013 | Special Issue Pulmonary Vein Diameter And Post Radiofrequency Ablation Atrial Fibrillation Recurrence: Does Size Matter? H.J. Quiroga Ponce, N. Al-Shoaibi, S.J. Connolly, J.S. Healey, S. Divakaramenon, C.S. Ribas, N. Kansal, C.A. Morillo Hamilton Health Sciences, Mc Master University, Hamilton, ON, Canada Abstract Background Pulmonary veins (PV) have been identiied as triggers for Atrial Fibrillation (AF), and catheter radiofrequency ablation (RFA) is an effective treatment for AF. Recurrence of AF post-RFA can be predicted by clinical factors, including hypertension, left atrial enlargement and persistent AF. The importance of PV diameter in AF recurrence is less established. Methods: We retrospectively analyzed 295 patients that underwent a irst RFA between 2004 and July of 2011. A pre-procedure cardiac CT scan with PV diameter measurements was performed in all patients. Primary endpoint was documented ECG symptomatic recurrence of AF between 3 and 12 months post RFA. ROC curves and c-statistics were performed on all PV measurements and best cutoff value was determined. Multivariate analysis using logistic regression for predictors of AF recurrence was performed: Age > 65, AF Type (Paroxysmal vs. Persistent), Isolation of all 4 PVs, average of the largest diameter for all the PV and a single PV diameter equal or greater than 29 mm were considered. Results: Mean age was 58±10 years and follow up 36±22 months. AF recurrence between 3 and 12 months post RFA was documented in 144 patients (49%). Multivariate Analysis identiied Persistent AF (OR 2.6 95% CI 1.52 – 4.7 p=0.0006) and age > 65 (OR 1.8 95% CI 1.053.3 p=0.03) as the strongest predictors for AF recurrence. Interestingly, a PV diameter > 29 mm in any of the PV independently predicted AF recurrence (OR 13.1 95% CI 1.55-112.3 p=0.02). Isolation of all PVs was also a signiicant predictor of RFA success (OR 0.57 95% CI 0.34 -0.96 p= 0.03). Conclusions: The strongest predictors were persistent AF and age with a 2-fold increase in risk of AF recurrence post RFA by 12 months. PV isolation of all PVs predicts RFA success. PV diameter > 29mm is an independent predictor of AF recurrence post RFA and should be further investigated. www.jaib.com 93 October, 2013 | Special Issue The Impact Of Termination Strategies In Atrial Fibrillation Ablation M. Faustino, T. Agricola, D. Capuzzi, E. Agushi, L. Santarella, C. Pizzi Casa di Cura Pierangeli , Pescara. Dipartimento di Medicina Specialista, Diagnostica e Sperimentale University of Bologna, Bologna, Italy Abstract Background: During catheter ablation, atrial ibrillation (AF) can be terminated in various modes, directly in sinus rhythm or evolved into a regular atrial tachycardia (AT) and, subsequently, in sinus rhythm or after direct current (DC) cardioversion. The aim of the present study was to evaluate the inluence of termination mode on clinical outcomes in patients who underwent an ablation approach aiming at AF termination Methods and results: This prospective study included 399 consecutive patients (62.7 ±7.2) who underwent catheter ablation for drugrefractory persistent AF (4.6±2.4 months), using a stepwise ablation approach. A 12-month follow-up with repeated Holter monitoring was carried out. In 136 patients, the AF was terminated by radiofrequency application during catheter ablation directly in sinus rhythm. In 194 patients, sinus rhythm was restored via AT and, in the remaining 69 patients, sinus rhythm was restored by DC cardioversion after catheter ablation. During the follow-up, the patients in whom AF terminated after AT had a lower recurrence rate of atrial tachyarrhythmias than the patients in whom AF had terminated directly in sinus rhythm or after dc-cardioversion (19.6% vs. 27.9% and 71% respectively; p <0.001). The patients with recurrence of atrial arrhythmia who converted directly to sinus rhythm had a higher recurrence rate of AF (94.7% ) as compared to patients who converted via AT (13.2%; p<0.001). Multivariable logistic regression analysis demonstrated that termination of AF via AT during ablation (HR 0.44; 95% CI: 0.25-0.77, P = 0.004), DC cardioversion (HR 3.26; 95% CI: 1.57-6.77) and baseline atrial ibrillation cycle length, (HR 0.95; 95% CI: 0.92-0.98; p = 0.005) were signiicant independent factors predicting the recurrence of atrial arrhythmia. Conclusions: The termination of AF after AT during catheter ablation is associated with a better clinical outcome in patients with AF. www.jaib.com 94 October, 2013 | Special Issue Prognostic Value Of Programmed Atrial Stimulation After Pulmonary Vein Isolation With Phased Radiofrequency O.C. Grebe, T. Leitsch, E.G. Vester EVK - Department of Cardiology, Duesseldorf, Germany Abstract Background: Few is known about the prognostic value of inducible atrial ibrillation after pulmonary vein isolation using phased radiofrequency ablation. Methods: 84 consecutive patients with paroxysmal (76%) or persistent (24%) atrial ibrillation (AF) have been followed for 3 months after pulmonary vein (PV) isolation using the PVAC technique. The PVAC (Medtronic, Minneapolis, Minnesota, USA) is a steerable over-the-wire circular ablation catheter utilizing phased radiofrequency (RF). After successful PV isolation (conirmed as PV entrance and exit block) and waiting time as well as optional additional ablation for PV reconnection a programmed atrial stimulation with a base cycle length of 400ms and up to two extra stimuli as well as an atrial burst stimulation was performed. Any atrial ibrillation or atypical lutter >30s was counted as a positive test. Since PV isolation could be completed in all patients, in case of inducible persistent AF the patient underwent electrical cardioversion to sinus rhythm before discharge. Two patients suffered from a groin hematoma with conservative treatment, no severe complications occurred. Complete follow-up was available in 71 patients including at least two 24h holter ECG (pre-discharge and after 3 month) as well as assessment of symptomatic atrial ibrillation. Results: At 3 month follow-up 77.5% of the patients remained free of atrial ibrillation. Of these patients, in 32.7% AF had been inducible AF post ablation, corresponding to 20% in patients with recurrent AF during follow-up. Sensitivity, speciicity, positive and negative predictive value was 33%; 80%; 15% and 75%, respectively. Conclusions: In this single center series the PVAC technique was safe and offered a good short-term success. Recurrent AF could not be predicted by programmed atrial stimulation, but non-inducibility of AF after procedure had an acceptable negative predictive value www.jaib.com 95 October, 2013 | Special Issue Acute Pulmonary Vein Reconnection Is A Predictor Of Atrial Fibrillation Recurrence Following Pulmonary Vein Isolation E. Anter, F. Contreras-Valdes, A. Shvilkin, C.M. Tschabrunn, M.E. Josephson Harvard-horndike Electrophysiology Institute Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA, USA Abstract Introduction: The prognostic implications of detection and treatment of acute PV reconnection is not well understood. Methods: This prospective study included 44 patients (22 men, 60±7 years) who underwent index PVI procedure for treatment of atrial ibrillation (AF). Acute PV reconnection and/or dormant PV Conduction were assessed sequentially in response to a ≥30 minute waiting period, intravenous isoproterenol infusion and/or adenosine. All cases of PV reconnection and/or dormant conduction were successfully targeted. Results: Freedom from AF at 1 year was 75% (83.3% in paroxysmal and 65% in persistent AF, p=ns). AF recurrence was documented in 8/16 patients with acute reconnection, but only in 3/28 patients without acute reconnection group (p=0.009). Three patients underwent a redo procedure, all with previous PV reconnection. In a multivariate analysis, acute PV reconnection was a strong predictor of arrhythmia recurrence (HR 8.3, 95% CI 1.78-39.2). Conclusions: Identiication of acute PV reconnection, even when successfully targeted, is a strong predictor of arrhythmia recurrence following PVI. Table Patient characteristics 1 Variable AF-free (n=33) AF-recurrence (+) (n=11) Tp-value Age (year), M ± SE 59.8 ± 1.1 60.6 ± 2.4 0.27 Male gender, (%) 17 (51.5) 5 (45.5) 1.00 BMI (kg/m2), M ± SE 29.1 ± 0.9 27.2 ± 0.8 0.26 Persistent AF, n, (%) 13 (39.7) 7 (63.6) 0.19 Hypertension, n, (%) 23 (69.7) 7 (63.6) 0.72 Diabetes, n, (%) 8 (24.2) 4 (36.4) 0.46 Coronary Artery Disease, n, (%) 7 (21.2) 4 (36.4) 0.43 LVEF (%),M ± SE 52.4 ± 1.8 52.7 ± 2.1 0.93 LA dimension (mm), M ± SE 49.7 ± 1.2 51.4 ± 1.2 0.49* OSA, n (%) 3 (9.4) 4 (36.4) 0.06 Acute PV reconnection 8 (24.2) 8 (72.7) 0.009 www.jaib.com Figure 1: The effect of acute pulmonary vein reconnection on AF recurrence 96 October, 2013 | Special Issue Assessment Of Echo And Ecg Characteristics Of Pts With Acute And Late Arrhythmia Recurrence After Radiofrequency Catheter Ablation Of Atrial Fibrillation A. Ardashev1, E.A. Dolgushina2, E.G. Zhelyakov1, A.V. Konev1, V.N. Ardashev3 Federal Scientiic and Clinical Centre of FMBA, Moscow 2Clinical Hospital of the Academy of Science, Moscow 3Central Clinical Hospital, Moscow, Russia 1 Abstract Objectives: To estimate predictors of acute and late periods of arrhythmias recurrence in pts underwent de novo atrial ibrillation (Aib) circumferential and linear ablation using 3D system approach. Materials and methods: 214 patients (an average age – 53.65±11.5 years, ranged - 22 to 76 years) underwent an index RFA of Aib (43 women). There were 84 paroxysmal (39.25%), 63 persistent (29.44%) and 67 long-lasting persistent (31.31%) Aib pts involved. According to the period of recurrence of arrhythmias all patients were divided into two groups: acute (3 mos.) period recurrence (AR) – 25 (11,6%) pts and late recurrence (LR) (up to the 3 years of follow-up) - 52 pts (24,2%). At the beginning of protocol TT ECHO- as well as ECG-parameters were evaluated. We used nonparametric statistics methods to estimate value of ECHO and ECG parameters to predict atrial arrhythmia recurrence within the either acute or late periods after RFA. Results: There were no signiicant changes revealed between two groups in following parameters: LV EDD – 57.6±7.2 mm in AR pts vs. 56.5±6.0 mm in LR pts, LV ESD - 40±8.3 mm in AR pts vs. 37.7±6.8 mm in LR pts, LV ESV - 74.3±41.0 ml in AR pts vs. 63.3±31.5 ml in LR pts, LV EDV – 167.9±50.3 ml in AR pts vs. 160.0±38.0 ml in LR pts, LA – 44.7±5 mm AR pts vs. 45.4±5.9 mm in LR pts, LV mass – 204.2±46.5 g in AR pts vs. 215.5±48.2 g in LR pts. EF in pts with blanking period arrhythmias was signiicantly lower (57.2±11.7 % vs. 59.9±8.1 %) comparing with late recurrence arrhythmias pts (p<0,05). ECG indings: There were no signiicant differences observed in PQ interval (177,5±17,7 mm in AR pts vs. 185,2±31,5 mm in LR pts) as well as anterior hemiblock, left bundle branch block or right bundle branch block occurrence between the groups. Conclusions: There were no signiicant differences in TT ECHO or ECG characteristics but ejection fraction observed between subgroup of pts who expressed acute period or late recurrence (up to 3 years) arrhythmias at the follow-up after an index 3-D RFA of Aib www.jaib.com 97 October, 2013 | Special Issue Surgery For Cardiac Arrhythmias Beneit Of Ablation Of First Diagnosed Atrial Fibrillation In Patients Submitted To Coronary Artery Bypass Grafting A. Strelnikov, S. Bayramova, D. Losik, E. Pokushalov, A. Romanov, A. Chernyavskiy, A. Karaskov Arrhythmia Department, Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia Abstract Introduction: In patients with long-term history of paroxysmal atrial ibrillation (AF) a decision can be made to go for concomitant coronary artery bypass grafting (CABG) and epicardial AF ablation procedures. Whether patients with recent onset of PAF might beneit of epicardial AF ablation concomitant to CABG is not known. Aim of this prospective, randomized, single-center pilot study is the comparison of patients with irst diagnosed AF submitted to CABG and treated with and without epicardial pulmonary vein isolation (PVI). Methods: Patients with irst diagnosed paroxysmal AF and indication for CABG were enrolled in this prospective randomized pilot study. The primary endpoint was AF free survival (AF burden <0.5%) between two groups at 18 months follow up. The secondary end-points were: the percentage of AF burden deined through continuous monitoring using an implantable loop recorder, thromboembolic events and procedural complications. All patients were implanted with a subcutaneous cardiac monitor to track the cardiac rhythm and measure the AF burden. Results: This study enrolled 43 patients (mean age 59±7 years, 74% males), followed up for 18 months after CABG. The patients were randomly allocated to two groups, CABG alone (n=21) and CABG with concomitant PVI (n=22). At the 18 - month follow-up after surgery, 19 (86%) patients in the CABG+PVI group were AF-free (i.e. AF%<0.5%) vs 9 (43%) in the CABG only group (Log-Rank test, p=0.007). At the end of follow-up, the mean AF burden in the CABG and CABG+PVI group was 7.8±5.1% and 1.6±1.8%, respectively (P<0.001). Four (26%) of the 15 patients with AF recurrences were completely asymptomatic. Conclusion: Patients with recent-onset atrial ibrillation submitted to CABG may beneit of concomitant ablation of the arrhythmia for preventing recurrences. www.jaib.com 98 October, 2013 | Special Issue The Hybrid Approach For The Treatment Of Atrial Fibrillation In PTS With Giant Left Atriums And Ischemic Or Valvular Cardiomyopathy: Safe And Eficacious S. Gundry, W. Ehrman, H. Bhatka he International Heart and Lung Institute, Departments of Surgery and Cardiology,Desert Regional Medical Center, Palm Springs, CA, USA Abstract Introduction: We studied whether a combined surgical radiofrequency LA box lesion set, performed prior to cardiopulmonary bypass, coupled with post-operative EP study and additional catheter based lesion sets, would be safe and eficacious in high-risk surgical pts with AF, cardiomyopathy, and giant LA’s. AF ablation is deemed too risky in these pts, but restoration of NSR may be critical to short and long-term survival. Epicardial Ablation pre-bypass, followed by catheter ablation post op (Hybrid Approach), would eliminate the additional ischemia and bypass time, yet restore NSR if effective. Methods: Twelve (12) pts, aged 58-84, with EF’s </=30% (range 10-30%), with LA size 6.5-8.5 cm by TEE, have been studied. All pts underwent revascularization with 3-5 CABG’s/pt.; 10/12 (83%) had concomitant MV repair and TV repair; two/12 (16%) had AV replacement as well. All pts had PV isolation by a LA box lesion created epicardially using the Estech (San Ramon, CA) Cobra Adhere XL or the Fusion Varipolar Devices pre bypass. All pts had exit and entrance block. All left the OR in either NSR, or atrial paced or DDD paced rhythms. Results: Ten/12 pts (83%) developed AF or Alutter post-op. Four/10 (40%) were studied acutely and found to have RA lutter, which was ablated. One/11 required a second intervention for a left sided RA. Six/10 (60%) either converted or were cardioverted. Four/12 (33%) required permanent pacemaker implant for bradycardia. There were no deaths. At followup, 2/12 (16%) have persistent A Flutter with rate control. Conclusions: We conclude that the Hybrid approach to the treatment of AF in pts with giant LA’s and cardiomyopathy using an Epicardial LA Box lesion set, performed off pump with Bipolar and Unipolar Radiofrequency Ablation prior to cardiac surgery, is safe and eficacious in these high risk pts; restoring sinus rhythm in 84% at up to 2 year followup. www.jaib.com 99 October, 2013 | Special Issue Cardiac Resynchronization Therapy. Surgically Implanted Epicardial Left Ventricular Lead Compared With Coronary Sinus Lead Stimulation N. Martinenghi, N. Galizio, M. Mysuta, J.L. Gonzalez, F. Robles, A. Palazzo, G. X. Vallejo Deeb, G. Carnero, H. Fraguas Department of Cardiac Electrophysiology. University Hospital Favaloro Foundation Ciudad Autónoma de Buenos Aires, Argentina Abstract Introduction: Epicardial left ventricle lead (ELVL) is an alternative when a coronary sinus lead (CSL) implantation failed. The aim of the study was to assess the outcome of both approaches. Methods: A prospective analysis was performed in 97 pts with idiopathic dilated or ischemic cardiomyopathy who fulilled CRT-D indications. Group A: 22 pts underwent surgical implantation of ELVL. Group B: 75 pts received CSL implantation. Mean follow up: 21 months (2-69). Pts were considered responders if there was a LVEF improvement ≥5% and/or a reduction of ≥1 NYHA functional class. Responder rate, mean LVEF improvement and end diastolic left ventricle diameter (EDLVD) were assessed. Results: Baseline characteristics were similar in both groups. Responder rate was 86% vs 70.6% (ns), mean LVEF improvement was 11.5±10% vs 10.7±10% (ns) and EDLVD reduction was 11±13% vs 5.6±12.8% (ns) among group A and B respectively. Conclusions: In our study population ELVL implantation was an effective approach in performing an appropriate CRT. The rate of responders was high and there was no signiicant difference in terms of LVEF improvement and EDLVD reduction. www.jaib.com 100 October, 2013 | Special Issue Long-Term Results After Cardiac Resynchronization Therapy With Or Without Surgical Revascularization In Patients With Ischemic Heart Failure And Left Ventricle Dyssynchrony D. Losik, A. Strelnikov, S. Bayramova, A. Romanov, E. Pokushalov, A. Chernyavskiy, D. Prokhorova, V. Shabanov, I. Stenin, A. Karaskov Arrhythmia Department and EP Laboratory, State Research Institute of Circulation Pathology, Novosibirsk, Russia Abstract Introduction: We have tested the hypothesis whether epicardial cardiac resynchronization therapy (CRT) concomitantly with surgical revascularization is superior to CRT and medical therapy in patients with ischemic heart failure, LVEF<35% and LV dyssynchrony, who were eligible to coronary artery bypass grafting or medical therapy. Methods: A Ninety seven consecutive patients with severe ischemic heart failure were randomly assigned to endocardial CRT implantation plus medical therapy (n=48) or epicardial CRT implantation plus CABG (n=49). The primary end point was reduction in left ventricle systolic volume (LVESV) by 15% mesured by echocardiography. The major secondary endpoint included the all cause death. The patients were followed up during 24 months. Results: At 24 months, the mean LVESV was signiicantly lower in epicardial CRT plus CABG group compared with CRT plus medical therapy group (115.4±22.4.% vs. 137.8±19.7%, P=0.002). In epicardial CRT plus CABG group 6 patients (12.2%) died at 2-year follow compared with 11 (22.9%) in CRT plus medical therapy group (Log-Rank test, p=0.02). Totally, the number of patients with LVESV reduction by 15% were 37 (86%) in epicardial CRT plus CABG group and 25 (67.6%) in CRT plus medical therapy group (p=0.034). Conclusions: In ischemic heart failure patients with LV dyssynchrony, who are eligible to surgical revascularization or medical therapy, epicardial implantation of a CRT system concomitantly with CABG is superior to CRT plus medical therapy in terms of cardiac reverse remodeling and is associated with low mortality in long-term follow up. www.jaib.com 101 October, 2013 | Special Issue Short Term Results Of Original Approach For Permanent Endocardial Lead Extraction A. Ponomarev, V. Korshunov, A. Dodonov Arrythmology department of State Healthcare Institution Rostov Regional Clinical Hospital, Rostov-on-Don, Russia Abstract Introduction: The most dificult point of endocardial lead extraction (LE) problem is connected with large lead-assotiated vegetations .Our group developed a pump-off approach to LE which allows to avoid damage of targeted leads and prevent pulmonary artery embolization. Methods: The surgical approach includes sternotomy, canulation of aorta, SCV, ICV. The procedure is performed using assisted circulation and beating heart technique. After RA incision targeted leads are cut off and central parts of them are extracted. A special tool and visual control are used at this stage of operation. Peripheral parts of leads are extracted together with CIED through pocket incision. Our experience includes 18 cases. In addition TV prosthesis was performed in 11 cases, TV+MV prosthesis – in 5 cases and CABG – in 4 cases. Results: AComplete procedural success was achieved in 17 cases (94,4%, 51 leads extracted). Clinical procedural success was achieved in 1 case (5,6%, lead part 10 cm long was abandoned ). No hospital mortality or after-surgical complications were observed. Conclusions: The method has high clinical eficacy. Its reproducibility allows to use it widely in all cardiosurgery departments. www.jaib.com 102 October, 2013 | Special Issue A Comparison Of Esmolol And Dexmedetomidine For Attenuation Of Haemodynamic Responses In Patients Undergoing Elective Off-Pump Coronary Artery Bypass Grafting N. García, G. Careaga, E. Márquez, J.J. Dosta, C. Gutiérrez, J.F. López, R. Urías, A. Cuevas, E. Diaz Rodríguez, H. Vazquez Juarez Instituto Mexicano del Seguro Social, Departamento de Cirugía Cardiotorácica y Anestesia Cardiovascular de la Unidad Médica de Alta Especialidad, Hospital General "Dr. Gaudencio González Garza" del Centro Médico Nacional "La Raza" UNAM, Facultad de Medicina, Mexico City, Mexico Abstract Introduction: Our aim was to compare effectiveness of esmolol and dexmedetomidine in the treatment of increased hemodynamic response during off-pump coronary artery bypass grafting. (OPCAB) Methods: Twenty adult patients undergoing elective OPCAB were recruited for this prospective study. Inclusion criteria were elective OPCAB and age 18–75 years. Patients were excluded preoperatively if they gave a history of severely impaired cardiac function, ejection fraction less than 30%, history suggestive of sensitivity to drugs used during the study. Those requiring emergency surgery were also excluded. Receiving standardized etomidate– vecuronium- fentanyl-based anaesthesia. Randomly received infusions of esmolol 0.5 mg /kg/1 min (Group E, n=10) or Dexmedetomidine 0.5 mcg/kg/hr.(Group DEX, n=10). The infusion was started after sternotomy. The goal was to maintain bradycardia (≥50 bpm) and mean arterial pressure (MAP) ≤60-75mmHg. Results: After drug, HR reductions were signiicant during the intraoperative period in group Dexmedetomidine. Hemodynamic Variables: HR, MAP, Svo2 .70% and a serum lactate concentration ≤2.0 mmol/L, time of surgery and narcotic consumption, values of the two groups during the study. In the DEX group (HR) was signiicantly lower than the baseline in all measurement times. Conclusions: Although esmolol and dexmedetotimidine attenuated hemodynamic response during coronary artery bypass grafting period, dexmedetotimidine was more effective in hemodynamic stabilization. www.jaib.com 103 October, 2013 | Special Issue Prevention Of SD By ICD Twelve-Year Follow-Up Of Out Of Hospital Cardiac Arrest Resuscitation Without Chest Compressions A. Capucci1, D. Aschieri2, V. Pelizzoni2, F. Guerra1, G.H. Bardy3 1 Clinica di Cardiologia, Marche Polytechnic University, Ancona, Italy2 Divisione di Cardiologia, Guglielmo da Saliceto Hospital, Piacenza, Italy3 Seattle Institute for Cardiac Research, University of Washington, Seattle, WA, USA Abstract Introduction: The aim was to examine survival in a population of out-of-hospital cardiac arrest (OOHCA) victims where responders do not always perform CPR. Methods: Prospective, observational study involving all OOHCA victims in Piacenza, Italy. Of the two parallel systems set for OOHCA reply, one set of rescuers (Progetto Vita) only used automated external deibrillators (AEDs) and did not perform CPR, while standard EMS personnel performed CPR according to the current guidelines. Results: On 2735 OOHCAs, survival to hospital discharge occurred in 53.2% of the Progetto Vita patients and in 7.9% of the EMS patients (p<0.001). Progetto Vita intervention was independently associated with a 4.7-fold risk of survival to discharge, as shown in Table 1. The estimates of survival for 12-years follow-up are 32.4% for Progetto Vita versus 3.7% for EMS (Figure 1). Conclusion: Progetto Vita provides the irst demonstration of excellent survival from OOHCA without CPR of any sort. The superior outcome of AED-only, compared to CPR based resuscitation, holds true even when confounders are considered. Finally, true long-term outcome of OOHCA survival are recorded here for the irst time. www.jaib.com 104 October, 2013 | Special Issue Value Of The Deibrillator West Asa Bridging-Therapy Before Implantation Of A Cardioverter Deibrillator (ICD) J. Sperzel, M. Jung, E. Akkaya, T. Neumann, S. Szymkiewicz, H. Esser, M. Kuniss Kerckhof Clinic, Department of Cardiology, Bad Nauheim, Germany Abstract Introduction: The deibrillator vest (LifeVest®) is an option for treating patients at risk for ventricular tachycardia (VT) or ventricular ibrillation (VF) due to underlying cardiac pathology, especially during their evaluation for ICD implantation. Patients wear the LifeVest externally. The device can detect abnormal cardiac rhythms and deliver shocks to terminate these rhythms. Patients have the option to actively inhibit shock delivery. Methods: From June 2010 to September 2012, 42 patients (pts) (38 males; age 48±14 y) were managed with the LifeVest. Indications were: Newly diagnosed myocarditis (MYC): 24 pts (57%), other forms of dilated cardiomyopathy (DCM): 9 (21%) pts, status post (s/p) ICD explantation (EXPL) for device infection: 4 pts (10%), markedly lowered LV ejection fraction (LVEF) and acute myocardial infarction (CHD): 2 pts (5%), ion channel disorder (GEN): 1 pt (2%), and others (OTH): 2 pts (5%). By echocardiography, the LVEF was below 15% in 10.8%, between 16 and 25% in 45.9%, between 26 and 35% in 13.5%, and above 35% in 29.7% of patients. Results: Patients wore the LifeVest for an average of 23 hours per day over a mean period of 83 days. In 32 pts (76%), a total number of 276 events were detected. In one patient who was hemodynamically compromised due to VT, the arrhythmia was successfully terminated by shock delivery. Another patient actively withheld therapy delivery when the LifeVest detected VT until emergency medical personnel arrived. One patient inhibited shock delivery throughout a 55 second episode of atrial ibrillation with rapid conduction. The other events were shorter than 15 seconds (detection window) or artifacts. Out of the cohort of 42 pts, 18 (43%) received an ICD. In 5 pts (12%), CRT-D (cardiac resynchronization deibrillators) were implanted. Two pts (5%) received dual chamber and 11 pts (26%) single chamber ICDs. In 24 pts (57%), ICD implantation was waved after further assessment of the underlying cardiac pathology. Four pts s/p ICD infection underwent ICD reimplantation, leaving 14 pts (37%) for de novo ICD implantation. Conclusions: After a mean treatment duration of 83 days with the LifeVest in this population with a high risk of malignant cardiac arrhythmias, only 43% (n=18) required an ICD. Our data show that the LifeVest is useful for bridging before ICD implantation. It is safe and economical. www.jaib.com 105 October, 2013 | Special Issue Sudden Death After Tavi. Are Bradyarrhyhtmias Always The Cause? L.P. Papavasileiou, K. Spargias, G. Zervopoulos, M. Chrisocheris, A. Chalapas, K. Bellos, L. Santini, G. Forleo, T. Apostolopoulos Electrophysiology Pacemaker and ICD Unit, Hygeia Hospital, Athens, Greece. University Hospital of Rome "Tor Vergata", Cardiology Department, Rome, Italy. Transcutaneous Heart Valves Department, Hygeia Hospital, Athens, Greece. 1rst Cardiothoracic Surgery Department,Hygeia Hospital, Athens, Greece Abstract Introduction: Transcatheter Aortic-Valve Implantation (TAVI) is consider to be highly effective in the treatment of patients with severe aortic stenosis who are inoperable. After TAVI, the rate of pacemaker implantation is from 6.5%-40%. Some reports of sudden death after TAVI are mostly attributed to bradyarrhythmias. We report the case of three patients how experienced sudden cardiac death or aborted sudden cardiac death after TAVI. All patient underwent TAVI for severe aortic stenosis and were affected from ischemic heart disease with an ejection fraction ~ 40%. All patients underwent pacemaker implantation (PM) after the procedure due to 1rst degree atrioventricular block (AV) and left bundle branch block (LBBB). One of the patient’s died suddenly 30 days after the procedure. The PM interrogation reveled many episodes of non sustain ventricular tachycardias (NSVT) [ig 1] and ventricular ibrillation (VF) [ig 2]that lead to death. The other two patients had presyncope and during PM interrogation episodes of NSVT >15 sec were recorded [ig 3]. Conclusions: Particular attention should be addressed in patients affected by ischemic heart disease undergoing TAVI especially in the presence of borderline coronary lesions. The physiopathologic mechanism of sudden arrhythmic death in these patients needs to be clariied. Figure 1: Arrhythmic events recorded www.jaib.com 106 October, 2013 | Special Issue Journal of Atrial Fibrillation Figure 2: Ventricular ibrillation as seen in the IEGM Figure 3: Episode of NSVT causing presyncope www.jaib.com Speical Issue 107 October, 2013 | Special Issue The Utilization Of Implantable Cardioverter Deibrillators In Patients With Chronic Heart Failure D. Giedrimiene, R. Mulamala, M. Rai, F. Zaeem, L. O'Bara, M. Skarzynski, K. Mueller, R. Mulamala, J. Radojevic, J. Gluck, D. Wencker Heart Failure Center, Hartford Hospital, Hartford, CT and University of Saint Joseph, West Hartford, CT, USA Abstract Background: The purpose of the study was to examine if there is any gender-based gap in the use of ICDs for primary or secondary prevention in patients with chronic heart failure (HF). Methods: The data analysis included the records of more than 400 visits during 2.5 years period related to 84 pts (31 females and 53 males) who had multiple daily treatment sessions at Outpatient Clinic-Infusion Center for HF. Primary disorders, co-morbidities, arrhythmias, ejection fraction (EF) and reasons for ICD implantation were evaluated. Patients were followed in order to assess the frequency of rehospitalizations and their survival. Results: The study demonstrated that mean age was 68.9±13.4 years without signiicant difference between gender groups (69.2±13.3 in females vs 68.7±13.5 in males). EF was higher in females than males (41.2±18.6% and 36.5±17.8%, accordingly), however the incidence of reduced systolic function (EF≤35%) was similar in both groups. Utilization of ICDs for primary or secondary prevention was signiicantly higher in males than females despite similar frequency of arrhythmias (including AFib). The rate of re-hospitalizations at 30 days, 6 months and during 12 months period was higher in males, however the mortality during 12 months follow-up was signiicantly higher in females. Conclusions: More males had the ICD implanted as compared to females despite similar frequency of cardiac arrhythmias in both gender groups. There is a gender-based gap in the use of ICDs for primary or secondary prevention in patients with chronic heart failure (HF), which requires a better identiication of females with HF for timely implantation of ICDs. Table Utilization of ICD’s and follow-up www.jaib.com Outcomes Total N=84 Females N=31 Males N=53 P-values Arrhythmias (including AFib) 35 (41.7%) 13 (41.9%) 22 (41.5%) p =0.16 ICD Implantation 34 (40.5%) 7 (22.6%) 27 (50.9%) 0.016* ICD for Primary prevention 24(28.6%) 6 (19.4%) 18 (33.9%) 0.05* ICD for Secondary prevention 10 (11.9%) 2/31 (6.5%) 8 (15.1%) 0.012* Re-hospitalization at 30 days 13 (15.5%) 3 (9.7%) 10 (18.9%) 0.021* Re-hospitalization at 6 months 35 (41.7%) 9 (29.0%) 26 (49.1%) 0.05* Mortality at 12 months 11 (13.1%) 5 (16.1%) 6 (11.3%) 0.045* 108 October, 2013 | Special Issue Interventricular And Atrial Rhythm Dissociation During Intraoperative Shock Test Of CRT-D Device J.C. Buenil Medina, M. Millan Catalan, N. Juarez Pelcastre, N. Alonzo Ortiz Cardiology Department, Hospital General Naval de Alta Especialidad, Mexico City, Mexico Abstract Introduction: After T-wave shock induction test, we observe VF pattern in ECG, but in the available IEGM inlections it shows sinus rhythm for RA, an unstable ventricular tachycardia with 155 bpm for the RV, and a stable LV rhythm at 250 bpm. Methods: Patient stratiied as MADIT II for isquemic cardiomyopathy, diabetes mellitus with insulin dependent. The patient was cocaine user, 17% EF, Previous MI 8 years ago without reperfusion therapy. During device implantation (Fig. 1), and induction with T-wave shock, presented dissociated rhythms in the 3 chambers. Results: Presented in the Figure 2, we observe total rhythm dissociation in the 3 chambers and VF pattern in the ECG. The automatic shock therapy (at 182bpm) was not delivered, and then proceeds in manual therapy rescue with the device programmer. Conclusions: The actual CRT-D technology only allows delivery shock when the RV frequency rise up the programmed VF zone, but in this case, was not enough. We need to start to look at LV for arrhythmia detection. Figure 2: ECG and IEGM results after T-wave shock induction Figure 1: Lead position during CRT-D implantation www.jaib.com 109 October, 2013 | Special Issue A Scoring System For Appropriate Therapy Risk Assessment In Patients With Implantable Cardioverter - Deibrillator For Primary Prevention Of Sudden Cardiac Death And Coronary Artery Disease G. Gromyko1, S. Chetverikov2, M. Didenko3, G. Pasenov3, S. Yashin1 Saint - Petersburg State Medical University named after I.P. Pavlov, Saint-Petersburg, Russia 2Khanty - Mansiysk district hospital, Khanty - Mansiysk, Russia 3Military Medical Academy, Saint-Petersburg, Russia 1 Abstract Introduction: The aim of this study was to create a scoring system for the ICD therapy risk assesment in primary prevention in patients with coronary artery disease (CAD) and reduced left ventricular (LV) ejection fraction (EF). Methods: Fifthy two patients (50 men, mean age 60,4 + 12,6 years) with LV EF < 40% due to prior myocardial infarction were included in our study. ICD implantation was performed in all cases for primary prevention of sudden cardiac death. Data from standard diagnostic procedures, performed before ICD implantation (coronary angiogram, echocardiogram, percent of scar, calculated using Selvester QRS score) were used for scoring system creation. Patients were divided in two groups: group 1 - 27 patients with no appropriate ICD therapy during follow-up, group 2 - 25 patients with appropriate ICD therapy. Only patients with more than 6 months follow-up were included in our study. Mean follow up was 17,3 + 11,7 months. Results: During statistical analysis ive sign were found to have OR more than 2,0. They were: LAD proximal stenosis > 75%, peripheral arterial disease, LV dilatation more, than 202 ml without wall thickening more than 11 mm, presence of right bundle brunch block, percent of scar, calculated using Selvester QRS score. Incidence of this signs is demonstrated in table 1. Using method of classiication trees scoring system was created – see table 2. Statistical analysis showed higher risk of appropriate ICD therapy between patients, who had more, than 4 points of our scoring system and those, who had less or equal, than 4 points (OR 10,67, p < 0,01). Conclusions: Our scoring system can be used for appropriate therapy risk stratiication in patients with CAD and ICD implanted for primary prevention of sudden cardiac death. Table 1 Incidence of signs in study population Table 2 Points for created scoring system Sign Group 1, 27 patients Group 2, 25 patients OR PAD 1 PAD (%) 3 (11) 5 (20) 2 LVD-no H 1 LVD-no H (%) 5 (19) 10 (40) 2,93 RBBB 1 RBBB (%) 1 (4) 5 (20) 6,5 LAD 2 LAD (%) 22 (82) 25 (100) 12,47 Scar 9-21 2 Scar 9-21 (%) 13 (48) 10 (40) 8,56 Scar > 21 4 Scar > 21 (%) 9 (33) 15 (60) 17,95 Total maximum 9 Sign PAD - peripheral arterial disease, LVD-no H - LV dilatation more, than 202 ml without wall thickening more, than 11 mm, RBBB - right bundle brunch block, LAD - LAD proximal stenosis > 75%, Scar 9-21 percent of scar, assessed by twelve lead ECG using Selvester QRS score between 9 and 21 points, Scar > 21 - percent of scar, assessed by twelve lead ECG using Selvester QRS score between 9 and 21 points www.jaib.com 110 Points PAD - peripheral arterial disease, LVD-no H - LV dilatation more, than 202 ml without wall thickening more, than 11 mm, RBBB - right bundle brunch block, LAD - LAD proximal stenosis > 75%, Scar 9-21 percent of scar, assessed by twelve lead ECG using Selvester QRS score between 9 and 21 points, Scar > 21 - percent of scar, assessed by twelve lead ECG using Selvester QRS score between 9 and 21 points October, 2013 | Special Issue Health Care Utilization By Patients Experiencing Appropriate ICD Shocks D. Giedrimiene, C. Coleman, S. Bhavnani, J. Kluger Cardiology, Hartford Hospital, Hartford, CT, USA Abstract Introduction: Our hypothesis was that the impact of ICD shocks on healthcare utilization is very signiicant and costly. Methods: We conducted a case-control analysis of ICD patients at a single institution from 1997-2010. Cases included all patients experiencing an appropriate ICD shock during the irst 12 months after implantation. Propensity scores based on 36 covariates were used to match cases to controls. We compared the rate (occurrences/person year (PY)) of healthcare utilization immediately following shock to the end of the 12 month follow up period to the rate in the no shock group. Results: A total of 81 patients experiencing appropriate ICD shocks were matched to 81 no shock patients. Mean age was 66.2±12.8 years; 85.2% were males and 64.2% received an ICD for primary prevention. Conclusions: Patients experiencing an appropriate shock more frequently had cardiovascular (CV)-related clinic or emergency room visits and were hospitalized more frequently. Moreover, they had a higher overall 12-month treatment cost. This increased utilization of health care conirms the signiicance of timely identiication or prediction of shocks in patients with ICDs. Table 1 Results of Health Care Utilization. www.jaib.com Endpoint Appropriate shock Mean ± SD n = 81 No shock Mean ± SD N = 81 P-value CV-Related Clinic Visits 4.46 ± 2.01 3 .70 ± 2.41 0.007 CV-Related Clinic Visit Charges (2011US$) $1,662 ± $748 $1,381 ± $897 0.007 CV-Related Emergency Room Visits 0.15 ± 0.39 0.04 ± 0.19 0.025 CV-Related Emergency Room Visit Charges (2011US$) $198 ± $539 $89 ± $469 0.032 CV-Related Hospitalizations 0.75 ± 0.80 0.33 ± 0.71 <0.001 CV-Related Hospital Charges (2011US$) $15,176 ± $23,405 $13,964 ± $52,219 <0.001 Total CV-Related Hospital Days 3.16 ± 4.67 2.68 ± 10.23 <0.001 All Treatment Charges (2011US$) $20,980 ± 26,915 $17,741 ± 53,994 <0.001 111 October, 2013 | Special Issue Low Total Root-Mean Square QRS Voltage In Signal-Averaged ECG Predicts Ventricular Tachyarrhythmias In Ischemic ICD Patients W. Zareba, J. Daubert, O. Costantini, E. Rashba, S. Rosero, L.S. Rosenthal, G. Turitto, S. Winters, for M2Risk Investigators University of Rochester, Rochester, NY, Duke University Medical Center, Durham, NC, MetroHealth System, Cleveland, OH, Health Sciences Center, Stony Brook, NY, U Mass Memorial Medical Center, Worcester, MA, New York Methodist Hospital, Brooklyn, NY, Electrophysiology Associates, Morristown, NJ, USA Abstract Introduction: The Multicenter ICD Risk Stratiication Study (M2Risk Study) was designed to determine which clinical and novel ECG-based variables will predict arrhythmic events in post-infarction patients with EF≤35%. Methods: Study population consisted of post-infarction patients with EF≤35% who received their ICDs for primary prevention of mortality. At enrollment, the following were collected: routine clinical data, 12-lead ECG, 24-hour Holter monitoring (Mortara Instruments), signalaveraged ECG [SAECG] (Arrhythmia Research Technology), and exercise-induced T wave alternans [TWA] (Cambridge Heart). The ECG-based parameters included: heart rate variability, heart rate turbulence, deceleration capacity, ventricular arrhythmias on the 24-hour Holter, QRS duration, QRS complexity, QTc duration, T wave complexity, SAECG-derived:total QRS root mean square voltage (TRMS) and late potentials parameters (fQRSd, RMS, LAS), and TWA presence. Primary endpoints included: VT/VF requiring ICD therapy, death, and VT/VF or death. Results: Among 484 patients enrolled (mean age 64±10 years), VT/VF occurred in 10%, death in 9%, and VT/VF or death in 19% of patients who were followed for 27±18 months on average. The TRMS<25μV from the SAECG was the strongest predictor of VT/VF with hazard ratio of 2.42 (p<0.01). VT/VF also was predicted by frequent VPBs >500/24hours (HR=1.95; p<0.05). Abnormal turbulence slope <2.5 RR/ms was independently associated with mortality (hazard ratios of 2.5 = 2.48; p=0.025). Combination of TRMS in SAECG and VPBs in Holter identify patients at high, intermediate and low risk for VT/VF (Figure). Conclusions: Low QRS voltage on the SAECG is predictor of ventricular arrhythmic events and could help identifying ischemic cardiomyopathy patients beneiting from ICD therapy. www.jaib.com 112 October, 2013 | Special Issue Transvenous Lead Extraction Lead Dependent Infective Endocarditis- In Whom And When? Predisposing Factors A. Polewczyk1, A. Kutarski2, A. Tomaszewski 2, K. Boczar3, M. Janion1,4 District Hospital, II Clinical Cardiology Department Kielce, Poland 2Medical University, Department of Cardiology Lublin, Poland 3Department of Electrocardiology, John Paul II Hospital, Krakow, Poland 4he Jan Kochanowski University, Department Sciences of Healthy Kielce, Poland 1 Abstract Background: TLead dependent infective endocarditis (LDIE) is a very severe, peridious disease. The factors inluencing LDIE development are relatively poor documented. Methods: We reviewed clinical data of 1220 patients treated by transvenous leads extraction (TLE) in single Reference Center in years 2006-2012 and separated 320 LDIE cases. Demographic and clinical data were collected and LDIE predisposing factors were assessed. Results: The results were demonstrated in the table. Conclusion: LDIE could be inluenced by clinical and procedural factors. The present study demonstrated increase of the risk of lead dependent infective endocarditis in older, diabetic, male patients. LDIE development is also connected with the higher number of previous procedures with the bigger number of implanted leads, particularly abandoned leads presence. Moreover, LDIE can be affected by unnecessary too long loops of the leads. Very important is a little known intracardiac abrasion leads phenomenon. www.jaib.com LDIE Control group- non LDIE P No of patients Mean age [years (SN)] Sex (women %) 320 66,3 ±15,0 98 (30,6%) 900 63,75 ±17,3 358 (39,8%) 0,02 0,005 Diabetes [%] 70 21,9% 155 17,2% 0,06 Renal insuficiency [%] 14 4,5% 23 2,6% 0,1 Sternotomy in anamnesis [%] 46 14,4% 132 14,7% 0,88 Mean number of leads before TLE [SN] 2,2 ±0,82 1,9 ±0,78 0,0001 Mean lead dwelling time before TLE [months (SD)] 89,1 (±63,7) 83,7 (±64,7) 0,20 Number of procedures before TLE (SD) 2,27 (±1,44) 1,85 (±1,13) 0,0001 Unecessery loop of lead [%] 84 26,2% 167 18,6% 0,004 Number of abandoned leads (SD) 0,31 (±0,67) 0,23 (±0,57) 0,04 Intracardiac abrasion of the leads [%] 98 30,6% 168 18,7% 0,0001 113 October, 2013 | Special Issue Optimal Treatment Strategy Choice In Patients With Large Right Heart Vegetations A. Polewczyk1, A. Kutarski2, A. Tomaszewski 2, K. Boczar3, M. Janion1,4 District Hospital, II Clinical Cardiology Department Kielce, Poland 2Medical University, Department of Cardiology Lublin, Poland 3Department of Electrocardiology, John Paul II Hospital, Krakow, Poland 4he Jan Kochanowski University, Department Sciences of Healthy Kielce, Poland 1 Abstract Objectives: Right heart vegetations (RVH) are the serious signs of lead dependent infective endocarditis (LDIE) and consists class 1 indication for transvenous leads extraction (TLE) procedures, but large size of RVH is often considered to cardiosurgery removal. Methods: Analysis of safety and effectiveness of TLE in 41 (mean age 66,2±12,7 years, 17 women) patients with vegetations over 2 cm was performed. This group (12,8%) was separated from 320 LDIE consecutive patients managed with TLE in single Reference Center in years 2006-2012. Results: The vegetations were localized in right atrium in 30 cases (73,2%), on tricuspid valve in 6 (14,6%), in the right ventricle - in 3 (7,3%) and in vena cava superior in 2 cases (4,9%). Considering risk of TLE and open heart surgery in all pts TLE was performed and systems were removed as a whole. In 9 of them nitinol basket catheter was used for pulmonary vascular bed protection. The mean time of TLE was 122,2±56,2 min. Complete procedural success was achieved in 37 patients (90,2%), clinical success in 39 (95,1%) patients. Major complications (severe pulmonary embolism) in 2 (4,9%) patients were observed. Control examination after TLE showed the vegetation presence in 19 (46,3%) patients The in-hospital survival was 97,6% - one patient died on the next day after TLE. Conclusions: TLE procedure in patients with vegetations over 2 cm is relatively safe and effective and the and may be considered as a saver option for patients with risk factors for cardiac surgery. Option of pulmonary bed protection during TLE seems to be interesting and will need dedicated tool. www.jaib.com 114 October, 2013 | Special Issue Residual Fibrotic Tissue After Transvenous Pacemaker/ICD Transvenous Leads Extraction A. Tomaszewski, A. Kutarski, M. Poterala*, M. Tomaszewski, W. Brzozowski Cardiology Department Medical University, Lublin, Poland * Municipal Hospital, Radom, Poland Abstract Objectives: The cardiac leads may induce ibrous tissue reactivity and produce the ibrous sheath along its course. Residual ibrotic tissue can be diagnosed especially by transesophageal echocardiography (TEE) examination after transvenous leads extraction (TLE). Materials and methods: We analysed (2011-2012) 589 patients after TLE: male 61,8%, female 38,2% in average age 64,4 ± 16,5 y. The reason of TLE was: needless leads -57,1%, pocket infection -25,8%, lead dependent infective endocarditis (LDIE) 17,1%. All patients had transthoracic and transesophageal echocardiography, (iE 33 PHILIPS) before and after PM/ICD TLE. Results: We found ibrous tissue debris after TLE in 95 patients (16,1 %). Mean length was 28,1 mm (from 4 mm to 80 mm). The form of these structures relected the lead shape. Conclusions: 1.TEE is very useful in identiication of residual ibrotic tissue after TLE 2. The most common localization of ibrous tissue debris is superior vena cava near oriice (50% of patients) 3. Fibrotic debris (relecting lead course) may be localized in any place of the right heart. 4. The knowledge about residual ibrous tissue incidence is important to avoid misdiagnosis. Table Localisation of ibrous debris Debris localisation (number/%): www.jaib.com More than one localisation 24 (25,3%) Superior vena cava 48 (50,5%) Right atrium 14 (13,7%) Right ventricle 7 (7,4%) Tricuspid valve 2 (2,1%) 115 October, 2013 | Special Issue Severe Superior Cava Vein Stenosis In Patients Referred For Transvenous Lead Extraction A. Kutarski1, M. Czajkowski2, M. Polewczyk3 R. Pietura4 Dept of Cardiology Medical University of Lublin Poland1, Dept of Cardiac Surgery Medical University of Lublin, Poland 2 , Medical University of Warsaw, First Faculty of Medicine, Poland3, Department of Interventional Radiology and Neuroradiology Medical University of Lublin, Poland4 Abstract Introduction: Severe stenosis or occlusion of superior cava vein (SCV) consist rare but terrible complication of permanent lead dwelling in vascular bed. It may cause dificult the new lead implantation or to cause wide spectrum of clinical symptoms. Objectives: The analysis of frequency of appearance of stenosis or occlusion of superior cava vein (SCV) in patients (pts.) referred for transvenous lead extraction (TLE). Results: During last 7y. we extracted 2167 leads in 1283 pts. due to infective (49,5%) or non-infective indications (50,5%). In 183 pts. occlusion subclavian / anonymous vein (or both of them) were recognised but only in 32 (2,5%) narrowing affected of SCV. 7 pts presented full clinical picture of SCV syndrome, in 4 – incomplete symptoms of SCV syndrome and in remained 21 asymptomatic clinically. In 6 pts narrowing was limited to local of SCV fragment and in 26 narrowing was accompanied by anonymous vein occlusion and was located below anonymous vein. Permanent mechanical local irritation of SVCV wall (roundel lead loop or dislodged J shape lead ending) have been considered in 5 pts, crossing of multiple lead implanted with both side of the chest in another 5 pts and previous ineffective attempt of simple traction in 2 pts. seems to be mechanism of local thrombosis ant later strong connecting tissue scar. Among 4 mid-symptomatic patients in 3 vena azygos consisted main drainage of upper part of the body. In 1 asymptomatic patient this role played preserved left SCV. In 9 of patients lead replacement with elimination lead loops in SCV overmuch of leads passing SCV slightly improved local venous return but in most of the pts. TLE procedure with following lead replacement in spite of subjective symptoms reduction does not change postoperative venography picture. It is very important that in all pts. standard lead introducer set was to short for the new lead implantation and nonstandard longer set had to been utilized or even the new lead was introduced via polipropylene Byrd dilator directly after old lead extraction. Conclusions: Severe stenosis or occlusion of superior cava vein consist rare complication of permanent pacing (2,4% among pts. referred for TLE). Patients with SCV syndrome consists about 0,5% of pts referred for TLE. Venous angioplasty with stenting of SCV brings positive but not always permanent effects. Unrecognised stenosis or occlusion of superior cava vein may to consist severe trap during lead replacement because longer introducer set have to be utilised. www.jaib.com 116 October, 2013 | Special Issue Transvenous Lead Extraction. Using Conventional Mechanical Systems. Experience With Extraction Of 2197 Permanently Implanted Leads In 1295 PTS A. Kutarski1, M. Czajkowski2, R. Pietura3, K. Boczar4, M. Polewczyk5 Dept. of Cardiology Medical University of Lublin1, Dept. of Cardiosurgery Medical University of Lublin, Poland 2, Department of Interventional Radiology and Neuroradiology Medical University of Lublin, Poland 3Department of Electrocardiology, John Paul II Hospital, Krakow, Poland 4Student of Medical University of Warsaw, First Faculty of Medicine, Poland 5Neuroradiology Medical University of Lublin, Poland4 Abstract Introduction: It is observed recently rise necessity for transvenous lead extraction (TLE). TLE with conventional technique using mechanical systems, is counted as safer but less effective and more laborious technique. Objectives: analysis of the effectiveness & safety of mechanical systems for TLE. Methods: we have extracted 2197 ingrown (PM >12, ICD >6 mths) leads in 1295 pts. (61,6% M) mean age 64.4y, with PM and ICD systems. 73,2% leads were PM-BP, 10,1% - PM – UP and 14,8% ICD –% and 2,0% consisted VDD PM leads. 67,0% - passive ixation and 33,0 – active ixation. 35,6% were RA (RAA, BB), 6,5% LA (CS, CSO), 54,3% RV (RVA, RVOT), 3,5%, LV vein and 0,3% LA or LV (erroneous placement). Mean dwelling time was 82,4 mths. In 42,8% of pts. 2 leads were explanted, in 44,8% - single and in the remaining 12,5 % - 3 (max. 6) leads. The most common (57,0%) indications for TLE were non-infective; local pocket infection and endocarditis and the were less frequent (25,8% & 17,2%). Results: Aver. procedure time was 110,2 min. (30-420). Lead venous entry approach was used for most (83,8%) of leads; femoral approach were used for free loating leads and combined - (including jugular approach) for extraction of broken leads - in 1,8% and 2,2% respectively. Simple extorsion and traction was utilized in 11,7% for active ixation leads. Full radiol. success: 94,6%; remained tip only 2,3%, led fragment (<4 cm) 2,5% and only 8 leads were left due to high risk of tricuspid valve damage. Clinical success: 98,1%. Major complications appeared in 18 cases (1,39%): 9 hemopericardium (surgery), 4 hemopericardium (drainage) and 1 pleuropericardium (drainage), 1 pleuropericardium (surgary), 1 pulmonary embolism 1 severe hypotonia and 1 cerebral stroke. Minor complications were more frequent (1,7%): pulmonary embolism (3), hemothorax (3), hemopericardium (6) tricuspid regurgitation (4), subclavian vein thrombosis (2) but problems were solved without invasive intervention. 5 procedure related deaths were noted. Technical complications (prolonging procedure, forced to change venous approach and utilize additional technique and tools) happened in 210 (16,2%) cases. Conclusions: 1. TLE in experienced centre is very effective (nearly 95%) even in cases very old (>20 y) and dual-coil ICD leads 2. In experienced centre it is safe procedure (0,3% of death); major complications are infrequent (1,4%) 3. TLE may to need numerous complementary techniques; disposement of alternative techniques are necessary to completion procedure of 4% procedures 4. Cardiosurgery stand-by is necessary (was utilized in 10/1295 procedures). www.jaib.com 117 October, 2013 | Special Issue Transvenous Lead Extraction In Octogenarians. Safety And Effectiveness A. Kutarski1, K. Boczar2, A. Zabek2, M. Polewczyk3 Dept of Cardiology Medical University of Lublin, Poland 2Department of Electrocardiology, John Paul II Hospital, Krakow, Poland, 3Student of Medical University of Warsaw, First Faculty of Medicine, Poland 1 Abstract Introduction: There is considerable controversy regarding safety of transvenous lead extraction (TLE) in elderly patients due to theirs potentially worse general condition, more concomitant diseases and more dificult sedation / analgesia and current experience is not so big. Objectives: The comparison of safety and feasibility of TLE in elderly and middle age pts. Methods: Using standard mechanical systems we have extracted ingrown PM/ICD leads from 1060 adult pts (21-70y) and in 192 octogenarians within the last 7 years. We compared effectiveness & complications of the TLE procedures in mentioned two groups of pts. Observations: There are more woman in octogenarians referred for TLE. In this group there are more pocket infections and less noninfective indications for TLE and ICD systems as well. Results: P Conclusions: Ripe old age does not inluence on TLE effectiveness. So TLE can be performed safely and successfully in octogenarians. www.jaib.com Patient / procedure 21-79 y 80 and > y P Number of patients 1060 192 - Patient’s age (SD) 62,7±13,4 83,4±3,10 0,000001 Sex (% of male patients) 669 (63,1 %) 105 (54,7%) 0,0331 Endocarditis 189 (17,8%) 31 (16,1%) 0,6446 Pocket infection 259 (24,5%) 71 (37,0%) 0,0004 Non-infective indications 611 (57,7%) 90 (46,9%) 0,0072 Number of leads before TLE (SD) 2,01±0,81 2,06±0,77 0,4280 VH therapy (ICD) lead extraction 305 (28,8%) 14 (7,3%) 0,000001 Leads body dwelling time (SD) 83,5±63,0 76,4±56,8 0,1451 Major complications 16 (1,51%) 3 (1,56%) 0,7907 Minor complications 20 (1,88%) 2 (1,00%) 0,6019 Full radiological success 1002 (94,6%) 187 (97,4%) 0,1354 Partial radiological success 46 (4,34%) 5 (2,6%) 0,3571 Operating room stay-in time (minutes) (SD) 111,44±47,7 103,9±45,7 0,0776 118 October, 2013 | Special Issue Transvenous Lead Extraction In Young Patients. Speciicity And Disparateness A. Kutarski1, K. Bieganowska2, A. Zabek3, A. Polewczyk4 Dept of Cardiology Medical University of Lublin, 2Dept. of Cardiology Children's Memorial Health Institute Warsaw Poland, 3Department of Electrocardiology, John Paul II Hospital, Krakow, Poland, 4District Hospital, II Clinical Cardiology Department Kielce, Poland 1 Abstract Introduction: There is considerable controversy regarding safety of transvenous lead extraction (TLE) in young pts and children due to different anatomy, more strong connecting tissue scar and it earlier it calciication. Objectives: The comparison of safety and feasibility of TLE in young and adult pts. Observations: Using standard mechanical systems we have extracted ingrown PM/ICD leads from 1060 adult pts (21-70y; 62,7±13,4y) and in 36 <20y (14,9±3,6y) within the last 7 years. We compared effectiveness, complications and technical problems during TLE procedures in mentioned two groups of pts. Results: Results: P Impression: TLE in young pts in much effort consuming (much stronger connecting tissue scar, frequent calciication or mineralisation) and entails more experienced operator because lead break is relatively frequent and lead have to be extracted in parts. Rare occurrence of pocket infection may be explained by implantation procedure in operation room m but not in EPS lab. Conclusions: 1. Infective indications are much less frequent in young than adult pts. 2. In spite of simpler systems in young pts., effectiveness of TLE remain slightly lower; break of non-extractable distal lead fragment or tip of lead occurs in one-fourth TLE. 3. Young-age do not inluence on appearance of major & minor TLE complications. Patient / procedures www.jaib.com <21 y 21-80 y P Sex (% of male patients) 29 (80,6%) 669 (63,1%) 0,049 Endocarditis 3 (8,3%) 189 (17,8%) 0,2108 Pocket infection 0 (0,0%) 259 (24,5%) 0,0014 Non-infective indications 33 (91,7%) 611 (57,7%) 0,00013 Leads extracted in one pt. (SD) 1,32±1,2 1,70±0,81 0,0067 Leads in the system (SD) 1,36±0,49 1,81±0,66 0,000054 ICD lead extraction 5 (13,9%) 305 (28,8%) 0,0781 Implant dwelling time (y) (SD) 6,88±3,5 6,96±5,2 0,9322 Major complications 1 (2,8%) 16 (1,5%) 0,9362 Minor complications 1 (2,8%) 20 (1,9%) 0,8145 Full radiological success 27 (75,0%) 1002 (94,6%) 0,000003 Partial radiological success 8 (22,3%) 46 (4,3%) 0,000002 Operating room stay-in time (SD) 112,8±28,3 111,44±47,7 0,8650 119 October, 2013 | Special Issue CRT: Techniques & Imaging Aspects Impact Of Different Right Ventricular Lead Positions On Mortality In Patients Implanted With Permanent Pacemakers C.G. Wollmann, K. hudt, L. Witzersdorfer, P. Vock, H. Mayr III. Med. Klinik, Landesklinikum St. Pölten-Lilienfeld, St. Pölten, Austria Abstract Introduction: Frequent right ventricular (RV) apical pacing was shown to have deleterious effects on left ventricular function and – therefore.- may negatively inluence morbidity and mortality in patients implanted with permanent pacemakers (PM). The potential beneit of non-apical RV lead placement on mortality of patients implanted with permanent PM remains unclear. The purpose of our study was to compare mortality of patients implanted with PM and who had different RV lead positions. Methods: Mortality was retrospectively analyzed in all patients implanted with permanent single and dual chamber PM at our department between Jan 2009 and Dec 2011. RV lead position (apical [position#1], septal/mid-septal [position#2], high septal [position#3], RVOT [position#4]) was assessed by reviewing either implantation reports and/or luoroscopic lead documentation at implantation or thereafter. Fatal events were retrieved from the Statistical Department of the Austrian government (observational period until Dec 31, 2011). Categorial variables were compared using the chi-square, and Fisher`s exact test, where appropriate. Kaplan-Meier survival curves using the log rank test were calculated for survival for the different lead positions. Multivariate analyses were performed using Cox regression. A p-value < 0.05 for two-sided comparisons was considered statistically signiicant. Results: A: Within the observational period 782 patients (female 353 [45%], mean age 77±10 years, AV block 2nd and 3rd degree 43%, sick sinus syndrome 24%, single chamber PM 195 [25%], RV lead position #1/#2/#3/#4 562 [72%]/65 [8%]/38 [5%]/117 [15%]) were implanted with PM. The mean follow-up duration was 445±302 days. Within the observational period 97 patients (12%) died. There was no difference in mortality with respect to RV lead position (all-cause mortality pos#1/#2/#3/#4: 75 [13%]/9 [14%]/3 [8%]/10 [9%], logrank=ns; cardiovasc. mortality pos#1/#2/#3/#4: 42 [8%]/3 [5%]/2 [5%]/6 [5%], log-rank=ns). Cox regression analyses revealed an age > 80 years, a history of renal insuficiency and stroke, but not RV lead position to be predictive for death after permanent PM implantation Conclusion: In this standard PM patient cohort non-apical RV lead positions had no beneicial effect on all-cause and cardiovascular mortality when compared with apical lead position. www.jaib.com 120 October, 2013 | Special Issue Detrimental Effect Of Apical Stimulation In Patients With Atrial Fibrillation And Preserved Left Ventricular Ejection Fraction G. Vanerio CASMU- Arrhythmia Service British Hospital Montevideo Arrhythmia service, Montevideo, Uruguay Abstract Introduction: Patients with atrial ibrillation (AF) have higher mortality rates. Underlying cardiac disease and co-morbidities that AF aggravates could explain these observation. Pacemaker implantation in patients with AF, could have an impact on patient prognosis, as a wide paced QRS with a left bundle block coniguration is created, with a harmful effect on cardiac performance. There is some evidence of the beneit of septal stimulation which achieves a narrower QRS and generates a different activation pattern. Objectives: Compare survival between two different sites of stimulation in the right ventricle in patients with history of with atrial ibrillation and a left ventricular ejection fraction above 40% that received a permanent pacemaker. Results: The right ventricular electrode was implanted in two different positions; right ventricular apex in 429 patients (75%) and right ventricular septum in 139 patients (25%). When mortality was compared between the two groups, the apical group showed a mortality of 172/429 (40%) and the septal stimulation group of 35/139 (25%). One tail without Yates correction Chi2 = 2.77, p = 0.048] Survival curves were analyzed in the same population, comparing apical versus septal stimulation. The curves were signiicantly different favoring septal stimulation, that showed a signiicant lower mortality (log rank Mantel-Cox Chi2 4664 p = 0.031) Conclusions: In this retrospective study, it appears that patients with documented AF and a preserved left ventricular ejection fraction (>40%) whom underwent permanent pacemaker implantation the site of right ventricular stimulation has an impact on mortality. Apical pacing showed a signiicant higher mortality when compared to septal stimulation. www.jaib.com 121 October, 2013 | Special Issue Conduction Block Corrected With Para-Hisian Pacing But Hemodynamic Response Comparable To Biv Pacing In Patients With HF And LBBB F. Ayala-Paredes, R. Barba-Pichardo, P. Morina-Vazquez, J.M. Fernández-Gómez, H.F. Tse, J. Neuzner, R. Yee, A. Shuros, S. Hahn, A. Sharma, J. Ding, L. Manola, C. Butter Université de Sherbrooke, Sherbrooke, Canada (F.A.P); Hospital Juan Ramón Jiménez de Huelva, Huelva, Spain (R.B.P, P.M.V, J.M.F.G); University of Hong Kong, Hong Kong, Hong Kong (H.F.T); Klinikum Kassel, Kassel, Germany ( J.N); University of Western Ontario (R.Y); Boston Scientiic, Saint Paul, USA (A.S, S.H, A.S, J.D, L.M); Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Germany (C.B) Abstract Introduction: Studies suggest pacing from the para-Hisian region can correct LBBB in patients with HF, but unlike conventional biventricular pacing (BiV), little is known of the acute hemodynamic response to para-Hisian pacing (PHP). The purpose of this study is to compare acute hemodynamics during BiV and PHP. Methods: Fourteen patients undergoing de novo CRT implant were studied. Along with standard CRT lead implant, a pacing catheter was placed in the His bundle region and a pressure sensor in the LV. Signals were recorded during periods of BiV and PHP. Results: Conduction correction with PHP was evident in 6 of 14 patients (43%). The mean percent improvement in peak LV dP/dt for BiV and PH paced beats was 23.0±3.2% and 21.3±1.58% (P=NS), respectively. Conclusions: In patients exhibiting conduction correction, the hemodynamic response was comparable between PHP and BiV. This suggests that PHP may be of value in the treatment of heart failure and conduction disease. www.jaib.com 122 October, 2013 | Special Issue CRT Device Implantation Using A Non Fluoroscopic Mapping System Can Reduce The Radiation Exposure M. Del Greco*, M. Marini*, R. Bonmassari*, S. Indiani° * Cardiology Department S. Chiara Hospital Trento Italy ° St. Jude Medical Italy Abstract Background: X-ray guided CRT device implantation is widely performed and the radiation dose may be elevated for operators and patients. Aim of the present study was to describe the usefulness of the electroanatomic approach to minimize the luoroscopy exposure during CRT device implantation. Methods: 25 patients with indication to CRT-D implantations, were used a steerable 5F catheter and a unipolar guidewire (visionwireTM) to perform the CS electroanatomic map. Local LV activation times were recorded from CS vessels during right ventricular pacing. Optimal pacing choice and inal CS lead position were based on the maximum LV activation delay. Fluoroscopy time and dose were recorded. Results: All the permanent pacing leads were successfully positioned aided by the mapping system (MS). X-rays were only used to check the inal positions. In all cases CS os was identiied and cannulated without X-ray. In 21 cases, geometry validation through angiography was performed afterwards. The average luoroscopy time was 6.1 min. Conclusions: The implantation of a CRT device using a MS is feasible and reliable. In our experience we had a luoroscopy reduction of 70%. www.jaib.com 123 October, 2013 | Special Issue Electrocardiogram-Gated Single-Photon Emission Computed Tomography Phase Analysis: Value In CRT Patients A. Magalhães, A. Veiga, M. Cantinho, A. Ramalho, H. Pena, N. Cortez-Dias, J. Sousa Cardiology Department, Hospital Santa Maria, Lisbon, Portugal Abstract Introduction: Patients’ selection for CRT is a matter of concern since the non-responders rate remains high (30%). Gated-SPECT myocardial perfusion imaging with phase analysis evaluates dyssynchrony in an automatic and reliable way. We aimed to determine its value in predicting CRT-induced reverse remodeling. Methods: We performed GSPECT with technetium-99m tetrofosmin before and 21±9 months after CRT implantation. Left ventricular (LV) volumes, ejection fraction (EF) and LV dyssynchrony were assessed. Reverse remodeling was deined as end-systolic LV reduction ≥15% or EF increase >5% (absolute value). Results: Of the 20 patients evaluated (68±9 years, 90% male), 9 (45%) had reverse remodeling. The reduction of dyssynchrony in response to CRT as assessed by phase standard deviation (PSD) was a strong predictor of CRT response: responders had higher reductions of PSD (15.7±15.8 vs. -4.6±18.2, p=0.025), the reduction of PSD correlated positively with EF increase (R=0.467,p=0.038) and PSD had good accuracy in predicting reverse remodeling (AUC=0.80, 95%CI 0.60-0.99, p=0.025). Conclusions: The reduction of dyssynchrony as assessed by Gated-SPECT is a valuable predictor of CRT response. www.jaib.com 124 October, 2013 | Special Issue Myocardial Scar Characterization Predicts Device Therapy In Cardiac Resynchronization Therapy Patients. A Three-Year FollowUp A.L. Cipoletta, A. Berruezo, R. Evertz, D. Penela, J. Fernández-Armenta, D. Andreu, J.M.Tolosana, E. Arbelo, J.T. Ortiz, M. Sitges, L. Mont, J. Brugada Arrhythmia Section, Cardiology Department, horax Institute, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer) Abstract Introduction: Survival beneit of CRT-D over CRT is not clear and selecting appropriate therapy in HF patients is challenging. Myocardial scar characterization could predict long-term ventricular arrhythmias (VA). Methods: 97 HF patients (age 63 ± 12y, NYHA class 2.7±0.7 and EF 25±8%), undergoing CRT-D implantation, were prospectively enrolled. DE-MRI was performed before implantation and analyzed with customized post-processing software. Total scar area, core area and border zone (BZ) of myocardial scar were measured. The relationship between scar characteristics and ICD therapy was analyzed. Results: During a follow-up of 36 ± 24 months, appropriate ICD therapy occurred in 16 patients. Scar mass area <12,4g and BZ mass < 7.1g showed a negative predictive value of 96 and 97% respectively (ROC analysis, igure 1). A scar area with greater percentage of BZ was associated with a higher risk of VA (igure 2). Conclusions: Scar mass percentage and BZ mass are independent predictors of appropriate ICD therapy. Scar heterogeneity is associated with a higher arrhythmia risk and could be used to discriminate patients who beneit from a backup deibrillator Figure 2: Figure 1: Patients with ICD therapy had a more heterogeneous scar (larger border zone) ROC curve of scar mass and border zone mass for appropriate ICD therapy www.jaib.com 125 October, 2013 | Special Issue CRT: CLINICAL ASPECTS & OPTIMIZATION Gender Difference In Presentation, Management And Survival Of Patients With Heart Failure D. Giedrimiene, F. Zaeem, J. Radojevic, J. Gluck, D. Wencker Cardiology Department, Hartford Hospital, Hartford, CT, USA. Abstract Introduction: Recent literature suggests that heart failure (HF) may be a different entity in women than in men. The purpose of the study was to examine any differences in the presentation, management and survival with respect to gender in patients with HF. Methods: The data analysis included the records of more than 400 visits during 2.5 years of 84 pts (31 females and 53 males) who had multiple daily treatment sessions at Infusion Center. Primary disorders, co-morbidities, arrhythmias and reasons for ICD implantation were evaluated. Patients were followed in order to assess the frequency of re-hospitalizations and their survival. Results: The study demonstrated that CAD and hypertension were the most common causes of HF in men and women. DM and thyroid disease was found at the same frequency in both gender groups. However renal disease was signiicantly more prevalent in males. Despite very similar frequency of cardiac arrhythmias in both gender groups, signiicantly more males had the ICD implanted as compared to females. Conclusion: The rate of re-hospitalizations at 30 days and during 6 months period was higher in males than females, however the survival during 12 months follow-up was signiicantly lower in females than males. www.jaib.com Clinical variables Total n=84 Females n=31 Age, mean (SD), y 68.9±13.4 69.2±13.3 68.7±13.5 0.87 EF (%) 38.2±17.9 41.2±18.6 36.5±17.8 0.028* Renal Disease 52 (61.9%) 11 (35.5%) 41 (77.4%) 0.012* ICD Implantation 34 (36.9%) 7 (22.6%) 27 (50.9%) 0.016* Re-hospitalization at 6 months 35 (41.7%) 9 (29.0%) 26 (49.1%) 0.05* Survival at 12 months 73 (86.9%) 26 (76.2%) 47 (88.7%) 0.045* 126 Males n=53 P-value October, 2013 | Special Issue Pulmonary Vascular Resistence In Patients With Severe Left Ventricular Dysfunction T. Minarik, M. Fedorco, M. Taborsky University Hospital Ostrava, University Hospital Olomouc, Czech Republic. Abstract Introduction: The aim of this study was to evaluate pulmonary vascular resistence /PVR/ by invasive and echocardiographic measurement in patients /pts/ with severe left ventricular /LV/ dysfunction. All the pts were candidates for CRT. Methods: Standard transthoracic echocardiography and right heart (RH) catheterization were performed before CRT. Hemodynamic measurements, including mean pulmonary artery pressure (mPAP;mmHg), mean pulmonary capillary wedge pressure (PCWP;mmHg) and cardiac output (CO;L/min) were performed using a Swan-Ganz thermodilution catheter. PVR was estimated from hemodynamic measurements (PVR = (mPAP – PCWP )/CO; in Wood units (Wu)). Echocardiographic PVR was obtained using the peak tricuspid regurgitation velocity (TRV;m/s) and the time velocity integral (TVI;cm) of the right ventricular outlow tract (RVOT). Echo equation was: PVR = TRV/TVIRVOT x 10 + 0,16 (Wu). Before CRT and 3 month after, clinical evaluation ( NYHA functional class, 6-minute walking test (6MWT)) and echocardiographic parameters were evaluated. Clinical responders (R) to CRT were deined to NYHA deinition (with reduction of functional class > or =1) and improvement of 6MWT. Results: 22 pts (12 pts with CAD, 10 pts with DCMP, age 68.1±8.7 years; 19 men) with advanced heart failure (LVEF 21.8±4.5 %, NYHA III-IV, LVEDD 70.5±6.6 mm, LAESD 50.2±6.1 mm, mitral regurgitation 2.1±0.5 gr., tricuspid regurgitation 2.0±0.7 gr.) were included in analysis. RH catheterization indings were: mPAP 35.3±11.3 mm Hg, PCWP 25.4±8.6 mm Hg, CO 3.5±0.9 L/min, PVRcat 2.64±1.78 Wu. Echocardiographic values were: TRV 3.0±1.1 m/s, TVIRVOT 16.1±6.0 cm, PVRecho 2.16±1.36 Wu. There was no signiicant difference between both PVR measurements (2.64±1.78 vs. 2.16±1.36 Wu; p=0.21) with r value of 0.79. 4 pts (18%) were non-responders (NR). Before CRT the values of PVR were signiicantly higher in NR (NR 4.93±2,0 Wu vs. R 2,21±1,20 Wu; p<0.001). Also transpulmonary gradient (mPAP – PCWP) was signiicantly higher in NR (NR 15.3±5.1 mm Hg vs. R 8.0±3.1 mm Hg; p<0.05).After 3 month despite echo equation PVR decreased, still remained signiicantly higher in NR (NR 2.23±0.96 Wu vs R 1.37±0.92 Wu; p<0.05). Conclusion: 1/ Our preliminary results indicate singniicant difference of PVR a transpulmonary gradient values in the response to CRT. But these results should be conirmed in larger group of pts. 2/ A positive correlation between echocardiographic and invasive PVR equation in pts with severe LV dysfunction was demonstrated. www.jaib.com 127 October, 2013 | Special Issue Triple-Site Biventricular Pacing: A New Approach For Cardiac Resynchronization Therapy? A. Magalhães, P. Marques, A. Bernardes, D. Silva, P. Carrilho-Ferreira, A. Nunes Diogo, J. Sousa Cardiology Department, Hospital de Santa Maria, Lisbon, Portugal. Abstract Introduction: Since a signiicant proportion of patients (pts) fail to respond to CRT, using alternative multi-site ventricular pacing strategies may provide incremental beneit. We aimed to investigate the acute effects of a triple-site biventricular pacing system in hemodynamic and ventricular dyssynchrony. Methods: Cohort study of pts with permanent atrial ibrillation eligible for CRT. A TriVentricular (TriV) device was implanted with 2 RV leads in the apex (RA) and septum (IVS) and 1 LV lead, connected to atrial, RV and LV outputs in the generator. Echocardiography was performed during TriV, RA+LV, IVS+LV and RA+IVS conigurations. Results: Four pts were studied,70-85 years, EF 20±5%.Pts improved by at least 1 NYHA class and there were no ventricular arrhythmias or hospitalizations. Comparing the 4 conigurations, there were signiicant differences in hemodynamic parameters as well as in interventricular dyssynchrony and septal to lateral wall motion delay (S-LWMD). There was a trend towards greater CO and SV with TriV comparing with IVS+LV mode (p=0.066). S-LWMD was lower in TriV than in RA+LV (p=0.068). Conclusion: TriV system is feasible, secure and a promising approach for CRT in selected pts. Variables TriV RA+LV IVS+LV RA+IVS CO (L/min) 3.45±0.58 3.38±0.85 3.10±0.86 2.90±0.97 P-value 0.012 SV (mL) 46.0±7.7 44.5±11.1 41.8±11.3 39.5±12.3 0.016 MR – vena contracta (mm) 3.0±1.7 3.6±1.5 3.6±2.1 4.4±1.2 NS dPdT (mmHg) 753±112 735±113 742±95 622±88 0.059 EF (%) 24±4 23±5 23±4 21±4 NS Interventricular mechanical delay (ms) 21±11 23±17 22±13 39±19 0.048 Septal-lateral wall motion delay (ms) 46±17 80±32 67±49 101±41 0.077 Anterior-inferior wall motion delay (ms) 67±8 70±37 67±4 92±44 NS Septal-posterior wall motion delay (ms) 59±31 75±20 71±58 80±18 NS CO – cardiac ouput; SV – stroke volume; MR – mitral regurgitation; EF – ejection fraction; RA – right ventricular apex; IVS – interventricular septum; LV – left ventricle www.jaib.com 128 October, 2013 | Special Issue Feasibility Of A New Generation Quadripolar LV Lead – First Italian Single Centre Experience D. Ricciardi, V. Calabrese, L. Ragni, D. Grieco, G. Di Giovanni, F. Marullo, G. Di Sciascio Cardiovascular Sciences Department, Campus Bio-Medico University of Rome, Italy. Abstract Introduction: High thresholds, phrenic nerve stimulation can reduce the success of CRT options. A new generation quadripolar lead (Quad-LV - Attain Performa) with shorter spacing between the two center electrodes and 16 different pacing vectors has been introduced to overcome LV lead troubles. Methods: Eight patients were implanted with CRT-d. Median procedural time 90min, luoroscopy 13min. In one patient the CS was not cannulated. One patient needed to switch to a bipolar LV lead. Only two patients another branch than the 1st target was cannulated (tortuosity or small size of the vessel). A vector different from the standard bipolar one was chosen in 4 patients. In one case, the lead was repositioned twice (phrenic nerve stimulation and pacing captures). In all the Quad-LV was suficiently stable when removing the delivery. Phrenic nerve stimulation (3 cases) was eliminated by changing the vector. All patients retained the choosen vector, while in one patient was modiied at 1st follow-up. Conclusion: Quad-LV provides excellent handling with good procedural and luoroscopy times, the option for vector changes further increase the CRT technical success. www.jaib.com 129 October, 2013 | Special Issue Optimisation Of Cardiac Resynchronisation Therapy In Clinical Practice During Exercise M.M.D. Molenaar, B. Oude Velthuis, M.F. Scholten, Y.J. Stevenhagen, W.A. Wesselink, J.M. van Opstal horax Centre Twente, Medisch Spectrum Twente, Enschede, he Netherlands. Abstract Introduction: Although CRT is an established treatment to improve cardiac function, a signiicant amount of patients do not experience noticeable improvement. Optimal timing of the AV delay is of major importance for effective CRT treatment and this optimum may differ between resting and exercise conditions. In this study the feasibility of haemodynamic measurements by the non-invasive inger plethysmographic method (Nexin) was used to optimise the AV delay during exercise. Methods: Thirty-one patients implanted with a CRT device in the last four years participated in the study. During rest and in exercise, stroke volume (SV) was measured using the Nexin device for several AV delays. The optimal AV delay at rest and in exercise was determined using the least squares estimates method. Results: Optimisation created a clinically signiicant improvement in SV of 10%. The relation between HR and the optimal AV delay was patient dependent. Conclusion: A potential increase in SV of 10% can be achieved using Nexin for optimisation of AV delay during exercise. A considerable number of patients showed beneit with lengthening of the AV delay during exercise. www.jaib.com 130 October, 2013 | Special Issue Determination Of The Longest Intra-Patient Left Ventricular Electrical Delay May Predict Acute Hemodynamic Improvement In Cardiac Resynchronization Therapy Patients F. Zanon*, E. Baracca*, G. Pastore*, C. Fraccaro*, L. Roncon*, S. Aggio*, A. Mazza*, F. Prinzen§ *Santa Maria Della Misericordia Hospital, Rovigo, Italy § Maastricht University Medical Center, Maastricht, he Netherlands. Abstract Aims: One of the reasons for patient non-response to cardiac resynchronization therapy (CRT) is a suboptimal left ventricular (LV) pacing site. LV electrical delay has been indicated as a prognostic parameter of CRT response. This study evaluates the LV delay for optimization of LV pacing site. Methods: Twenty-six consecutive patients (18 male, mean age 71±11 years, LV ejection fraction 31±7%, 14 with ischemic cardiomyopathy, mean QRS 180±27 ms), underwent CRT device implantation. All the available tributary veins of the coronary sinus were tested and LV electrical delay (Q-LV) was measured at each pacing site. The hemodynamic effects of different sites were evaluated by invasive measurement of dP/dtmax at the baseline and during pacing. Results: An average of 2.8±0.8 different veins and 5.9±2.2 pacing sites were tested. In 25/26 (96%) patients, the highest dP/dtmax coincided with the maximum Q-LV. Q-LV correlated with the increase in dP/dtmax in all patients at every site (R=0.53; p<0.0001). A cut-off value of 95 ms corresponded to a minimum increase of 10% in dP/dtmax in all patients at every pacing site. An inverse correlation between paced QRS and improvement in dP/dtmax was seen in 20 patients (77%). Conclusion: Pacing the LV at the latest activated site is highly predictive of the maximum increase in contractility, as expressed by an increase of dP/dtmax. A positive correlation between Q-LV and hemodynamic improvement was found in all patients at every pacing site, a cut-off value of 95 ms corresponding to a minimum increase of 10% in dP/dtmax. www.jaib.com 131 October, 2013 | Special Issue New Onset Of Phrenic Nerve Stimulation During Left Ventricular Pacing At Mid-Term Follow-Up: A Multicenter Clinical Experience F. Zanon1, E. Baracca1, G. Pastore1, V. Calzolari2, M. Crosato2, M. Zecchin3, F. Longaro3, E. Bertaglia4, F. Zoppo, G. Neri5, D. Vaccari5, P. Delise6, E. Marras6, S.S. Barold* Ospedale S. Maria Della Misericordia, Rovigo, Italy. 2Ospedale Ca’ Foncello, Treviso, Italy. 3Ospedale Cattinara, Trieste, Italy. 4Ospedale di Mirano-VE, Italy. 5Ospedale di Montebelluna-TV, Italy. 6Ospedale di Conegliano-TV, Italy, *Florida Heart Rhythm Institute, Tampa, Florida, USA. 1 Abstract Introduction: Phrenic Nerve Stimulation (PNS) is a challenging problem of transvenous left ventricular (LV) pacing. Leads and devices that allow multiple pacing vectors may reduce or eliminate PNS. Methods: The study involved 6 centers and 98 patients (mean age 70 ± 8 years, 74 males) who received a quadripolar LV lead (QuartetTM, St Jude Medical) for cardiac resynchronization (CRT) according to standard indications. The mean LV ejection fraction was 29 ± 5%, and the mean QRS was 161 ± 22ms. Twenty-six patients were in chronic atrial ibrillation. In 18 cases the quadripolar LV lead was implanted in a postero-lateral coronary vein, and in 67 patients in a lateral vein. The prevalence of PNS was determined at the time of implantation and at mid-term follow-up. Rise in pacing threshold was also evaluated at mid-term follow-up. Results: At implantation the mean inal pacing threshold was 1.27 ± 0.94 V at 0.5ms and mean pacing impedance was 805 ± 299 ohms. PNS (at 5V, 0.5ms) was reported in 31 patients (32%) at a site where the pacing threshold was satisfactory. With alteration of the pacing vector, PNS was eliminated in all the patients without repositioning the LV lead. Pacing vectors involving proximal electrodes were also used in 7 more patients, due to better anatomical position of the electrodes. At mid-term follow up (4 ± 3 months), 28 patients (29%) experienced a new onset of PNS (14 pts, 14%, spontaneous, at programmed output) or a rise in LV pacing threshold (14 pts, 14%, more than 1V above the value measured at implant). PNS and high pacing threshold were managed by reprogramming the LV pacing vector, with a new inal mean threshold, in all patients, of 1.5 ± 1.2 V at 0.5 ms and LV pacing impedance of 780 ± 263 ohm. Conclusion: Quadripolar LV leads and device programmability are useful in CRT patients for the management of PNS and high pacing threshold. www.jaib.com 132 October, 2013 | Special Issue CRT: Long-Term Outcome Usefulness Of Bi-Ventricular Pacing Study For Chronic Heart Failure Patient With Narrow QRS Duration Before Cardiac Resynchronization Therapy Y. Nagata, T. Mayumi, T. Harada, M. Kinoshita, I. Aburadani, M. Hirazawa, M. Maruyama, K. Usuda Division of Cardiology, Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan. Abstract Introduction: In the patients with left ventricular systolic dysfunction and narrow QRS complex, cardiac-resynchronization therapy (CRT) beneits were restrictive. Methods: Twenty-eight chronic heart failure patients were examined for acute effects in a bi-ventricular pacing study using external pacemakers. Twenty-ive patients who had acute positive hemodynamic effects were classiied into three groups according to QRS duration; group A (N=7, <120 msec), group B (N=10, 120-150 msec) and group C (N=8, >150 msec). The echocardiography examined before and after CRT device implantation. Results: The changes of the acute hemodynamic state were similar among three groups. The CRT responders were observed in 6 patients of group A (85.7%), in 7 patients of group B (70.0%) and in 6 patients of group C (75.0%). The changes of ejection fraction were as good as the three groups (Group A; +16.3 ± 13.3%, Group B; +8.3 ± 4.3%, Group C; +9.3 ± 7.9%). Conclusion: In the heart failure patients with narrow QRS complex, acute positive hemodynamic effects using bi-ventricular pacing study were expected in CRT responders. www.jaib.com 133 October, 2013 | Special Issue Cardiac Resynchronization Therapy-Pacemakers In Heart Failure Patients With Left Bundle Branch Block And Left Ventricular Ejection Fraction 36-50%: The Design Of The Miracle Ef Study C. Linde1, A.B. Curtis2, G.C. Fonarow3, K. Lee4, W Little5, A Tang6, F. Leyva7, S. Momomura8, T. Bergemann9, C.M. Manrodt9, M. Cowie10 Karolinska University, Stockholm, Sweden. 2University at Bufalo, Bufalo, NY. 3UCLA, Los Angeles, CA. 4Duke Clinical Research Institute, Durham, NC. 5University of Mississippi, Jackson, MS. 6University of British Columbia, Victoria, BC, Canada. 7Queen Elizabeth Hospital, Birmingham, UK. 8Jichi Medical University, Saitama, Japan. 9Medtronic, Inc. Mounds View, MN. 10he Royal Brompton Hospital, London, UK. 1 Abstract Purpose: The beneits of Cardiac Resynchronization Therapy (CRT) for New York Heart Association (NYHA) Class II-III heart failure (HF) patients with a wide QRS, reduced left ventricular ejection fraction (LVEF ≤35%), and optimal medical therapy has been well established. Recent studies indicate large beneits in patients with left bundle branch block (LBBB). Sub-studies from the REVERSE and PROSPECT trials indicate that CRT beneit may be present among patients with LVEFs >35%. Symptomatic patients with NYHA Class II-III HF and mid-LVEF remain at high risk of mortality/morbidity, but have few established treatments, compared to low-LVEF HF patients. Therefore, the aim of the MIRACLE EF study is to test the hypothesis that CRT beneit reduces time to death or HF event in patients with NYHA Class II-III HF and LVEF of 36 to 50% and LBBB. Methods: The MIRACLE EF study is a prospective, randomized, controlled, double-blinded, global multi-center study to evaluate CRT-P ON vs CRT-P OFF in NYHA II-III HF patients with LBBB and LVEF of 36% to 50%. Patients in persistent atrial ibrillation or already indicated for cardiac pacing or ICD therapy are excluded. Following baseline assessment, eligible subjects are implanted with a CRT-P and randomized 2:1 to either treatment (CRT-P ON) or control (CRT-P OFF) groups. Subjects are followed for a minimum of 24 months or until study closure, and remain in their randomized groups until the study is stopped or until their 60 month visit, whichever comes irst. The primary endpoint is a composite endpoint of time to irst HF event and all-cause mortality. Secondary endpoints include mortality, time to irst event deined as death, HF event or worsening systolic function, recurrent HF events, quality of life, healthcare system cost-effectiveness and echocardiography data. Results: The MIRACLE EF study, which includes heart failure patients with LBBB and LVEF 36-50%, is currently enrolling, and is expected to be conducted at up to 275 centers worldwide. Approximately 2,900 subjects are to be enrolled to reach approximately 2,300 randomized subjects. This sample size provides 90% power to detect a hazard ratio of 0.75 or less if 10% of the control group per year experiences an event. The results are expected to emerge in 2018. No adverse events were reported. Conclusion: If trial results of this prospective randomized trial are positive, the indications for CRT may become wider and accessible to HF patients with mild to moderately reduced LVEF. (clinicaltrials.gov NCT 01735916). www.jaib.com 134 October, 2013 | Special Issue Connection Of QRS Width With Survival In Patients After CRT By Left Ventricular Lead Placement Via Lateral Thoracotomy - 3 Years Follow-Up B. Malecka1, A. Zabek1, J. Lelakowski1, A. Kutarski2, R. Pitzner3 John Paul II Hospital, Department of Electrocardiology, Krakow, Poland. 2Medical University of Lublin, Department of Cardiology , Lublin, Poland. 3Jagiellonian University, Cardiology Institute, Dept. of Cardiovascular surgery & Transplantation, Krakow, Poland. 1 Abstract Introduction: Surgical epicardial LV lead implantation (CRT-S) is an acceptable alternative when lead placement via the coronary sinus is not feasible. Methods: In the last 7.5 years 29 pts (7 F, 22 M), mean age 65.9±8.2 years (49.9-78.5) with NYHA class III (21 pts) and IV (8 pts) underwent CRT-S. 10 pts (34%) had sustained AF with high-degree AV block (5 pts after AV junction ablation). The remaining pts were in sinus rhythm. All pts met the ESC inclusion criteria for CRT. The reasons for left ventricular lead placement via lateral thoracotomy were: CS cannulation failure (23 pts), high LV pacing threshold or diaphragm stimulation (3 pts), left subclavian vein occlusion preventing LV lead placement in patients with previous pacemaker implantation (3 pts). 11/29 pts had previous surgical intervention (10 pts after CABG). In all pts RV and/ or atrial leads were placed transvenously, and then LV lead distal end was attached surgically to the postero-lateral wall in the sub-annular upper part of the left ventricle and tunneled to the left subclavian pocket. Results: The mean follow-up was 37±29 months (4.5-93.6). There were 7 (24%) deaths: one death caused by stroke in the early postoperative period, 6 deaths due to worsened heart failure. The QRS width was shortened after CRT-S (167±26 vs 143±21 ms, p<0.001). Comparison of the surviving pts with dead pts is presented in the table. Conclusion: Surviving pts are characterized by initially wider QRS complex and greater degree of QRS narrowing after CRT-S. Parameter www.jaib.com Pts alive Pts dead p value Number 22 7 - Age [years] 66.5±7.4 64.1±11.0 p=0.5241 QRS before CRT-S [ms] 173±25 150±23 p=0.0379 QRS after CRT-S [ms] 145±23 139±12 p=0.4148 Shortening QRS [ms] 28±16 11±15 p=0.0176 NYHA class before CRT-S 3,22±0,43 3.43±0.53 p=0.3237 LV EF before CRT-S [%] 26±7 25±6 p=0.6431 135 October, 2013 | Special Issue Detection Of Adverse Timing In Cardiac Resynchronization B. Ismer, J. Härtig, M. Heinke, J. Hörth, J. Melichercik Peter Osypka Institute for Pacing and Ablation at Ofenburg University of Applied Sciences, Ofenburg, Germany MediClin Heart Center Lahr/Baden, Germany. Abstract Background: Decrease of non-responder rate is the main challenge in cardiac resynchronization therapy (CRT). The problem could partly be solved by consequent individualization of hemodynamic pacing parameters. Adverse timing can be assumed in patients with AV delays shorter than individual implant-related individual interatrial conduction intervals (IACT). Objectives: To detect and to prevent hemodynamic adverse timing in CRT patients using esophageal left atrial electrogram. Methods: By perorally applying a TOslim electrode in 20 patients (5 f, 15 m, aged 69±10 yrs) carrying CRT with AV delay (AVD) in factory settings, esophageal left atrial electrogram (LAE) of the Biotronik ICS 3000 programmer was utilized to quantify IACTs in VDD and DDD operation and to individualize the AVDs by AVD = IACT + 50ms. Results: We measured IACTs of 30±26 ms in VDD and 97±33 ms in DDD pacing, at mean. In 3 of the 20 patients (15%) we observed hemodynamic adverse timing. In this patients, the IACTs exceeded the factory AVDs by 23±5 ms, at mean. Conclusion: Esophageal left atrial electrogram is a useful method to exclude hemodynamic adverse timing in CRT patients. www.jaib.com 136 October, 2013 | Special Issue Clinical And Anatomic Aspects Of CRT Beneit In Chf Patients. Our Experience R.S. Latypov, O.V. Sapelnikov, Yu.V. Mareev, A.S. Partigulova, I.R. Grishin, V.N. Shitov, M.A. Saidova, R.S. Akchurin Cardiology Research Center, Moscow, Russia. Abstract Introduction: Nowadays the cardiac resynchronization therapy is one of the most beneicial among the methods of heart failure treatment. Nevertheless there are too much problems unsolved yet how to make it more effective. Objectives: The aim of our study was to evaluate our experience of CRT in CHF patients with sinus rhythm and permanent atrial ibrillation (AF) in order to primary localization of left ventricle electrode. Methods: 31 patients with CHF and the average heart rate below 90 bpm have been observed: 10 patients with permanent AF and 21 on sinus rhythm. CRT-P was implanted into 26 and CRT-D into 5 patients. All patients underwent 6 minutes walk test. Well response to CRT was considered in patients with an increase in 6 minutes walk test more than 40 m and EF more than 5%. The measurement of EF by echocardiography and 24-hour ECG-monitoring were done before and after CRT implantation. The percentage of BV pacing calculation has been done in both groups by ECG-monitoring. If patient had less than 90% BV complex and his “fusion” beats had less hemodynamic response as BV complex we recommend ablation of AV node. Surgical aspects of the implantation: in 26 cases the left ventricular electrode has been implanted in lateral cardiac vein with acceptable parameters, in 4 cases – in posterior vein and in 1 case we had only choice to deliver it into anterior vein closer to the apex. Results: There were 10 responders (47%) in group of sinus rhythm and 6 responders (60%) in group of AF (p=0,7). The mean time of follow-up was 2 years. There was 1 SHD in group of AF and 3 deaths in group of sinus rhythm (2 SHD and 1 HF). All SHD cases occurred in patients with CRT-P. There was one death in group of patients of sinus rhythm because of CHF increasing. That was the patient with left electrode located close to apex. In other patients the pacing data has been staying on acceptable level in all period of follow-up. 3 of 10 patients with permanent atrial ibrillation had <90% BV complexes. In one patient “fusion” complexes were the same doppler VTI as BV complexes and the amount of BV and fusion complexes was more than 90%. For 2 patients the ablation of AV-node was recommended. Conclusion: CRT effects in patients with sinus rhythm and permanent AF are mostly comparable especially in irst year of follow-up. The ablation of AV node in patients with AF is more helpful if percentage of BV pacing on drug therapy is lower then 90%. The best beneit of CRT may be reached by left electrode implantation in lateral or posterior cardiac veins. www.jaib.com 137 October, 2013 | Special Issue Patient Survival And Device Longevity In Patients After CRT Implantation M. Gwechenberger, A. Hammer, M. Huelsmann, R. Pacher, C. Adlbrecht, H. Schmidinger, G. Stix Department of Cadiology, Medical University of Vienna, Austria. Abstract Introduction: Cardiac resynchronization therapy (CRT-P and CRT-D) is an established therapy in heart failure. However, data on the device longevity and the relation to patients survival are scarce. Methods: We retrospectively analyzed 627 patients who underwent CRT implantation between 1999 and 2012 (76.7% male; mean age 66.2+11.9 years; Group 1: 304 CRT-P; Group 2: 323 CRT-D). The mean follow up was 3,5+2,7 years. Results: Death occured in 236 (37,4%) patients during follow up. There was no signiicant difference between the patients survival between both groups. Replacement of the device occured in 55 (18,1%) patients in group 1 and 80 (24,8%) patients in Group 2.Device longevity was signiicantly longer in CRT-P than in CRT-D Sytems (3.7+1.7 vs. 4.8+2,5 years; p<0.001) and was signiicantly different among manufacturers. Conclusion: Device longevity was signiicantly shorter in CRT- D than in CRT-P. However, there was no siginiicant difference in the survival of the patients between the groups. www.jaib.com 138 October, 2013 | Special Issue Outcome Of Patients With Cardiac Resynchronization Therapy. Comparison Between Elderly And Adult Patients N. Martinenghi, N. Galizio, M. Mysuta, J.L. Gonzalez, F. Robles, A. Palazzo, X. Vallejo Deeb, G. Carnero, H. Fraguas Department of Cardiac Electrophysiology, University Hospital Favaloro Foundation, Buenos Aires, Argentina. Abstract Introduction: There is little evidence about the beneit of CRT in elderly. The aim of the study was to assess the outcome of CRT in elderly patients (pts) compared with adults. Methods: A prospective analysis was performed in 32 elderly pts (≥70 years) and 65 adults (21-69 years) with idiopathic dilated or ischemic cardiomyopathy who fulilled CRT-D indications. Pts were considered responders if there was a LVEF improvement ≥5% and/or a reduction ≥1 NYHA functional class. Responder rate, LVEF improvement and cardiovascular mortality (CVM) were assessed. Mean follow-up was 21 months (2-49). Results: Mean age was 75.2±10.5 years in elderly pts and 58.8±10 years in adults (p<0.05). Responder rate was 75% vs 73.8% (ns). Mean LVEF improvement was 6.2 ±10% vs 9.3 ±10% (ns). CVM was 3.12% vs 3.07% (ns) among elderly and adults respectively. Conclusion: In our study population, CRT was as effective in elderly as in adults in terms of responder rate, improving LVEF and CVM. Age alone should not be a restricting factor for CRT in heart failure patients. www.jaib.com 139 October, 2013 | Special Issue Ablation Of Different Cardiac Arrhythmias Delayed Effects Of Cryoablation Of Perinodal Tissue G. Katsouras, M. Grimaldi, A Petruzzellis, F. Quadrini, G. Diaferia, T. Langialonga Ospedale Miulli, Acquaviva delle Fonti, Italy. Abstract Background: Cryoenergy as a modality for transcatheter ablation has been well established in the last decade. Direct cell injury from freezing manifests sometimes in a delayed manner. We present two clinical cases of a delayed effect of cryoablation in perinodal tissue. Methods and Results: A 37 y female, without structural heart disease, presented with numerous repetitive parahisian extrasystoles highly symptomatic. We conducted a detailed mapping of AV node with the Carto system and we performed cryoablation. After each lesion we noted junctional beats partially different from the original arrhythmia. At one month follow-up the patient didn’t present any extrasystoles. We performed cryoablation of a medioseptal accessory pathway in a 14 y male with preexcitation (the effective refractory period of the by-pass tract was 240msec). Two hours after ablation the patient presented evidence of preexcitation. Nevertheless, at one month follow-up there was no evidence of preexcitation. Conclusion: We describe two clinical cases of delayed effects of cryoablation in perinodal tissue. These effects are likely secondary on apoptotic cell death occurring after application of cryoenergy. Further studies are needed to exclude other possible mechanisms. www.jaib.com 140 October, 2013 | Special Issue Long-Term Follow-Up Of Catheter Ablation Of Incessant Tachycardias E.A. Ivanitskiy, A.P. Tsaregorodtsev, D.A. Shlyakov, D.B. Drobot, V.A. Sakovitch Department of Cardiovascular Surgery, Federal centre of Cardiovascular Surgery, Krasnoyarsk, Russia. Abstract Objective: To analyze and compare long term follow up of ablation of incessant supraventricular tachycardias in patients after open heart surgery and after catheter ablation. Materials and Methods: From January 2007 to August 2012 we performed 32 catheter ablation procedures to patients with supraventricular incessant tachycardias. We studied long term follow up of 28 patients, mean age 39 + 27 years, who had incessant atrial tachycardias due to open heart surgery or catheter ablation in the past. Patients were divided into two groups: in the irst group (12 patients) were included patients who had undergone open heart surgery in the past, in the second group (14 patients) were included patients who had had catheter ablation before. Catheter ablations of all incessant tachycardias were performed by using 3-D navigation system. Mean follow up period 20 + 14 months. Results: In a group of patients after open heart surgery sinus rhythm was restored in all patients. 10 patients experienced only one catheter ablation, 2 patients had recurrences in other supraventricular tachycardias (AV nodal reentrant tachycardia and focal right atrial tachycardia respectively) after the irst ablation. And after the second procedure one patient was on sinus rhythm, in the second case dual chamber pacemaker was implanted due to transient symptomatic AV block 2 degree. In the second group sinus rhythm was restored in 10 patients. Two patients of this group insisted on pacemaker implantation and AV node ablation after two or three unsuccessful catheter ablations and highly symptomatic tachycardias. In two other patients pacemakers were implanted in combination with AV node ablation due to recurrences of AF after incessant tachycardias elimination. Conclusion: Catheter ablation of incessant tachycardias wether after open heart surgery or after catheter ablation is very effective method of treatment. In our study these two groups of patients are very different (all incessant tachycardias of the second group were recurrences of atrial ibrillation ablation and in 100% of cases localized in the left atrium, in the irst group 7 tachycardias were right sided) and this can be the rationale of different effectiveness of ablation. www.jaib.com 141 October, 2013 | Special Issue Evaluation Of Cavo-Tricuspid Isthmus Anatomy By Multi-Slice Computed Tomography In Patients With Cavo-Tricuspid Isthmus Dependent Atrial Flutter M. Nakao, S. Kobayashi Division of Cardiology, Chibaken Saiseikai Narashino Hospital, Chiba, Japan. Abstract Introduction: Cavo-tricuspid isthmus (CTI) ablation for CTI dependent typical/reverse typical atrial lutter (AFL) has been established. However there are still some cases that can not be created a standard block line on CTI. CTI anatomical characteristics can inluence the result of ablation. Methods: 17 patients (66.5+/- 7.8 years) who underwent CTI ablation for typical/reverse typical AFL were enrolled. We assessed CTI anatomical morphology by multi-slice computed tomography (MSCT) before CTI ablation. The result of ablation was also assessed. Results: CTI morphologies were divided by MSCT into four groups (lat: F, concave: C, pouch: P and huge Eustachian ridge: E). 11 patients were contained in group F, 2 in group C, 3 in group P and 1 in group E. CTI bidirectional block was not completed in 1 patient in group F and 2 in group C. Conclusion: The frequency of anatomical variations of CTI is not low when minor variations are included. Though most of these variations can be ablated normally, anatomical information of MSCT can help to ablate CTI by selecting devices, techniques and strategies in dificult cases. www.jaib.com 142 October, 2013 | Special Issue Usefulness Of The 3D-Anatomical Reconstruction Of The Right Atrium In The Zero-Fluoroscopic Approach For The Cavotricuspid Isthmus Catheter Ablation M. Álvarez, R. Macías, J. Jiménez, T. Barrio, M. Jiménez, L. Tercedor Arrhythmia Unit, Hospital Universitario Virgen de las Nieves, Granada, Spain. Abstract Introduction: The zero-luoroscopic approach for the catheter ablation of the cavotricuspid isthmus (CA-ICT) is feasible and safe. The inluence of the 3D-anatomical reconstruction of the right atrium (3D-RA) on the results of this procedure has not been studied yet. Methods: One hundred and seventy nine (174) procedures of CA-ICT performed with zero-luoroscopic approach as a irst line of treatment were analyzed. An open-irrigated ablation catheter was used in all the procedures; bidirectional block was used as the end-point of the procedure. In 69 procedures (39.7%) the 3D-RA was carried out at the discretion of the attending staff. Forty-six (66.7%) 3D-RA were performed by the Ensite-NavXTM system and 23 (33.3) by the Carto3® system. The non-luoroscopic navigation system and the use of two diagnostic catheters were related with the 3D-RA. The procedures with 3D-RA were longer (157±49 vs. 127±42 minutes) because a longer diagnostic procedures (82±33 vs. 57±36 minutes). The 3D-RA had not inluence on the percentage of neither success nor complications. The use of luoroscopy was not increased by the 3D-RA. The radiofrequency time was shorter in those procedures performed with 3D-RA (13±12 vs. 17±17 minutes). Conclusion: The tridimensional reconstruction of the right atrium in the zero-luoroscopic approach of the cavotricuspid-isthmus catheter ablation prolongs the length of the procedure and reduces the radiofrequency time. Other variables (success, complications and need of luoroscopic) were not inluenced. www.jaib.com 143 October, 2013 | Special Issue A New Procedure For A Trans-Conduit Puncture Using A Snare Catheter As The Catheter Ablation Of Supraventricular Tachycardias After An Extra Cardiac Fontan Operation H. Aoki, Y. Nakamura, T. Takeno, T. Takemura Department of Pediatrics, Kinki University, Faculty of Medicine, Osaka, Japan. Abstract Background: SVT occur after an extrcardiac Fontan (EFs) and are dificult to treat using catheter ablation (CA) because of the access. There are a few reports on performing conduit punctures (CPs), but it is dificult to stabilize the tip of the needle during the puncture. We developed a new procedure for CPs using a snare catheter. Case report: 1One 15-year-old patient with tachycardias associated with an accessory pathway and twin AVNs underwent an EF using GORE-TEX® for right isomerism heart and atrioventricular septal defect. Another 15-year-old patient with an accessory pathway underwent an EF for mitral atresia. Two patients underwent CA via a CP with a snare catheter. The tip of the dilator of a long sheath was grasped with a snare in order to prevent the tip of the needle from slipping. Then a BRK needle was advanced from within the dilator of the sheath to the atrium under luoroscopy or intracardiac echocardiography guidance. The CA procedures were successful without any complications. Conclusion: CA of SVTs after an EF could safely and successfully be ablated via a CP utilizing a snare catheter. www.jaib.com 144 October, 2013 | Special Issue Cover Page Mechanisms and Genetics of Cardiac Arrhythmias Mitochondrial Reactive Oxygen Species (ROS) Production Causes Stretch-Induced Increase in Calcium Spark Rate K. Kaihara, K. Naruse Cardiovascular Physiology, Okayama University, Okayama, Japan Abstract Introduction: We have previously reported that myocardial stretch induces an increase in Ca2+ spark rate. In the present study, we investigated the involvement of mitochondrial reactive oxygen species (ROS) production in stretch-induced acute increase in Ca2+ spark rate. Methods: Isolated mouse ventricular myocytes were exposed to 5-8 % axial stretch using carbon ibers attached to both cell ends. Diastolic spark rate was studied using Fluo-4 loaded cells. ROS production was studied using DCF loaded cells. The slope of the DCF signal indicates ROS production. Results: Axial stretch signiicantly increased Ca2+ spark rate (142.1 ± 13.1 %, n = 10), and slope of DCF signal (107.7 ± 3.2 %, n = 14). Applying 5 μM of FCCP (mitochondrial uncoupler) in the presence of 5 μM oligomycin (to prevent ATP depletion) blunted the increase in both spark rate (98.8 ± 4.5%, n = 11) and slope of DCF (99.2 ± 1.7%, n = 10). Conclusions: Our present results suggest that stretch-induced mitochondrial ROS production possibly play a role in stretch-induced increase in Ca2+ spark rate. www.jaib.com 145 October, 2013 | Special Issue Down-Regulated Endothelial Function by Atrial Fibrillation: Results from Peripheral Arterial Tonometry G. Zhong, J. Wang, H. Chi Department of Cardiology, Bejing Chaoyang Hospital, Capital Medical University, Bejing, China Abstract Introduction: Endothelial nitric oxidase was reported to be down-regulated by atrial ibrillation (AF). We hypothesized that endothelial function may be down-regulated by AF. Method: We measured the endothelial function in patients with AF with Peripheral Arterial Tonometry (PAT), a novel noninvasive method to assess endothelial function. We divided 79 patients with AF into 2 groups, paroxysmal AF (n=50) and persistent AF (n=29). We measured 20 healthy volunteers with matched age and sex as control. Results: RHI (reactive hyperemic index) in paroxysmal AF group was 1.75±0.5, 1.58±0.6 in persistent AF group, and 2.02±0.58 in control. One way ANOVA analysis showed that persistent AF group had a signiicantly lower RHI than control (p<0.05). Although RHI in persistent AF group tended to be lower than in paroxysmal AF group, yet we did not ind the difference signiicant. Neither was the difference between paroxysmal AF group and control. Conclusions: Persistent AF may damage the endothelial function. Paroxysmal has a tendency to damage the endothelial function, which needs to be proved by large scale study. www.jaib.com 146 October, 2013 | Special Issue Histopathalogical Substrate of Fractionated Electrograms in Patients with Chronic Atrial Fibrillation B.L. Nguyen, S. Poggi, A. Persi, G. Riitano, C. Gaudio, E.S. Gang, M.C. Fishbein, P.S. Chen Sapienza University of Rome, Italy; Cedars-Sinai Medical Center, Los Angeles, USA; Indiana University, Indianapolis, USA Abstract Introduction: Ablation of complex fractionated atrial electrograms (CFAEs) is an important adjunctive therapy in atrial ibrillation (AF). The underlying substrate is poorly understood. Autonomic nervous system modulation appears to inluence the complexity characteristics of atrial electrograms (EGMs). This study sought to examine the histological substrate of CFAEs in chronic AF patients. Methods: We stained 24 biopsies taken from the pulmonary vein-left atrium junction and right atrial appendage from 8 chronic AF patients and 4 sinus rhythm patients undergoing mitral valve surgery using trichrome, and antibodies to tyrosine hydroxylase and cholineacetyltransferase (ChAT). Local EGMs were recorded from the same sites using a bipolar recording catheter before samples were taken. Results: A total of 48 slices have been analyzed. In AF patients, the myocardium was disorganized and the intercellular space was occupied by abundant interstitial ibrosis. Sympathetic nerve twigs and parasympathetic nerve densities were present. There was a signiicant association between AF and EGMs duration and delections (p=.035, and p=.04, respectively). In AF, EGMs duration correlated positively with the amount of ibrosis (r=.149, p=.017), and the number of EGM delections was positively related to the ChAT nerve density (p=.007). Conclusions: Fibrous tissue and parasympathetic nerve structures in the atria may account for the substrate of CFAEs and serve as potential targets of chronic AF ablation. www.jaib.com 147 October, 2013 | Special Issue Status of Selenium and Selenoprotein Glutathione Peroxidase in Patients with Recent-Onset Atrial Fibrillation M.N. Negreva, A.P. Penev, S.J. Georgiev, A. Aleksandrova, R. Georgieva, A. Angelov Department of Cardiology, Varna University Hospital “St. Marina”, Varna, Bulgaria; Bulgarian Academy of Sciences, Institute of Neurobiology, Soia, Bulgaria; National Center of Public Health and Analyses, Soia, Bulgaria Abstract Introduction: To study activity of erythrocyte selenoprotein glutathione peroxidase (GSH-Px) and plasma content of its cofactor selenium in patients with recent-onset (<48 hours) AF and structurally normal hearts. Methods: We examined 33 patients (60.03±1.93 years, 17 males) and 33 healthy controls (59.27±1.72 years, 17 males). Blood samples were collected prior to medical treatment (baseline), on 24th hour and 28th day after sinus rhythm restoration. Selenium was quantiied by atomic-absorption spectrometry and GSH-Px was measured by spectrophotometric assay. Results: At baseline, patients’ GSH-Px and selenium were decreased (25.51±1.08 vs 31.01±1.11 nmoles/min/mgHb, p<0.001; 70.91±1.97 vs 77.15±1.87 mcg/L, p<0.05). On 24th hour GSH-Px was diminished (26.71±1.39 vs 31.01±1.11 nmoles/min/mgHb, p<0.05) whereas selenium approximated that of controls (74.06±2.04 vs 77.15±1.87 mcg/L, p>0.05). No signiicant differences were observed on 28th day (GSH-Px - 30.19±0.81 vs 31.01±1.11 nmoles/min/mgHb, p>0.05; selenium - 75.15±1.84 vs 77.15±1.87 mcg/L, p>0.05). Conclusions: Our results show that recent-onset AF in structurally normal hearts is associated with Se deiciency and loss of GSH-Px activity. Early changes in status of Se and GSH-Px make us assume they are related to AF triggering mechanisms. www.jaib.com 148 October, 2013 | Special Issue Dynamics of Antioxidant Defense System Indicators in Patients With Atrial Fibrillation M.N. Negreva, S.J. Georgiev, A.P. Penev, A. Aleksandrova Department of Cardiology, Varna University Hospital “St. Marina”, Varna, Bulgaria: Bulgarian Academy of Sciences, Institute of Neurobiology, Soia, Bulgaria Abstract Objectives: To examine enzymatic antioxidants catalase (CAT) and superoxide dismutase (SOD) and nonenzymatic antioxidant glutathione (Er-GSH) in erythrocytes of patients with recent-onset (<48 hours) AF and structurally normal hearts. Methods: The study included 51 patients (59.8±1.6 years, 26 males) and 52 healthy controls (59.5±1.5 years, 26 males). Blood samples were collected prior to treatment (baseline), on 24th hour and 28th day after SR restoration. All indicators were measured spectrophotometrically. Results: Patients’ Er-GSH was lower baseline (997.00±32.60 vs 1347.00±32.61 ng/mg pr, p<0.001) and on 24th hour (1215.00±46.71 vs 1347.00±32.61 ng/mg pr, p<0.05). SOD and CAT were elevated baseline (8.46±0.26 vs 5.81±0.14 U/mg Hb, p<0.001; 7.36±0.25 vs 4.76±0.12 E240/min/mg/Hb, p<0.001) and on 24th hour (7.19±0.25 vs 5.81±0.14 U/mg Hb, p<0.001; 5.30±0.21 vs 4.76±0.12 E240/min/ mg/Hb, p<0.05). On 28th day no signiicant difference (p>0.05) was established in Er-GSH (1321.00±44.57 vs 1347.00±32.61 ng/mg pr) and SOD (5.90±0.16 vs 5.81±0.14 U/mg Hb). CAT tended to reach controls (5.11±0.08 vs 4.76±0.12 E240/min/mg/Hb). Conclusions: Early changes in antioxidants with their follow-up dynamics give us grounds to assume that antioxidant system play role in recovery process after AF episode. www.jaib.com 149 October, 2013 | Special Issue The Voltage-Gated Potassium Channel Subunit KCNE3 Regulates Electrical Conductance in Atria and AV Node U. Lisewski, B. Spallek, C. Gaertner, N. Lange, T.K. Roepke Experimental and Clinical Research Center (ECRC), Charité Medical Faculty and Max Delbrück Center for Molecular Medicine (MDC), Berlin, Germany Abstract Introduction: KCNEs are beta-subunits of voltage-gated potassium channels (Kv), which are essential for repolarization of cardiomyocytes. The co-assembling of KCNEs with Kv alpha- subunits characterizes their functional properties. Mutations in the KCNE3 gene are associated with Brugada syndrome and atrial ibrillation (AF). Methods: In this study we used a conventional generated Kcne3 knockout (KO) to investigate the role of KCNE3 in adult mouse heart. In vivo electrophysiology studies revealed a shortening of effective refractory period (ERP) in atria accompanied by AF in pacing induced. Results: Furthermore, whole-cell patch clamp recordings of cardiomyocytes results in a higher current density in Kcne3 deicient atria, but ventricular myocytes were unaffected. Detailed functional analysis of atrial cardiomyocytes demonstrated an altered Kv channel properties of Kv4.3 (Ito) and Kv1.5 (Ikslow1) that might involve KChIP2, an interaction partner protein shared between Kv4.3 and Kv1.5. Conclusions: Our novel mechanistic insights into the interaction of KCNE3 and these alpha subunits of Kv channels could help explain the selective effect of Kcne3 deiciency for atrial excitation, especially for development of AF. www.jaib.com 150 October, 2013 | Special Issue Genotype-Phenotype Correlation in a Large Family with Long QT Syndrome Type 2 and KCNH2-H562 Mutation C. Muñoz-Esparza, E. García-Molina, M. Salar, V. Cabañas-Perianes, P. Penaiel-Verdú, J.J. Sánchez Muñoz, J. Martínez Sánchez, A. García Alberola, M. Valdés Chavarri, J.R. Gimeno Virgen de la Arrixaca University Hospital, Murcia, Spain Abstract Introduction/ Purpose: The purpose of this study was to investigate the effect on clinical phenotype of a new autosomal dominant missense mutation (H562R/a1685g), not described previously, in KCNH2 gen. This mutation was originally described in a person of the family after suffering a resuscitated sudden cardiac death. Methods: We studied 30 related individuals (aged 44±26 years, 50% males) from a person with KCNH2-H562R/a1685g mutation. A clinical evaluation with electrocardiographic assessment was carried out in each of them. Results: We found the mutation in 13 individuals (43%), mean age 45±25 years and 46% males. In this group of patients, 76% (n= 10) had prolonged QT interval in the electrocardiogram, deined as QTc value >450ms en males and >470ms in females, being the mean value of the QTc in this population of 504,60ms±38,56ms. However, 3 individuals presented the genetic mutation without prolonged QTc. Among individuals with positive genetic diagnosis, 5 patients (38,5%) presented events: all of them suffered repetitive syncopes, one had a sudden cardiac death (SCD) and the other a resuscitated SCD. All clinical events occurred at rest and some of them in relation to the use of drugs that cause increased QT interval (erythromycin and luoxetine). Conclusions: KCNH2-H562R/a1685g is a new mutation responsible of long QT syndrome type 2. The study of 30 members of our family reveals a high penetrance of this new mutation. Further studies are required to analyze the effects of this mutation on the function and trafic of KCNH2 channels. www.jaib.com 151 October, 2013 | Special Issue Surface ECG & 24-Hour Holter Monitoring in the Evolution of Cardiac Arrhythmias Effect of Cigarette Smoking on TP-E Interval, TP-E/QT Ratio and TP-E/QTC Ratio A. Tokatli, F. Kilicaslan, M. Uzun, B.S. Cebeci Department of Cardiology, Golcuk Military Hospital, Kocaeli, Turkey; GATA Haydarpasa hospital, Istanbul, Turkey Abstract Introduction: Cigarette smoking increases the risk of sudden cardiac death. Smoking may predispose to ventricular ibrillation and sudden cardiac death by altering ventricular repolarization and enhancing sympathetic nervous system activity. We aimed to study the effects of smoking on ventricular repolarization. Methods: We studied 47 healthy subjects. 24 long-term heavy smokers (10 women, mean age: 40±5 years) constituted the study group. 23 non-smokers (10 women, mean age: 42±10 years) constituted the control group. ECG was obtained from all subjects. Tp-e interval, Tp-e/ QT ratio, Tp-e/QTc ratio were measured. These parameters were compared between the groups. Results: There was no signiicant difference at the basic clinical and echocardiographic variables (p> .05). QT interval and QTc interval were similar between smokers and nonsmokers. Tp-e interval (p=.001) and Tpe/QT (p=.003) ratio were higher in heavy smokers compared to non-smokers whereas Tpe/QTc ratio (p=.13) was marginally higher in smokers. Other ECG parameters were similar between smokers and nonsmokers groups. Conclusion: Tp-e interval and Tpe/QT ratio are prolonged in heavy smokers. Group I Non-smokers www.jaib.com Group II Smokers p PR 157.8 ± 21.1 148.8 ± 19.9 0.025 QT 381.6 ± 24.1 341.3 ± 22.5 0.554 QTc 389.8 ± 22.3 379.8 ± 35.2 0.535 TPe 78.9 ± 7.3 85.3 ± 10.7 0.001* TPe/QT 0.21 ± 0.02 0.25 ± 0.03 0.003* TPe/QTc 0.20 ± 0.02 0.23 ± 0.03 0.136 152 October, 2013 | Special Issue The Response of the QT Interval to Standing as a New Diagnostic Tool for Long QT Syndrome C. Muñoz-Esparza1, M. Salar Alcaraz1, E. Zorio Grima2, P. Peñaiel Verdú1, J. José Sánchez Muñoz1, A. García Alberola1, M. Valdés-Chávarri1, J. R. Gimeno Blanes1 Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain 2Hospital Politécnico y Universitario La Fe, Valencia, Spain 1 Abstract Introduction: Is known that the QT interval duration depends on the heart rate (HR) and is related with the autonomic nervous system regulation. Patients with Long QT Syndrome (LQTS) due to mutation of the potassium channels have an abnormal response to abrupt changes in HR and to the sympathetic stimulation that occurs with the brisk standing. Electrocardiograms (ECGs) performed immediately after standing could be a diagnostic tool for this syndrome. Objectives:To describe the presence of QT interval changes provoked by standing in patients with genetic conirmation of LQTS, and compare the results with a group of family members of patients with LQTS not carrying the familial mutation. Methods: We performed an ECG in the supine position and another immediately after getting up in 27 patients with LQTS and 22 unaffected relatives. We measured the corrected QT interval (QTc) (Bazett´s Formula) in supine position and immediately after standing in DII and V5. The increase in the QTc interval (QTc in standing-QTc in supine) was also evaluated. Results: LQTS patients had a mean age of 39 ± 18 years (mean±SD), and 40% were male. Among these, 8 (30%) had LQTS1, 16 (59%) LQTS2, and 3 (11%) LQTS7.In the control group the mean age was 42 ± 19 years, 50% males. QTc values in supine and in standing positions for both groups are shown in Table 1. Patients with LQTS mutations showed statistically signiicant differences between the mean QTc interval in supine and after brisk standing (p = 0.003 DII, P <0.001 V5). In contrast, the control group showed no differences (p = 0.928 DII, p = 0.432 V5). We also noted signiicant differences when compared the mean increase in the QTc interval between both groups (p = 0.001 DII, P = 0.015 V5). In the subgroup analysis, the increase in the mean QTc interval was 53 ± 51ms in DII and 31 ± 35ms in V5 for LQTS1; and 34 ± 34ms in DII and 29 ± 26ms in V5 for LQTS2, evidencing no signiicant differences between both subtypes of LQTS (p = 0,65). Conclusions: Our population of patients with congenital LQTS had an abnormal QTc interval adaptation with the standing, showing a signiicant increase of this measure. Since our controls did not show this behavior, the performance of this test could be a useful tool in the diagnosis of individuals with baseline QTc interval at the upper limit of normal. QTc DII in supine www.jaib.com QTc DII in standing QTc DII increment QTc V5 in supine QTc V5 in standing QTc V5 increment LQTS 477±66 516±50 45±47 472±33 510±45 36±39 Controls 423±33 417±42 0±31 423±34 425±40 6±33 153 October, 2013 | Special Issue P Wave Dispersion and Recurrences After Cardioversion in Atrial Fibrillation Patients with Normal Left Atrium Size Y.J. Song1, D.K. Kim1, D.S. Kim1, T.H. Yang1, J.S. Jang1, J.S. Seo1, H.Y. Jin1, Y.A. Park1, J.I. Yang1, H.Y. Lee1, K.H. Kim2 1 2 Department of Cardiology, Busan paik Hospital, Busan, Republic of Korea Department of Cardiology, Haeundae paik Hospital, Busan, Republic of Korea Abstract Introduction: Increased P-wave dispersion is well known to be the predictor of recurrences after cardioversion in patients with atrial ibrillation. However, there is little data about relation between recurrence of atrial ibrillation and increased P-wave dispersion in normal LA sized patients after electrical cardioversion. Methods: We reviewed the electrocardiograms taken within a day in atrial ibrillation patients with successful cardioversion. All patients received antiarrhythmic drug after cardioversion. We compared P wave dispersion and maximum P-wave duration between recurrent group and non-recurrent group. Results: In 27 patients with persistent atrial ibrillation with normal LA size, 14 patients (51.8%) recurred atrial ibrillation after cardioversion. There were no difference in baseline characteristics including sex, age, hypertension and diabetes between two groups. P wave dispersions were signiicantly higher in the recurrent group than the nonrecurrent group (44.5±20 vs 30±12 ms, P<0.038). Furthermore, recurrent group showed signiicantly prolonged maximum P wave compared with that of nonrecurrent group (134±16 vs. 118±19, p=0.035). Conclusions: Increased P wave dispersion and prolonged maximum P-wave duration were associated with the recurrence of atrial ibrillation in patients with normal LA size after electrical cardioversion. www.jaib.com 154 October, 2013 | Special Issue Non-Invasive Spectral Comparison of Atrial Fibrillation Versus Atrial Tachycardia after Pulmonary Vein Isolation Using EcgDerived Waveform Analysis J. Fleitman, E. Ciaccio, W. Whang, H. Garan, A. Biviano Department of Medicine, Division of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York, USA Abstract Introduction: Patients who undergo pulmonary vein isolation for atrial ibrillation can develop recurrent atrial ibrillation (AF) and/or atrial tachycardia (AT). We hypothesized that analyzing AF and AT surface waves on electrocardiograms using spectral analysis techniques would offer insights into the differences between post-ablation AF versus AT. Methods: We performed a retrospective study of 70 patients who had undergone pulmonary vein isolation and returned for a second ablation due to recurrent AF or AT. Surface electrocardiograms were analyzed using waveform spectral analysis to calculate the following atrial parameters: dominant frequency, dominant amplitude (the amplitude of the dominant frequency), and mean spectral proile (average amplitude of the normalized spectrum) and standard deviation. Results: Surface electrocardiogram analyses revealed that AF patients manifested the following features when compared to AT patients: higher dominant frequencies (5.80 vs. 4.30 Hz, p≤0.0001), lower dominant amplitudes (2.44 vs. 3.68, p<0.0001), higher mean spectral proiles (0.31 vs. 0.19, p<0.0001), and higher standard deviations of mean spectral proiles (0.173 vs. 0.156, p=0.0015). Conclusions: Non-invasive, electrocardiogram-based signal analyses can be used to measure the degree of differences between atrial frequency as well as spectral organization in patients with AF vs. AT. Further analyses are required to assess whether these techniques can help to differentiate among various types of post-ablation ATs. www.jaib.com 155 October, 2013 | Special Issue Electrocardiographic Abnormalities in Patients with Schizophrenia M. Gegenava T. Gegenava Tbilisi State Medical University, Department of Internal Medicin, Tbilisi, Georgia Abstract Introduction: It is known that some antipsychotics are associated with increased risk of sudden death from the potentially fatal ventricular arrhythmia. The aim of present work was to reveal electrocardiographic changes in patients with schizophrenia. Methods: 71 patients with the diagnosis of schizophrenia were investigated, among them 30 females and 50 males. . Results: It was detected such kind of changes by Electrocardiography: Sinus tachycardia 8,45 %; sinus bradycardia 11,26%; QTc was prolonged in 21.4 %, p= 0.047., post infarction scarring Q wave and QS complex was detected in 19,71%. Extrasystolic arhythmia revealed in 45%, Conduction block was detected in 5,63 %. There was high correlation between QTc prolongation and Haloperidol dosage p<0,001. Totally electrocardiographic changes were manifested in 44.3 % of the patients. Conclusions: As the results have shown, ECG changes occurred in quite high rate among the patients with schizophrenia. Use of electrocardiograms (ECGs) to monitor the safety of pharmacotherapy is the best way in psychiatric clinics. Because neuroleptics affect cardiac repolarization, QTc has been found to be an accurate indicator of their effect on the heart. www.jaib.com 156 October, 2013 | Special Issue Rhythm Disorder During Therapeutic Hypothermia in Paediatric Patients S. Dinarevic, R. Spahovic, F. Jonuzi, R. Gojak*, M. Halimic Paediatric clinic CCU Sarajevo, Clinic for Infective Disease CCU Sarajevo*, Bosnia and Herzegovina Abstract Introduction: Hypothermia is therapeutic procedure which is used in seriously ill asphyctic and post CPR children with the aim of stabilisation patient’s general condition. The aim of this study was to evaluate hypothermia effects, especially on cardiac rhythm. Methods: During 1.1.2010-1.1.2013.at Paediatric clinic, group of 14 sick paediatric and neonatal patients were conducted for therapeutic hypothermia. Results: First Neonatal Group /10 pts/ with diagnosis of aspyhxia perinatalis; 40% had sepsis, raised CRP, cardiac enzymes /95%/. All pts pre procedures had: metabolic acidosis, normal ECG, during procedure sinus bradycardia /100%/, post procedure: normal ECG. BP pre procedure 39.2mmHg, post: 52.8mmHg. Second Paediatric Group /4 pts/: 50% were post CPR, 25% had vasculitis, 25% epi suprarefractorius; pre procedure: CRP 62, post CRP 38; cardiac enzymes: 2/4 raised, post: normal, pre procedure: metabolic acidosis, post: normal; ECG in ¾ myocardial insufitienty, post: ECG normal. BP pre: 50mmHg post 64mmHg. Statistically signiicant myocardial response obtained in: ECG, BP p=0.001, pH p=0.007, EB p=0.003. Conclusions: Therapeutic hypothermia as additional curative tool is very useful in treatment of sick paediatric patients with good cardiac cell response www.jaib.com 157 October, 2013 | Special Issue The Association Between QT Interval and the Presence of Myocardial Fibrosis and its Territories: Insight from Cardiac Magnetic Resonance T. Boonyasirinant, R. Krittayaphong Division of cardiology, Department of Medicine, Siriraj hospital, Mahidol University, Bangkok, hailand Abstract Introduction: Corrected QT interval (QTc) has been demonstrated as a marker of sudden cardiac death (SCD). Cardiac magnetic resonance (CMR) has unique property to demonstrate myocardial ibrosis. The relationship of QTc with myocardial ibrosis and its territories has not been explored. Methods: 450 patients referring for delayed enhancement CMR were consecutively enrolled. Patients were categorized according to the presence of ibrosis. Electrocardiogram (ECG) was performed on the same day and QTc was analyzed. Results: Mean age was 67+12 years and 58% were male. Myocardial ibrosis was present in 33.1%. The QTc was signiicantly longer in patients with ibrosis, compared to those without ibrosis (456 ms vs. 447 ms, p 0.02). Furthermore, QTc was signiicantly increased in the scar of RCA territory, but not in LAD or LCX territories. The association between each territory QTc and ibrosis was established. Conclusions: This is the irst to establish the correlation between QTc and myocardial ibrosis, particularly RCA territory. These indings may emphasis myocardial ibrosis using CMR as a potential risk of repolarization abnormally. The association between ibrosis and arrhythmia outcomes warrants further study. www.jaib.com 158 October, 2013 | Special Issue Increased Short-Term Variability in the Peak-To-End of the T Wave in Heart Disease Y. Ishihara, T. Sasano, H. Sekine, M. Oya, S. Hibi, K. Hirao, M. Matsuura Department of Bio-functional Informatics and Heart Rhythm Center,Tokyo Medical and Dental University, Tokyo, Japan Abstract Introduction: Previous studies have shown that the interval between the peak-to-end of the T wave (Tpe) is a predictive factor for ventricular arrhythmias. We hypothesized that the short-term variability of the Tpe interval (TpeV) also indicates ventricular instability. The aim of this study was to establish TpeV measurement, and evaluate the association between the TpeV and heart disease. Methods: Bipolar electrocardiograms were recorded for 30 minutes in 26 patients with heart disease, 19 aged controls, and 22 young controls. We calculated the standard deviation of Tpe (SD-Tpe), with and without normalization with QT or RR intervals. We also analyzed the QT interval variability (QTV) and heart rate variability (SDNN). Results: A 15 minute ECG recording was suficient to obtain a reproducible SD-Tpe. There was no difference in SD-Tpe between the aged and young controls, but it was signiicantly increased in the patients with heart disease. The normalized SD-Tpe had the same results as SDTpe. QTV and SDNN did not correlate with SD-Tpe. Conclusion: TpeV was calculated from a 15-minute ECG recording. TpeV was not affected by age, but increased with heart disease. www.jaib.com 159 October, 2013 | Special Issue Correlating Symptoms and the Frequencies of Arrhythmias, in Different Age Groups, Using a 24-Hour Holter Monitor Recording Z. Jamal, A. Aisha, SH. Ghaniwala, A. Fasih, M. Nasim, H. Khalid, F. Haider, I. Roohi, M. Zahid, A. Zahid national institute of cardiovascular diseases, karachi, Pakistan 2 Ziaddin University, Karachi, Pakistan 3 Baqai University, Karachi, Pakistan 4 Nixor College, Karachi, Pakistan 5 Foundation Public School, Karachi, Pakistan 1 Abstract Introduction and objectives: Palpitations and syncope are complaints that are often worrisome for patients and cardiologists alike. Although mostly benign, these symptoms may be the prodrome of signiicant cardiac events. The purpose of this study was to formulate an association between such symptoms and the frequencies of arrhythmias, in different age groups, as identiied by a 24 hour holter monitor recording. Methods: The data was analyzed through SPSS version 18.0. 844 Patients from various age groups, of either gender, referred for Holter monitoring with symptoms of palpitations and syncope were evaluated for arrhythmias. Descriptive statistics were used to summarize the categorical variables in frequencies and percentages while the continuous variables were reported as mean and standard deviation. Proportion difference was observed between categorical variables using Chi-square independent test. P-value <0.05 was considered as signiicant. Results: The majority of patients belonged to the 57-75 age group (35.2 %). 41.7 % of patients were females. We identiied 59 subjects with VT and an equal percentage with wide QRS tachycardia. 33 patients were identiied to have CHB. 45 % of patients with syncope had an underlying arrhythmia. The most common arrhythmia amongst these patients was PSVT (27.7%). More patients complained of palpitations as a symptom but only 34.8% had an underlying arrhythmia. The most common arrhythmia amongst these patients was paroxysmal supra-ventricular tachycardia (21.8%) and Paroxysmal AF (8.0 %). Patients with palpitations more commonly had a sustained arrhythmia as compared to patients with syncope. Sinus arrhythmia, AF, VT and wide QRS tachycardia were more common in patients with palpitations, whereas heart blocks and sinus bradycardia were more common in patients with syncope. Wide QRS tachycardia, AV blocks, sustained and non sustained supraventricular arrhythmias were more common in the elderly population (75 +) whereas sinus arrhythmia was most common in patients younger than 19. The most common arrhythmia in the elderly population was AF Conclusions: 21.2 % of patients had symptoms during the recording period, out of which only 9.4 % correlated with the underlying arrhythmia. Ambulatory ECG monitoring can provide diagnostic, prognostic and therapeutic information only in some situations. Not all patients with an underlying rhythm abnormality had symptoms during the recording period. www.jaib.com 160 October, 2013 | Special Issue Autonomic Function in Patients with Irritable Bowel Syndrome A. Tokatli, F. Kilicaslan, M. Uzun, B.S. Cebeci Department of cardiology, Golcuk military hospital, Kocaeli, Turkey; GATA Haydarpasa hospital, Istanbul, Turkey Abstract Introduction: Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder. Impaired autonomic regulation is common in patients with IBS. Heart rate variability (HRV) and heart rate recovery (HRR) are used for assessing autonomic function. The aim of this study is to evaluate autonomic nerve system activity in IBS patients using HRV and HRR. Methods: The study group consisted of 25 consecutive patients (13 women, mean age: 39±10 years) who were diagnosed with IBS using the Rome III criteria. 25 healthy subjects (12 women, mean age: 41±10 years) were used as the control group. Time domain and frequency domain parameters of HRV and HRR were compared between the groups. Results: SDNN, RMSSD, LF/HF ratio were similar in study and control groups (78±12 ms vs 81±18 ms, p=.511; 41±17 ms vs 43±16 ms, p=.711; 0.7±0.2 vs 0.6±0.2 , p=.104; respectively). Also the other HRV parameters were not different between groups. IBS patients had signiicantly lower HRR values compared to the control group (15±5 bpm; 20±5 bpm; respectively; p=.009). Conclusion: Although HRV indices were similar HRR was signiicantly lower in patients with IBS compared with healthy controls. Table : HRV and HRR parameters of the groups. Variables IBS (-) (n=25) IBS (+) (n=25) p-Value SDNN (ms) 81±18 78±17 .511 RMSSD (ms) 43±16 41±17 .701 LF (ms2) 160±30 178±49 .114 HF (ms2) 266±62 252±58 .393 LF/HF HRR(bpm) 0.6±0.2 0.7±0.2 .104 20±5 15±5 .009 Values are presented as mean ± SD www.jaib.com 161 October, 2013 | Special Issue Remote Monitoring in the Province of Modena (Experience of Sassuolo Cardiology) F. Melandri, G. Lolli, P. Bellesi , S. Merighi, A. Guerra, M. Scapinelli, S. Martano U.O. Cardiologia, Nuovo Ospedale Civile di Sassuolo, Italy Abstract Background: The PM, ICD, and loop recorders (devices) can record and store a large amount of information regarding the operation of the implanted system, the functional capacity and heart rate. The data can be remotely controlled (“Remote Monitoring”). The control system sends remote technical and clinical data from the pacemaker / deibrillator / loop recorder device to the patient. This information can be transmitted both periodically in special circumstances decided by your doctor. The telephone network used and the type and frequency of transmissions vary depending on the system utilizzato.Tali data, in turn, are sent to a service center where they are processed, decrypted and made available in a readable format on a secure website dedicated to which can access the medical and clinical staff, with an ID and a password through the Internet. In cases of critical events pre-determined for each patient the doctor will be informed by e-mail, SMS or fax. The information sent through the System Remote Monitoring shall ensure that the doctor can better monitor the heart rhythm and the operation of the device without having to wait for the next ambulatory monitoring, which could be expected after weeks or months. The doctor uses the information obtained as a support to medical therapy, to optimize device programming and better clinical management of the patient. The system does not replace the regular outpatient visits, although it is possible to reduce the frequency or run them in a more focused manner. The system is an information system for emergency and the patient should activate the 118 cases of serious symptoms and disorders. Personal experience: Since November 2011 we follow more than 70 patients with implantable cardiac devices with Remote Monitoring quettro of the ive companies that have now also choose between the system. The low of information is to send monthly or quarterly or as needed data. Our organization integrates with HM ambulatory monitoring, so that all the devices are also seen at least once a year nell’ambulatorio. The service sees integration of the members of the team arrhythmology and colleagues who deal with heart failure in an outpatient clinic dedicated. We operate under a corporate procedure validated by the Quality Management and Health of our hospital. The patient signs an informed consent to the privacy and informed consent on the system. In the case of the red or yellow alarm that we receive via email or sms, technical staff contact the patient and calls for extraordinary visit, if necessary, after you have shared with the doctor in charge for that period the evaluation of the alarm. In the case of periodic inspection the technician checks the cases and then the doctor valid transmissions carteca A copy of the control is kept in the department Conclusion: From our initial experience we can draw some considerations: - High rating by patients who see the reduced number of accesses hospital - Reliability and security of the system as regards the follow-up electronic data and for hemodynamic monitoring - Reduced compliance by patients for manual transmissions. www.jaib.com 162 October, 2013 | Special Issue Decentralization of Pacemaker Follow-Up Visit to Local Specialty Care Centers Using Remote Transmission J.J. Ferrer-Hita, A. Rodríguez-González, R.A. Juárez- Prera, P. Jorge-Perez. M. Carrillo-Pérez-Tomé, C. DuqueGómez, M. Cubelo-Dornaleteche, R. Pérez-Quintero, I. Laynez Cerdeña. Arrhythmia Unit, Cardiology Department, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain Abstract Introduction: we analyze our initial experience with the decentralization of pacemaker follow-up visit (PFV) from the hospital to local Specialized Care Centers (SCCs) by remote monitoring transmission. Methods: 58 patients with pacemakers and internal loop recorder Medtronic™ with parameters autochecking and remote transmission capacities. We collected clinical and pacemaker characteristics and performed an initial consultation for programming and inclusion in the monitoring transmission system. Later we performed the irst remote PFV at the local SCCs by nurse with real time hospital assessment by the electrophysiologist. All patients passed two evaluation questionnaires. Results: In relation to the PFV in the local SCCs, 42 patients (82%) considered it better, 8 (16%) equal and 1 (2%) worse. However, most of patients (48 -94%) preferred it. 5 patients (10%) had to be r in the hospital (4 for our incorrect programming and 1 for patient preference). The rest of variables are shown in tables. Conclusions: PFV decentralization to the local SCCs by remote transmission is technically feasible, reliable and quick to make with clear beneits for patients. Mean age (years) www.jaib.com 72 ± 14 Male Gender 55% (32) Patients included/transmitted 58 / 51 Device type Pacemakers: 48 (83%): 40 Dual chambers 8 One chamber 100% ventricular pacing–dependent patients 14 (29%) Internal Loop Recorder: 10 (17%) Hospital Consultation Local SCCs Total Time (hours) 3,3 ± 0,9 1,47 ± 0,6 Mean Distance from residence (km) 33 ± 11 8±5 Predominant travel mode Particular (74%) Particular (69%) Patient preference for control 3 (6%) 48 (94%) Estimated consultation cost (euros) 14 ± 11 6±5 163 October, 2013 | Special Issue Vasovagal Syncope: Diagnostic Issues Evaluation of Baroreceptors Sensitivity in Young Adults with Vasovagal Syncope in Long-Term Follow-Up After the Correction of D-Transposition of Great Arteries by Senning Atrial Switch A.Z. Pietrucha, B.J. Pietrucha1, I. Bzukala, J. Jedrzejczyk-Spacho, D. Mroczek-Czernecka, E. Konduracka, O. Kruszelnicka, J. Nessler Coronary Disease Department, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland 1Children Cardiology Department, Children University Hospital, Jagiellonian University Medical College, Cracow, Poland Abstract Objectives: Evaluation of baroreceptors sensitivity in relation to presence of relex syncope in young adults with benign forms of sinus node dysfunction (SND) in near-asymptomatic young adults after reparation of d-transposition of great arteries d-TGA by Senning atrial switch (SAS) . Study population: we observed 21 pts (14 men) aged 18-21 yrs with d-TGA, with electrocardiographic signs of SND and history of presyncope and 21 sex and age matched healthy volunteers. Methods: All pts underwent head-up tilt test (HUTT) and transoesophageal atrial stimulation for evaluation of corrected sinus node recovery times (CNRT) before and after pharmacological blockade (PHB). CNRT>525 ms was assumed as abnormal. Non-invasive evaluation of baroreceptor sensitivity (BRS) during HUTT was evaluated in dTGA patients and healthy control group using NEXFIN analyser. Results: HUTT was positive in 6 pts (28,6%), negative in 7 pts, and doubtful (presence of bradycardia and/or hipotonia with aggravated prodroms) in 8 pts. Mean CNRT value was 698,2ms; SACT- 124,4ms and shorten signiicantely after PHB (CNRT to 362,8; SACT to 116,5ms). Mild prolongation of CNRT (<850 ms) with normalization after PHB was observed in 12 pts (57,1%). Reduction of BRS was observed in dTGA pts. in comparison to healthy controls. Signiicant depletion of BRS was also observed in pts. with negative HUTT in relation to non-fainter, both in dTGA(systolic BP: 11,4 vs 16,9 ms/mmHg; diastolic BP 18,4 vs 21,1 mmHg;p<0,03) and control groups(systolic BP: 12,6 vs 19,4 ms/mmHg; diastolic BP 13,3 vs 16,6 mmHg;p<0,02). Conclusions: 1. Relex vasovagal syncope frequently occurs after physiological correction of d-TGA. 2. Electrocardiographic signs of sinus node dysfunction rather then abnormal electrophysiological parameters were noticed in nearasymptomatic young adults after reparation of d-transposition of great arteries by Senning atrial switch 3. Signiicant reduction of baroreceptor sensitivity was observed after dTGA correction by atrial switch both in pts. with positive and negative HUTT. www.jaib.com 164 October, 2013 | Special Issue Evaluation of the Behavior of the QRS Interval from the Beginning of the Carotid Pulse Wave During a Tilt Test in 100 Patients with a History of Syncope and a Control Group of 30 Asymptomatic Volunteers A. Villamil, Y. Torres, J. Mariani, C. Perona, C. Tajer GEDIC Buenos Aires; Hospital El Cruce, Buenos Aires, Argentina Abstract Introduction: Syncope (S) is a common manifestation, being the vasovagal (VV) the most common cause. The diagnosis is based on interrogation and reproducibility of S in the tilt test (TT), but it has high incidence of false negatives and time consuming. Since 2008 we have evaluated the utility of measuring the delay of the pulse wave carotid from QRS onset during TT to early predict the outcome in patients (p) with a history of S VV with encouraging results. Objectives: To analyze the novel parameter for TT in P with S of probable VV compared with a control group without S. Methodology: Prospective observational study in 100 consecutive p S of probable VV and 30 volunteers without S, which was performed by recording conventional TT FC, SBP, DBP and the non-invasive wave of carotid pulse with pressure transducer in multichannel polygraph, measuring the interval from the onset of QRS to the carotid pulse wave by digital caliper accuracy + / - 2 mseg to 100 mm / sec, from baseline to the end of the study (s or 45 ‘). Capacity was evaluated under 17 sec delay of the pulse wave to predict the outcome of the TT in the irst 5 minutes of tilt. Statistically the baseline characteristics of the p of the three groups was compared using Fisher’s exact test. To assess predictors of outcome TT univariate models were created and the variables with p less than 0.05 were entered into multivariate model. After verifying the independent association between the delay of the carotid pulse wave and the result of the TT, we constructed COR curves to evaluate the discriminative ability of the parameter and detect threshold value better sensitivity and speciicity. The discriminative ability was assessed with the C statistic conidence interval of 95%. Result:There were not any signiicant differences between the characteristics of the groups with positive or negative TT, or the control group. The only statistically signiicant parameter associated with the result of the TT was the delay of the carotid pulse wave (greater than 17 mseg) within ive minutes of the inclination. Conclusions: The delay in the pulse wave identiied 78% of the S p with history and positive TT and S 2 in the control group developed. www.jaib.com 165 October, 2013 | Special Issue The Utiility of Echocardiography in the Diagnosis of Unexplained Syncopein Older Patients C.M. Seifer, M. Kotrec Section of Cardiology, University of Manitoba/St Boniface Hospital, Winnipeg, Canada Abstract Introduction: Syncope in older persons is common. A standardized approach can achieve a diagnosis in up 70% of patients. Current guidelines advise an echocardiogram (echo) is a helpful screening test if the history, physical examination, and ECG do not provide a diagnosis. However, there is minimal data on the diagnostic yield of echo in elderly patients. The purpose of this study is to assess whether echo adds diagnostic utility in older patients with syncope. Methods: TProspective study of patients attending a syncope clinic over a 12 month period in 2010. Inclusion criteria were age >65 years and ≥ 1 syncope in the previous 12 months. If clinical assessment, including ECG, was not diagnostic patients underwent transthoracic echo. Results: Sixty-one patients were included. The mean age was 78 (± SD 6.28) years and 32 (53%) were female. A diagnosis was achieved in 45 (74%) patients on clinical assessment. Echo was not diagnostic in the 16 patients with unexplained syncope. Conclusion: Echo in addition to clinical assessment did not increase the diagnostic yield in older patients with unexplained syncope. www.jaib.com 166 October, 2013 | Special Issue The Postural Orthostatic Tachycardia Syndrome (POTS) in Patients with Syncope and Presyncope H. Keller, C. Steger, E. Gatterer KA Rudolfstiftung, 2nd Med. Dep., Vienna, Austria Abstract Introduction: POTS is deined by orthostatic intolerance with abnormal increase in heart rate (>30 beats or >120 beats/min within 10 min). We assessed the incidence in patients allocated to head-up tilt table test (HUTT), evaluated therapy and treatment response. Methods: HUTT was performed in 120 patients from 2010 to 2012 (Task Force Monitor, 60-degree upright tilt for 30 minutes). Follow-up was done by phone or during ambulatory treatment. Results: POTS was diagnosed in 19/120 patients (16%), more often in women (11:8). 3 patients suffered from orthostatic hypotension (OH), in 5 patients a (pre)syncope occurred. Therapy included increased dietary luids, stockings, salt, counter maneuvers, active standing and moderate exercise. 3 Patients received beta blocker, 1 patient midodrine, a loop recorder was implanted in 1 patient, a pacemaker in 2 patients. Follow-up (mean 53 weeks) was performed in 18/19 patients. 60/81 of the recommended therapies were adopted by patients (74%), syncopes were reduced from 7,4 to 2,5/patient (- 67%). Conclusion: The prevalence of POTS was 16%. Compliance was good, syncopes were reduced by diagnosis, education and therapy. Non medical therapies are indicated as irst line therapy. Figure : POTS without syncope www.jaib.com Figure : 167 POTS with syncope October, 2013 | Special Issue Difference of the Clinical Pattern of Vasovagal Syncope Between Menstruating and Post-Menopausal Women J. Jędrzejczyk-Spaho, A.Z. Pietrucha, M. Wnuk, O. Kruszelnicka, M. Węgrzynowska, I. Bzukała, D. MroczekCzernecka, J. Nessler Coronary Disease Department, Institute of Cardiology Medical School of Jagiellonian University John Paul II Hospital, Cracow, Poland Abstract Introduction: Female hormones have well known inluence on the cardiovascular system. They participate in the regulation of vascular resistance, sensitivity of adrenergic receptors, plasma volume, skin blood low and others. In the perimenopausal period estrogen and progesterone levels begin to fall. The aim of this study was to evaluate if this changes modify the clinical pattern of vasovagal syncope. Methods: The study has enrolled 500 consecutive women,with the history of syncope of probably vasovagal etiology. On the basis of the medical history age of irst syncope, number of syncope and comorbidity have been analized. All women underwent the tilt test according to the recommendation of the ESC. Then we examined whether there were some differences in the frequency of positive or negative results of HUTT or the type of VVS for the comparison groups. Results: Age at irst syncope was higher in postmenopausal women. There were no signiicant differences in the incidence of syncope and presyncope episodes regarding medical history. In postmenopausal women comorbidities were more often. The difference of the incidence of positive and negative HUTT’s results between comparison groups didn’t have statistical signiicance. The occurrence of the vasodepressive response was signiicantly more frequent in postmenopausal women. Conclusions: This observation may be related to the postulated different mechanism of the vasovagal syncope in patients over ifty, which is used to be called a vasovagal disease and is related to the changes in autonomic nervous system. www.jaib.com 168 October, 2013 | Special Issue Syncope Unit: Diagnostic Yield of Additional Testing J. Estepo, C. Cáceres Monié, I. Tello Santacruz, F. Casas, A. Baranchuk, A. Cassano, O. Manuale Arrhythmias Department, Hospital Británico, Buenos Aires, Argentina Abstract Introduction: We evaluated the importance of multiple tests performed on patients (p) who entered a syncope unit (SU). Methods: From September 2004 to November 2011, 377 p. were admitted to the SU. Male (57.8%). Average age (67.2 ± 18.5 years). Following our diagnostic algorithm previously published, patients were risk stratiied into three groups: low risk (LR), intermediate risk (IR) or high risk (HR). LR patients were discharged home. IR patients had eventually echocardiogram (Echo), upright tilt test (TT), stress-echo (S-Echo) and Holter monitoring. Result: The cause of syncope was established in 93% of the patients (deinitive diagnosis 41%, presumptive diagnosis 52%). Neurally mediated (NM) in 56% and arrhythmic (A) in 25.8%. In the HR group the most frequent cause was A (56.3%). In IR group NM was more prevalent (64.4%). The rate of recurrent syncope was 29.7%. Conclusions: A SU streamlines the diagnostic approach to syncope, enhancing diagnostic yield and potentially reducing unnecessary testing and admissions. www.jaib.com Echo Holter S-Echo TT CT C. angio EP test EEG Positives 69 30 21 76 13 24 3 12 Total 260 213 152 175 122 37 19 45 % 36,1 14 13,8 43,4 10,6 64,8 15,7 26,6 169 October, 2013 | Special Issue Role of Mobile Telemedicine in Patients with Different Types of Arrhythmia and Syncope T. Gegenava, M. Gegenava, Z. Kirtava Tbilisi State Medical University, Department of Internal Medicin, Tbilisi, Georgia Abstract Introduction: The goal of the present study was to assess different types of arrhythmia and syncope with the help of mobile telemonitoring, which is an uncomplicated technology that facilitates the continuous monitoring and recording of arrhythmias. Methods: We investigated 54 outpatients in Georgia (Republic of) with different types of arrhythmia (n= 32 male and n= 22 female,), Investigations were made by 3-lead electrocardiograph-ECG loop recorder in automatic recording/transmitting mode.. Results: Arrhythmias were registered during 7-68 hours of observation. Arrhythmia relapse was detected in 35% of patients who underwent radiofrequency catheter ablation , mostly they were asymptomatic. Asymptomatic episodes of ventricular premature complexes were detected in patients who underwent aorto-coronary bypass graft surgery. From n= 10 patients with epilepsy we discovered n=3 patients with supraventricular tachycardia (SVT) and n=2 patients with sinus tachycardia. Among patients with unexplained syncope, we revealed patients with sinus tachycardia, with SVT and patient with sick-sinus syndrome. Asymptomatic episodes were detected in majority cases p=0.001 (52%) Conclusions: Mobile telecardiology is also a useful tool to detect a relapse or symptomatic and asymptomatic episodes of life-threatening arrhythmia and syncope. www.jaib.com 170 October, 2013 | Special Issue A Case Report: Vasovagal Syncope Supposed Resulting from Sand Bag Compression Applied After Coronary Angiography D. Çinar, N. Olgun 1. Balıkesir Military Hospital,Balıkesir,Turkey 2.Acıbadem University, Faculty of Health Sciences, Nursing, İstanbul, Turkey Abstract Introduction: Vasovagal syncope is considered as the most common factor in etiology of neurocardiogenic syncope. Numerous conditions could be responsible for this feature. The management of syncope is often succesful with the presence of a proved triggering factor. Case report: A sand bag compression was applied for bleeding control on the sheath applied on the femoral artery in case of angiographic stent intervention with the history of acute myocardial infarction. During the process, we encountered a sudden onset of hypotension and bradycardia, and consequent transient unconsciousness and asystole though no previous vital signs exist. After administering atropine of 1 mg intravenous bolus for treating bradycardia and stopping sand bag compression, a fast recovery was observed. We supposed that the sand bag compression at the point of intervention raised pain. We concluded that a painful stimulus caused by sand bag compression might be considered as triggering factor for vasovagal syncope in such a patient not carrying any preexisting arrhytmia and abnormal vital sign. www.jaib.com 171 October, 2013 | Special Issue Vasovagal Syncope: Therapeutic Issues Syncope Unit: Seven Years of Experience in a Community Hospital J. Estepo, C. Cáceres Monié, I. Tello Santacruz, F. Casas, A. Baranchuk, O. Manuale Arrhytmias Department, Hospital Británico, Buenos Aires, Argentina Abstract Introduction: The objective was to evaluate the usefulness of the Syncope Unit (SU). Methods: After complete clinical work-up and EKG, risk stratiication was performed in the SU following this diagnostic algorithm: Low risk (LR) patients were discharged. High risk (HR) patients were admitted. Intermediate risk (IR) patients were restratiied in the SU: patients with cardiac devices were interrogated. Those with normal device function or without cardiac devices, echocardiogram was performed. If abnormal, patient may be admitted or sent to the chest pain unit. If the echocardiogram was normal, an immediate tilt test was performed: if positive patient was discharged, if negative a Holter monitor was connected before discharge Results: From September 2004 until November 2011, 377 patients were admitted to the SU. Initially, 9.2% were stratiied as LR, 65.2% as IR and 25.4% as HR. Conclusions: By using a predetermined diagnostic algorithm in a SU, risk stratiication is feasible in all patients within a period of less than 12 hours, avoiding unnecessary hospitalizations. LR First episode Age < 40 y Normal EKG No structural heart disease No occupational hazard Not related to exercise No physical trauma Clearly Neurocardiogenic www.jaib.com IR Recurrent Syncope Age >40 y Occupational hazard Abnormal EKG Minor trauma Pacemakers with no dysfunction Structural heart disease Family history of sudden death 172 HR Life threatening arrhythmias History of serious arrhythmias Acute bundle branch blocks; AA drugs with new EKG changes QTc > 0,50 sec QTc < 0,35 sec Brugada syndrome Major trauma October, 2013 | Special Issue Evaluation of the Head-Up Tilt Training in the Treatment of Patients with Vasovagal Syncope I. Bzukala, A.Z. Pietrucha, M. Wnuk, W. Piwowarska. J. Nessler Coronary Disease Department, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland Abstract Objectives: Analysis of the usefulness of head-up tilt feedback training in comparison to classical tilt training in the treatment of patients with vasovagal syncope. Study population: we observed 120 pts (77 women) aged 18-55 (median of age - 23,1 yrs) , with vasovagal syncope (VVS) conirmed by head-up tilt test (HUTT). Methods: All pts underwent HUTT performed according Italian protocol. After positive HUTT result patient were randomly enrolled to one of two method of tilt training. Half of the patents were referred to classical tilt training proposed by H. Ector – repeated tilting until achieving two consecutive negative responses. The rest of patients were referred to head-up tilt feedback training. This method is based on combination of the tilt training with conterpressure manoeuvres feedback training during tilting performing twice per day. When the patients achieved the good tolerance of passive orthostatic tolerance, the NTG provocation (like in Italian protocol of HUTT) was managed, and the training was continued to protocol of training completion (20 min of tilting and 15 minutes after sl. NTG administration) without syncope. Both methods of training were introduced in hospital, after achieving the suficient tolerance of orthostatic stress, the treatment was continued by typical ambulatory tilt training by 30 min every day. We assessed the 6-mounth effectiveness of both methods as well as the time to achieve the suficient orthostatic tolerance (hospitalization time). Results: Mean hospitalisation time was a little bit longer in patients treated with typical tilt training in comparison to tilt training with conterpressure manoeuvres feedback training (4,7 vs. 3,1 days. P<0,05). The 6-month effectiveness of treatment was comparable in both methods of treatment: syncope recurrence was observed in 16 % of pts. after tilt training and 14,5 % after conterpressure manoeuvres feedback training. Patients compliance to the treatment (ambulatory tilt training) was comparable (68 vs 65%, NS). Conclusions: 1. Head-up tilt feedback training seems to as effective as classical tilt training in the treatment of vasovagal syncope. 2. Head-up tilt feedback training may lead to shortening of hospitalisation time necessary for initiaton such treatment of vasovagal syncope. www.jaib.com 173 October, 2013 | Special Issue AF: Cardioversion & Anti-Thrombotic Issues Awareness of Atrial Fibrillation and its Risk Factors M. Gwechenberger, A. Hammer, N. Pavo, M. Huelsmann, J. Strametz-Juranek Department of Cardiology, Medical University of Vienna, Vienna Austria Abstract Introduction: Atrial ibrillation (AF) is the most common arrhythmia. Methods: The study included 91 patients , randomly chosen to complete an anonymous questonnaire to assess their knowledge about AF and its risk factors. Results: Only 48,9% of the patients knew the term AF and 44% assumed an association between AF and stroke. In contrast only 20,7% of the patients were aware of the symptoms of AF, but 16,3% complained of irregular heart rhythm. Only 4,35 % of the patients had a diagnosis of AF, but 13% had a relative with AF. Forty one percent of the patients didn´t know anything about risk factors. However most patients could only identify some of the risk factors. Conclusions: Roughly half of the patients know the term AF and see some association between AF and stroke. The knowledge about risk factors of Af is even worse. % Coronary artery disease www.jaib.com 35,9 Hypertension 29,3 Adipositas 22,8 Thyroid disease 1,1 Cardiomyopathy 29,3 Family history of AF 9,8 Alcohol consumption 14,1 Diabetes 8,7 Lack of exercise 21,7 Hyperlipidemia 19,6 smoking 20,3 174 October, 2013 | Special Issue Relationship Between CHA2DS2-VASc Scores and Left Atrial Thrombus in Patients with Nonvalvular Atrial Fibrillation M. Nakajima, T. Harada, Y. Takagi, M. Takano, E. Nakano, Y. Takimura, S. Nishio, K. Yoneyama, T. Furukawa, K. Suzuki, Y. Akashi Division of Cardiology, St. Marianna University, Kawasaki, Japan Abstract Objectives: The aim of study was to evaluate the relationship of CHA2DS2-VASc scores with left atrial (LA) thrombus and to investigate clinical characteristic predictor of LA thrombus in patients with nonvalvular atrial ibrillation(NVAF). Methods: A total of 430 patients with NVAF were retrospectively investigated. Only 15% of the patients had international normalized ratio (INR) >2 at the time of transesophageal echocardiography(TEE). LA appendage low velocity and volume index (LAVI) were calculated from echocardiography images. Results: The prevalence of LA thrombus increased with ascending CHA2DS2-VASc score (score 0 [0%], 1 [1.5%], 2≤ [6.4%]) in 229 patients with paroxysmal AF and it also increased with ascending CHA2DS2-VASc score (scores 0 [11.4%], 1 [4.3%], 2≤[27.7%]) in 201patients with chronic AF. In the multivariate logistic regression analysis, slower LAA low velocity and greater LAVI were signiicantly associated with the presence of LA thrombus. Conclusions: The prevalence of LA thrombus could occur with greater frequency in patients with chronic NVAF. LA appendage low velocity and LAVI rather than CHA2DS2-VASc scores played important roles in LA thrombogenic circumstance in patients with NVAF. www.jaib.com 175 October, 2013 | Special Issue Journal of Atrial Fibrillation Table : Speical Issue Association of LA thrombus with CHA2DS2-VASc scores and LA parameters using univariate / multivariate analyses Logistic (95% CI) Univariate Multivariate Sex 0.84 (-0.49, 0.60) 0.823 Chronic AF 0.11 (-0.08, 0.79) 0.132 Cerebral infarction 0.36 (0.17, 0.54) 0.276 Hypertension 0.02 (0.10, 0.98) * 0.264 Diabetes mellitus 0.06 (-0.02,1.21) 0.141 Congestive heart failure 0 (0.62, 1.95) * 0.186 age >75 0.43 (-0.35, 0.82) 0.962 ischemic heart disease 0.24 (-0.32, 1.29) 0.203 Age 65-74 0.04 (0.02, 0.89) * 0.963 LAVI 0 (0.03, 0.07) * 0.001 * LAA low 0 (-3.41, -0.98) * 0.007 * *p<0.05 www.jaib.com 176 October, 2013 | Special Issue Relationship of a CHA2DS2-VASc Score and Peak Velocity of Left Atrial Appendagewith Left Atrial Thrombus Formation in Patients with Nonvalvular Atrial Fibrillation T. Harada, M. Nakajima, Y.Takagi, M. Takano, E. Nakano, Y. Takimura, K. Yoneyama, S. Nishio, T. Furukawa, K. Suzuki, Y. Akashi Division of Cardiology, St. Marianna University, Kawasaki, Japan Abstract Objectives: The aim of this study was to evaluate the relationship of CHA2DS2-VASc score and peak velocity (PV) of left atrial appendage (LAA) with left atrial (LA) thrombus identiied by transesophageal echocardiography (TEE). Methods: The study population consisted of 431 patients with NVAF who were calculated CHA2DS2-VASc score. The PV of LAA was calculated using TEE images. Results: Among 228 patients of CHA2DS2-VASc score >2, LA thrombus was present at 21 (44%) of 47 patients who showed a PV of LAA< 30m/sec, compared with 59(32%) of 181 patients who showed a PV of LAA >30m/sec (p=0.12). However, among low risk 203 patients assessed by CHA2DS2-VASc score <1, LA thrombus was present at 13 (34%) of 38 patients who showed a PV of LAA< 30m/sec, compared with 20 (12%) of 165 patients who showed a PV of LAA >30m/sec (p=0.0024). Conclusions: LA thrombus formation is not related with PV of LAA in patients with high CHA2DS2-VASc score, however, in patients with NVAF calculated low CHA2DS2-VASc score a PV of LA could play an important role of LA thrombogenic circumstance. www.jaib.com 177 October, 2013 | Special Issue Catheter Ablation of AF: Mapping Techniques Stable Rotors and Focal Sources for Human Atrial Fibrillation Lie Widely in Both Atria S.M. Narayan, V. Swarup; J.C. Daubert, J. Day, K. Ellenbogen, J. Hummel, R.C. Kowal, D.E. Krummen, J. M. Miller, V.Y. Reddy, K. Shivkumar, J.S. Steinberg, K. Wheelan Arizona Heart Rhythm Center, Phoenix, AZ, Duke University Medical Center, Durham, NC, Intermountain Heart Institute, Murray, UT, VCU Health System, Richmond, VA; Ohio State University, Columbus, OH, HeartPlace/Baylor University Medical Center, Dallas, TX; UCSD / VA San Diego Medical Center, San Diego, CA, Krannert Institute of Cardiology, Indianapolis, IN, Mt. Sinai Hospital, New York, NY, UCLA Cardiac Arrhythmia Center, Los Angeles, CA, Valley Health System, Ridgewood, NJ,USA Abstract Introduction: Clinical atrial ibrillation (AF) has been shown to be sustained by stable rotors or focal impulses, where Focal Impulse and Rotor Map (FIRM)-guided ablation improves patient outcomes. We studied source locations in a large multicenter prospective study. Methods: We mapped AF in 210 patients (28% paroxysmal) using 64 pole baskets in both atria, and analyzed AF using RhythmViewTM (Topera Inc). AF sources on FIRM-maps were related to patient-speciic three dimensional electroanatomic map locations (NavX) validated by luoroscopy. FIRM-guided ablation was performed in n=132 consecutive patients Results: We identiied stable sources in 129/130 mapped patients (99.2%), for 2.6±1.2 sources/patient. A total of 341 sources were identiied: 71.0% in left and 29.0% right atria (p<-0.05). Sources were widely distributed (igure), with little predilection (p=NS). Notably, 3040% sources tracked wide-area PV ablation lines, an additional 15-20% on the posterior wall and ~10% at the left atrial roof. Conclusion: Stable rotors and focal AF sources lie widely within both atria. AF source distributions are very similar to the CONFIRM trial, and are consistent with documented success rates of different anatomic AF ablation lines. These results motivate patient-tailored AF ablation at sources. www.jaib.com 178 October, 2013 | Special Issue Prevalence of Pulmonary Vein Activity in Patients with Atrial Fibrillation and Healthy Subjects Utilizing High-Sensitive Vector Magnetocardiography M. Oya, T. Sasano, K. Aoyama, M. Terui, R. Okamoto, Y. Ishihara, S. Hibi, K. Hirao, M. Matsuura Department of Bio-functional Informatics and Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan Abstract Introduction: Ectopic activity in pulmonary veins (PVs) triggers atrial ibrillation (AF). Although the PV excitation is considered as a crucial factor for AF, information on PV activity in healthy subjects is missing due to the lack of a noninvasive evaluation modality. We reported that high-sensitive vector magnetocardiography (VMCG) detected the right and left PV activity noninvasively. Thus we aimed to assess the PV activity in healthy controls and AF patients using VMCG. Methods: Thirty-ive healthy subjects and 41 AF patients were enrolled. VMCG was recorded for 2 minutes during sinus rhythm. Results: Five cases out of 76 were excluded due to a large noise level. VMCG detected the left and/or right PV activity in all AF patients. However, in the healthy subjects VMCG revealed PV activity on the left in 6 cases (19.4%), the right in 8 cases (25.8%), and on both sides in 3 cases (9.7%). The remaining 14 cases (45.2%) exhibited no signals. Conclusions: Half of the healthy subjects had no PV activity. The noninvasive evaluation of the PV activity by VMCG has the potential for risk stratiication of AF. www.jaib.com 179 October, 2013 | Special Issue Catheter Ablation of AF: Ablation Techniques Is Esophageal Temperature Monitoring Probe Reliable for Prevention of Esophageal Injury? H. Mani, Y. Nishikawa, H. Kitajima, D. Sato, Y.H. Chun Arrhythmia Care Center, Takeda Hospital, Kyoto, Japan Abstract Introduction: AThe purpose of this study was to evaluate the reliability of luminal esophageal temperature (LET) monitoring probe (SensiTherm, St. Jude Medical, Inc.) to avoid esophageal injury. Methods: Thirty consecutive patients (21 men, age 66 +- 10 years) with underwent extensive encircling pulmonary vein isolation (EEPVI) were enrolled. A LET monitoring probe was positioned proper site during ablation and energy delivery was stopped when the LET exceeded 420C. Endoscopic study was performed next few days. Results: Esophageal injuries were found in 5 patients (16.7 %). In these cases, LET rise occurred at 3.2 +- 1.9 sites of RF delivery, time periods above 420C were 14.9 +- 5.9 seconds, and maximum LETs were 43.5 +- 0.40C. These parameters were not statistically different from those without esophageal injuries. 3D-maps revealed continuous RF delivery on posterior LA might result in esophageal injuries. Conclusions: Any LET parameters did not predict occurrence of esophageal injuries. Discontinuous RF delivery may be required during posterior LA ablation when LET excess 420C. Monitoring LET during EEPVI is appropriate to preventing critical esophageal injury. www.jaib.com 180 October, 2013 | Special Issue Combined Dominant Frequency and Complex Fractionated Electrogram Ablation After Circumferential Pulmonary Vein Isolation in Atrial Fibrillation K. Kumagai, Y. Nakatani, K. Minami, T. Sasaki, S. Oshima Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan Abstract Introduction: This study aimed to evaluate an approach of circumferential pulmonary vein isolation (PVI) followed by a dominant frequency (DF) and complex fractionated electrogram (CFE) site ablation. Methods: Fifty consecutive AF patients (23 paroxysmal and 27 non-paroxysmal) underwent ablation using NavX. When AF continued after the circumferential PVI, high DF sites of ≥8 Hz and then continuous left atrial (LA) CFE sites deined by fractionated intervals (FI) of ≤50ms including the coronary sinus and right atrium were targeted. Results: AF terminated at high DF sites in 11 (22%) patients and continuous CFE sites in 1 (2%). However, AF could be induced in only 8% of patients after the procedure. The mean LA DF value before ablation was signiicantly lower in those without recurrence. The freedom from AF recurrence was 96%, 89% and 44% in paroxysmal, persistent and long-standing persistent AF patients, respectively, after 1 procedure over a mean follow-up of 12.0±0.2 months Conclusions: A combined high DF and continuous CFE site ablation in all chambers after circumferential PVI may be effective in the paroxysmal and persistent AF patients. www.jaib.com 181 October, 2013 | Special Issue Adenosine Infusion does not Facilitate Acute Pulmonary Vein Reconnection in Observation Period After Initial Isolation E. Lyan, A. Klukvin, G. Gromyko, F. Tursunova, A. Kazakov, A. Morozov, A. Merkureva, S. Yashin Cardiac Electrophysiology department, Pavlov State Medical University, Saint Petersburg, Russia Abstract Introduction: In some cases permanent acute pulmonary vein (PV) reconnection (AR) appears immediately after adenosine infusion. Study evaluated if adenosine-test facilitates AR in observation period. Methods: Study included 134 patients with paroxysmal and persistent atrial ibrillation, who had undergone Lasso-guided PVI. All patients were randomized to 2 groups. In ATP-group (65 patients) adenosine-test (without dormant conduction ablation) was performed followed by 30’ observation period. In control-group (69 patients) 30’ observation period was applied only. Results: In 134 patients 268 pairs of ipsilateral PVs were isolated. AR occurred in 49 (38%) of ipsilateral PV pairs (41 patients – 63%) in ATP-group and in 45 (33%) of ipsilateral PV pairs (43 patients – 62%). Difference between groups didn’t show statistical signiicance (χ2 =0,76; p=0,38). In ATP-group dormant conduction was revealed in 31 (23%) of ipsilateral PV pairs (27 patients – 42%). Only in 16 of 31 (52%) PVs dormant conduction site corresponded to the site of AR. The agreement between methods is fair (Kappa = 0,24; p = 0,004). Conclusions: Adenosine infusion does not facilitate acute pulmonary vein reconnection in observation period after initial isolation. www.jaib.com 182 October, 2013 | Special Issue Simultaneous Assessment of Contact Pressure and Local Electrical Coupling Index Using Robotic Navigation *M. Casella, *A. Dello Russo, *G. Fassini, *F. Bologna, *O. Al-Nono, *D. Colombo, *E. Innocenti, ‡P. Santangeli, ‡L. Di Biase, *E. Russo, *M. Zucchetti, *B. Majocchi, *M. Moltrasio, *F. Tundo, *V. Marino,* C. Carbucicchio *S. Riva, ‡J.J. Gallinghouse, ‡A. Natale, *C. Tondo * Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy ‡ Texas Cardiac Arrhythmia Institute at St David’s Medical Center, Austin, TX, USA Abstract Introduction: Contact with tissue is a critical determinant of lesion eficacy during atrial ibrillation (AF) ablation. The electrical coupling index (ECI) from the EnSite Contact™ system has been validated as an indicator of tissue lesion depth. In our study we aimed at analyzing ECI behavior during ablation maintaining a stable contact through the robotic Sensei X system. Methods: 15 patients undergoing AF ablation were enrolled. Pulmonary vein (PV) isolation was guided by the Sensei X™ system, employing the Contact™ catheter. Results: A total of 58 PVs were targeted and successfully isolated, while keeping contact force of 20-40 grams. In all PVs the ECI was signiicantly reduced during and after ablation (baseline ECI 99±18; ECI during RF 56±15; ECI immediately after RF 72±16; p <0.001). A mean reduction of 32% during RF delivery and 25% after RF stoppage compared to baseline ECI was observed. Conclusions: Successful PV isolation with good contact, as monitored by the Sensei X system, is associated with a signiicant decrease in ECI of 25%. This may be used as a surrogate marker of effective lesion. www.jaib.com 183 October, 2013 | Special Issue Atrial Fibrillation Ablation and Simultaneous Renal Sympathetic Denervation Using the Same Catheter and Navigation System F. Morgado, P. Cunha, J. Baptista, A. Nobre, R. Lopes, J. Abecassis, G. Morgado, R. Bernardo, A. Almeida, V. Gil Department of Cardiology Hospital Lusiadas, Lisbon, Portugal Abstract Introduction: Catheter Ablation (CA) has rapidly evolved as an established treatment of Atrial Fibrillation (AF). Nonetheless upstream treatment of atrial ibrillation is highly recommended, and in this respect hypertension (HTN) control is very important in order to avoid AF relapses. Catheter based renal sympathetic denervation (RSD) using a special designed catheter (not irrigated) has been recently demonstrated eficacy in lowering blood pressure (BP) in drug-refractory hypertensive patients. Purpose: Given the potential advantages of irrigated radiofrequency (RF) applications and 3-D mapping we sought to assess whether the same saline-irrigated RF ablation catheter used for AF ablation could be utilized for eficacious and safe renal artery denervation, when the applications are guided by the virtual image created by the fusion of the renal arteries (RA) angio CT-scan and the electroanatomical 3-D system Navex (in the same procedure). Methods: A 59 year male patient with paroxysmal AF referred for CA, that had also a history of drug-resistant HTN (on 4 anti-hypertensive drugs) was elected for both AF ablation and RSD. A cardiac angio CT-scan together with aorta and RA angio CT were undertaken in the day of the procedure. We used Navex System for guiding circumferential isolation of the pulmonary veins (PV). After AF ablation was accomplished we moved for RAD. Via femoral artery access the geometry of the descending aorta and renal arteries were reconstructed with Ensite Velocity and the resulting geometry was combined with the CT scan segmentation model using Ensite fusion, irst with “add at surface” points in the renal arteries ostia and after a selective angiography of both renal arteries. RF applications of 10 watts, during 30 seconds were delivered through the irrigated catheter separated by >5mm. Results: After successful PV isolation (common PV ostia in the left, silent right superior PV), 4 RF applications in the left and 5 in the right renal arteries were performed both longitudinally and rotationally. There were no acute complications and the renal arteries angiogram performed after RSD showed no damage. The patient was discharged in the following day. Five days after the procedure the patient BP was 120/80 and amlodipine was suspended. Conclusions: we report an initial case where simultaneous AF ablation and RSD were safely performed, using the same ablation catheter and navigation system, and to our knowledge this is the irst time that RSD was reported, combined with AF ablation, guided by the virtual image created by the fusion of the RA angio CT-scan and the electroanatomical 3-D system Navex. www.jaib.com 184 October, 2013 | Special Issue Results of Cryoballoon and Laser Ablation of AF Complications of Catheter Pulmonary Veins Cryoablation: Retrospective Trial of a High-Volume Centre A. Bohó, S. Misíková, P. Spurný, M. Hudák, M. Kerekanič, B. Stančák Department of Cardiology, Arrhythmology Section, Eastern Slovak Institute of Cardiovascular Diseases, Košice, Slovakia Abstract Introduction: Catheter pulmonary vein isolation (PVI) is a complex procedure with signiicant risk of complications, generally ranging from 5 to 6 % in RF ablation procedures. The objective of this single-centre study was to estimate the complication rate and corresponding risk factors of PVI procedures using the cryoballoon technique. Methods: In total, 158 consecutive patients (aged 57±9 years, 71,5% males, 73,3% paroxysmal AF) were enrolled. Out of 632 pulmonary veins, 611 (96,7%) were successfully isolated by 2-4 applications of cryothermal energy. All periprocedural and early postprocedural complications were systematically recorded. Results: We found 8 major complications (5,06%). Phrenic nerve palsy was recorded in 1 patient (0,63%), 2 patients (1,27%) experienced cardiac tamponade, 3 patients (1,9%) had transient embolic events. Furthermore, in 2 patients (1,27%) groin complications were noticed. No case of death was observed as well as permanent injury. The presence of AF periprocedurally was the only detected signiicant risk factor. Conclusions: Regarding presented complication rate, the cryoballoon PVI is non-inferior to conventional RF ablation procedures and has good attributes as irst-line therapy for the treatment of paroxysmal AF. . www.jaib.com 185 October, 2013 | Special Issue The Effect of Post-Procedural Cardiac Enzyme Surgeon the LongTerm Recurrence Rates After Cryo-Balloon Ablation for Atrial Fibrillation B. Candemir, S. Aghdam, M. Kilickap, C.T. Kaya, AT. Altin, A. Ongun, V.K. Vurgun, O. Akyurek, M. Guldal, C. Erol Ankara University School of Medicine, Ankara, Turkey Abstract Objectives: Cardiac enzymes, representing myocardial injury, increase after surgical or catheter ablation for atrial ibrillation (AF). However, signiicance and impact of this injury on recurrence rates after cryoballoon ablation (CBA) have not been studied before. We aimed to examine the effect of atrial injury on long-term recurrence rates in patients who underwent CBA for atrial ibrillation. Methods and results: Blood samples for CKMB and Troponin I were collected before and 24 hour after CBA in 33 consecutive patients with paroxysmal AF. At 6-month follow-up, 10 (30%) patients had recurrence. Both CKMB and troponin levels increased signiicantly 24 hour after CBA. Pre-procedural troponin level was higher in patients with recurrence but barely missed statistical signiicance (0.04 ± 0.17µg/L vs. 0.17 ± 0.36µg/L; p=0.055).Post-procedural and difference values for troponin I or CKMB did not differ in 2 groups. Table-1 summarizes patient characteristics according to AF recurrence. Conclusion: Post-procedural cardiac enzyme surge does not predict long-term recurrences in patients who underwent cryoballoon ablation for AF. No Recurrence (n=23) Recurrence(n=10) p Age 51.9±12.2 64.0±11.7 0.013 Male Gender 12 (52) 5 (50) 1.000 CHADS2VASC Score 1.4±1.0 3.3±1.7 0.007 Heart failure 0 (0) 2 (20) 0.085 Coronary artery disease 4 (17) 6 (60) 0.035 Left atrial diameter (cm) 4.3±0.4 4.3±0.4 1.000 Preprocedural CKMB 1,9 ± 1,2 1,9 ± 1,6 0.724 Postprocedural CKMB 20,2 ± 17,5 26,3 ±30,9 0.938 Difference_CKMB 18.3±17.6 24.4±29.7 0.860 Preprocedural Troponin 0.04 ± 0.17 0.17 ± 0.36 0.055 Postprocedural Troponin 3.40 ± 2.45 7.44 ± 10.43 0.164 Difference_Troponin 3.4±2.5 7.3±10.1 0.137 www.jaib.com 186 October, 2013 | Special Issue Pulmonary Vein Isolation Using Arctic Front™ Cryoballoon Vs. New Generation Arctic Front Advance™ Ballon Guided By Three-Dimensional Reconstruction of Left Atrium Based on Intraprocedural Rotational Angiography: Feasibility and Eficacy J. Kaufmann, J. Liu, M. Sirgiovanni, P. Milewski, C. Kriatselis, E. Fleck, J.H. Gerds-Li German Heart Institute Berlin Department of Internal Medicine – Cardiology, Berlin, Germany Abstract Background: The new generation ArcticFront Advance™ cryoballoon for pulmonary vein isolation (PVI) provides an optimized zone of balloon surface cooling comprising the whole frontal hemisphere. Methods: In this retrospective study, procedural parameters, immediate procedural and safety outcome in patients treated with PVI using ArcticFront™ cryoballoon (CB) and ArcticFront Advance™ cryoballoon (CBA) were analyzed. PVI procedure was guided by three-dimensional rotational angiography (3D-RTA). PV mapping was performed using Achieve™ catheter and the endpoint was deined as complete elimination of signals at PV antrum (28mm balloon size) with veriication of entrance- and exit block in each vein. Results: In the CB-group, 53 patients (aged 63±11 years) with symptomatic AF (83% paroxysmal AF) were enrolled to undergo PVI. 30 patients (aged 59±12 years, 80% paroxysmal AF) were included in the CBA-group. The ablation endpoint was achieved in 94% (CB) and 93% (CBA), respectively. Except RIPV, compared with CB a lower minimum ablation temperature could be achieved using CBA in all PV (all p<0.01). Ablation time at each PV decreased signiicantly in CBA (all p<0.01) and mean procedural time was shorter in CBA (105.5 min.) compared with CB (114.2 min., p<0.05). There was no difference in number of freezes needed for PVI, luoroscopy time and dose area product. Regarding acute safety outcome, one phrenic-nerve palsy was seen in the CB group. No other procedural related complications occurred. Conclusions: The novel technology of ArcticFront Advance™ cryoballoon guided by 3D-RTA suggests a feasible, safe, and time-saving alternative to conventional cryoballoon ablation. www.jaib.com 187 October, 2013 | Special Issue Conformal Impedance-Based Sensors for Cryoballoon Contact Assessment R. Ghafari, T. Mihalik, S. Lee, N. Coulombe, K. Heist, C. Liu, Y.Y. Hsu, L. Klinker, J. Work, J. Ruskin, M. Mansour Harvard Medical School, Massachusetts General Hospital, Boston, USA; MC10 Inc. Cambridge, USA; Medtronic Inc, Minneapolis, USA Abstract Introduction: Cryoballoon pulmonary vein (PV) isolation requires tissue contact and obstruction of passing blood low to achieve permanent, contiguous lesions. Although luoroscopy has enabled real-time visual assessment of circumferential contact for cryoballoons, this approach exposes patients and staff to harmful radiation. Thus, there is a need for safer sensing strategies to locally assess interfacial PV-cryoballoon contact. Methods: An array of 10 impedance-based contact sensors was afixed to the surface of a 23 mm Arctic Front® Cryoballoon in a staggered (Fig. 1A, B). Balloon inlation and cryoablation were performed in the superior vena cava and in the PVs (Fig. 1C). Results: A total of 30 balloon inlations were performed in three swine. There was concordance in the assessment of contact quality between the data from the sensors and contrast injection in all these trials. A rise in impedance by a factor of 30.9±3.7 above baseline was observed during cryotherapy for sensors in optimal contact with tissue. Conclusions: Impedance-based contact sensors on the cryoballoon surface provide an effective means for evaluating mechanical interactions at the balloon-tissue interface during balloon positioning and cryoablation. www.jaib.com 188 October, 2013 | Special Issue Cardiac Arrhythmias: Pediatric and Miscellaneous Issues Evaluation of Long-Term Follow-Up Exercise Capacity in Young Patients After Correction of Tetralogy of Fallot and After Atrial Switch (Senning Operation) of Transposition of Great Arteries B.J. Pietrucha, A.Z. Pietrucha1, A. Sulik, A. Rudziński Children Cardiology Department, Children University Hospital, Jagiellonian University Medical College, Cracow, Poland. 1Coronary Disease Department, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland Abstract Background and methods: We observed 52 patients who were divided into two groups: Group I - 37 patients after correction of tetralogy of Fallot TOF (7 females and 30 males) at the age from 8,7 to 21,7 yrs (mean age 14,6 yrs). Group II consisted of 15 patients after operation of transposition of great arteries ( TGA) by Senning method ( 6 girls and 9 boys) at the age from 7,3 to 17,8 yrs (mean age 13,1 yrs). In all patients 24-hour Holter ECG monitoring was performed with assessment of heart rhythm, presence of arrhythmias. Also treadmill exercise testing (TT) was done in all patients and modiied Bruce protocol was used. We estimated total metabolic equivalent (MET), total exercise time , presence of arrhythmias and changes in ST segment. Results: In 10pts (27,03%)from the group I ventricular arrhythmias were noticed, but only in 3 subjects complex arrhythmia was present. In patients from group II dysfunction of sinus node was observed -5 pts (35,7%). Signiicant changes of ST segment and dysfunction of right ventricle during TT was present in 5 patients after TOF (13,6%) whereas such changes with additional chest pain could be seen in 6 patients (40%) after Senning operation. During TT mean MET parameters achieved by pts after TOF were signiicantly higher than in patients after Senning operation (14,12 v 12,76) as well as TT time duration was signiicantly longer in pts after TOF operation (13:12 v 10:39). In 3 pts (8,1%) after TOF reoperation and/or ICD implantation was considered, while also 3 pts (20%) needed reintervention. Conclusions: 1. Patients after correction of tetralogy of Fallot have much more better long term prognosis in comparison to patients after Senninng operation of transposition of great arteries. 2. Systemic right ventricle dysfunction is frequently observed in patients after Senninng operation of transposition of great arteries. 3. Exercise treadmill test could be very useful in determination of high risk patients after complex congenital heart defects correction. www.jaib.com 189 October, 2013 | Special Issue Challenging Right-Submuscular Pacemaker Implantation in a Young Patient with Postoperative Atrio-Ventricular Block D. Ricciardi, V. Calabrese, L. Ragni, F. Gioia, G. Di Gioia, T. Pallara, D. Grieco, G. Di Sciascio, P. Persichetti Cardiovascular Sciences Department, Plastic Surgery Department, Campus Bio-Medico University of Rome, Italy Abstract Introduction: A case of right sub-pectoral pacemaker implantation in an adolescent subsequent to a right atrial myxoma operation, using the same scar and repairing the mini thoracotomic access. Methods: A 16 yo adolescent had a diagnosis of right atrial mass, was operatively approached using a right mini-thoracotomy. The postoperative follow-up was complicated for a persistent 3rd degree AV block. A dual chamber pacemaker implantation was planned. A thoracic asymmetry was present because of a lack of intercostal muscle suture and pectoral muscle retraction maintaining the intercostal incompetence and guaranteeing an acceptable respiratory function. Was planned a right submuscolar approach using the same thoracotomy scar. The leads were placed using the right cephalic vein within the delto-pectoral groove. Then the previous scar was opened, the pectoralis was dissected and a massive pneumothorax was elicited. The complication was obviated with a Parietex™ net anchored on the costal margins, the thoracic drain positioning the pacemaker was placed under the pectoral muscle after the tunnelization of the leads from delto-pectoral groove. Conclusions: In our case the pacemaker implant was unavoidable because of the AV block. The unusual approach was justiied by functional and aesthetically reasons, taking advantage of the previous scar and correcting with the device itself a structural defect created from the previous intervention. www.jaib.com 190 October, 2013 | Special Issue A Single Center Long-Term Follow-Up Experience of Pediatric Pacemaker Population T. Altin 1, C. Koca 1, A. Ongun 1, O. Akyurek 1, T. Ucar 2, B. Candemir 1, E. Tutar 2, A. Uysalel 3, M. Guldal 1, C. Erol 1 Ankara University, School of Medicine, Department of Cardiology, Ankara, Turkey 2 Ankara University, School of Medicine, Department of Pediatric Cardiology, Ankara, Turkey 3 Ankara University, School of Medicine, Department of Cardiovascular Surgery, Ankara, Turkey 1 Abstract Introduction: We aimed to investigate long-term results of the children with pacemakers. Methods: The records of 20 children who underwent pacemaker implantation between December 1984 and September 2012 were investigated. Results: Baseline and procedural characteristics were summarized in Table 1. Epicardial procedures were performed by cardiac surgeons and transvenous implantations were performed by cardiac electrophysiologists. In the transvenous group, 3 of 6 attempts of lead implantation via cephalic vein cut-down was successful. There were no procedure-related complications. Seven patients in the epicardial group eventually underwent transvenous system implantation at 89±62 months’ (range, 15-171) of follow-up. The number of invasive procedures including the irst implantation, lead repositioning, lead and/or generator replacement or lead extraction were 3.2±1.9 times for the epicardial and 2.7±1.8 times for the transvenous group. The follow-up problems were summarized in Table 2. Seven of these patients were symptomatic (syncope in 1, heart failure symptoms in 2, palpitation in 2, and reddening of pacemaker pocket in 2 patients.) The problems were solved by reprogramming in 5, implanting new transvenous leads in 8, lead extraction and new system implantation in 2 patients. Conclusions: The children with pacemakers have a high incidence of problems in long-term, however, there are plenty of methods for solution. Table 1: Baseline and procedural characteristics of the patients. Age (mean±SD) 66±40 (range, 15-153) Male, n 12 Pacemaker indication, n Initial route for implantation, n Pacemaker mode, n Total follow-up time, months (mean±SD) Table 2: www.jaib.com Sinoatrial block 1 Atrioventricular block 19 Epicardial 9 Transvenous 11 VVI 6 VDD 14 All patients 134±110 (range, 3-330) Epicardial group 130±121 (range 12-330) Transvenous group 140±106 (range, 3-296) Problems during follow-up Lead-related problems, n (Capture, sense, including atrial undersensing) 14 System infection, n 2 Left ventricular dysfunction, n 1 191 October, 2013 | Special Issue Evaluation of the Hypoglycemic Effects on the Sympathetic Activity in Type-2 Diabetes Patients T. Kajiyama, M. Ueda, M. Ishimura, N.Hashiguchi, Y. Kondo, T. Kanaeda, M. Nakano, Y. Hiranuma, Y. Yanagisawa, T. Saito, Y. Kobayashi Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba-city, Japan, Kashiwado Hospital, Chiba-city, Japan Abstract Introduction: Hypoglycemia in diabetic patients has been recognized as a risk factor for cardiac events in previous studies. Though it is considered that high sympathetic activity resulting from lowered glucose levels causes arrhythmias or ischemic attacks, there is little evidence in the real world. Methods: We recorded and analyzed the blood glucose level and electrocardiograms in 32 diabetic subjects (16 males; age, 63±17 years; diabetes duration, 16±14 years) that were taking hypoglycemic agents. A continuous glucose monitoring system and 12-lead Holter monitor were simultaneously used for at least 24 hours. A power spectrum frequency analysis of the electrocardiograms was performed by computer software. The LF/HF power during sleep was divided by the total LF/HF power to evaluate the alterations at night. Results: In 6 patients, hypoglycemia of under 70mg/dl during sleep was recorded. No signiicant increase in any arrhythmias was observed in the hypoglycemic group. The frequency analysis revealed that the sleeping LF/HF alterations in the hypoglycemic patients were higher than those in the other patient groups (1.00±0.06 vs. 0.85±0.25, p=0.04). Conclusions: Hypoglycemia in type-2 diabetic patients may cause higher sympathetic activity during sleep. www.jaib.com 192 October, 2013 | Special Issue Incidence of Cardiac Arrhythmias in Patients in the Coronary Care Unit Today E. Simantirakis, E. Arkolaki, P. Aravogliadis, S. Petousis, P.Vardas Cardiology Clinic, University Hospital of heraklion, Heraklion, Greece Abstract Introduction: To date, there is no current knowledge concerning the incidence of tachy- and bradyarrhythmias in patients admitted in the Coronary Care Unit (CCU). The aim of our study is to evaluate the incidence of cardiac arrhythmias in patients in the CCU. Methods: We have enrolled all patients admitted in the CCU from 1/1/2012 to 31/12/2012. From the study were excluded patients admitted for arrhythmiological cause. Results: From a total of 615 admissions, 59,5% were due to acute coronary syndromes, 29,8% acute pulmonary oedema, 3,9% myocarditis, 0,9% acute aortic syndromes and 5,8% other causes. 19,5% of all patients had a signiicant arrhythmia. The most common arrhythmias were non-sustained VT 32,5%, ventricular ibrillation or fast ventricular tachycardia 27,5%, atrial ibrillation 22,5% slow VT 10%, atrioventricular disturbances 7,5%. From all the patients admitted in the CCU due to STEMI of the inferior wall of the left ventricle 9,6% had complete heart block. None of the patients with myocarditis experiences any signiicant arrhythmia. Conclusions: Arrhythmias are frequently observed in patients admitted in the CCU even though therapeutical approach has signiicantly improved. www.jaib.com 193 October, 2013 | Special Issue Personal and Professional Proile of Electrophysiologists Women in Brazil E. Olivier Vilela Bragança, C.M. Boya Barcellos, E. Maria Marques Oliveira, L.F.R. Xavier, T. A. do Nascimento, K. do N. Couceiro Electrophysiology, CardioRitmo, São José dos Campos, Brazil Abstract Background: In the last decades of the twentieth century, one of the most striking facts in Brazilian society is the growth in the number of women who have entered the labor market. The feminization of the medical profession is a fact. Objective: To determine the personal and professional proile of Brazilian electrophysiologist women. Methods: Voluntary registration of Brazilian electrophysiologist women and answers to a questionnaire with 68 objective and open questions approaching the professional and personal proile on the Stimulier Council website, the irst and only Brazilian Council of Electrophysiologist Women. Results: In the Department of Artiicial Cardiac Stimulation (DECA) there are 646 members with a Specialist, Clinical or Enabled Title. In the Brazilian Society of Cardiac Arrhythmias (Sobrac) there are 258 members with Clinical Arrhythmia or Electrophysiology Title adding up to 904 members with Titles. Women represent 50 (7.7%) members of DECA with titles and 43 (16.7%) members of Sobrac with titles making up a total of 93 (10.3%) female members with titles. Forty electrophysiologists have registered and completed the questionnaire on the Stimulier Council website. Some of the results from the occupational aspect of the 68 questions are shown in Table 1. 87% of electrophysiologists are married, 35% to doctors and 10% to electrophysiologists; 32% with have children. Conclusions: The electrophysiologist women represent 10% of the contingent of Sobrac and DECA doctors nowadays and play multiple professional and personal roles. www.jaib.com Professional % Personal % Specialization: Clinical Arrhythmia Pacemaker Electrophysiology Pace and EP 62 52 37 15 Status Married Single with a boyfriend Single without a boyfriend Divorced Widow 87 10 3 0 0 Clinical practice Private ofice care Hospital Complementary tests Hospital Procedures Public ambulatory care 89 75 75 61 59 Married with doctor Marriedwithelectrophysiologist With children 35 10 32 High complexity procedures AF ablation ICD implant TRC implant 22 41 38 Physical activities Yes Speak another language Have pet 68 89 33 194 October, 2013 | Special Issue Antiarrhythmogenic Effect of Omacor After a Non-Q Wave Myocardial Infarction A. Ardashev, E. Zhelyakov, O. Kuzovlev Federal Scientiic and Clinical Centre of FMBA Department of Electrophysiology, Moscow, Russia Abstract Case report: An 84-year-old man reported several episodes of palpitations over the previous 6 months. He had previously suffered a nonQ-wave myocardial infarction (MI) in 2005. He was referred to our clinic 2 years later when he was diagnosed with sick sinus dysfunction while receiving treatment with a beta blocker (bisoprolol), aspirin, and an angiotensin-converting enzyme (ACE) inhibitor (perindopril). To treat his condition we implanted the patient with an ALTRUA dual-chamber pacemaker (DDDR) (Boston Scientiic, MN, USA). Analysis of the data in his pacemaker memory in December 2011 did not indicate any malfunctioning and veriied approximately 8,000 premature ventricular beats (PVBs) daily and nonsustained ventricular tachycardia (NSVT). The patient agreed to add omega-3 fatty acid ethyl ester supplementation (1 g/day) to his regimen. Pacemaker analyses 3 months later indicated no NSVT and only 215 PVBs daily. The patient has remained well and has had no further ventricular arrhythmias. Omega-3 fatty acid ethyl ester supplementation may be beneicial in post-MI patients with pacemakers who develop ventricular arrhythmias. Conclusions: There was a clear positive association between cessation of palpitations and commencement of treatment with Omacor by this patient, although any link must be considered speculative. The observed dramatic beneit sustained over 6 months of follow-up, in the absence of beta blocker or ACE inhibitor therapies, suggests a genuine effect of Omacor. Thus, non-invasive omega-3 fatty acid ethyl ester supplementation with Omacor may be of beneit in post-MI patients with ICDs who develop ventricular arrhythmias. www.jaib.com 195 October, 2013 | Special Issue Reel Syndrome in a Patient with Alcoholic Liver Disease E. Fanchiotti, G. Provenza, S. Semonella, P. Innelli, G. Romaso, F. dell’Aquila, R. Lo Piccolo, F. Marra, A. MazzeoCicchetti Cardiology Department, Villa d’Agri Hospital, Marsicovetere (PZ), Italy Abstract Introduction: The Reel syndrome is an uncommon recently described cause of pace-maker dysfunction characterized by rotation of generator on its transverse axis with rolling of the electrode around it. Case Report: An 80 years old woman who suffered with alcoholic liver disease was referred to our hospital for congestive heart failure and bradycardia. She underwent two weeks before a single chamber pacemaker (VVI-mode) implantation for symptomatic atrial ibrillation with a slow ventricular rate. Surface ECG showed an inconstant capture defects and a promptly device evaluation conirmed an high-threshold stimulation on ventricular leads. Chest radiograph showed an unexpected and surprising picture: the ventricular lead was dislodged and the pulse generator was rotated 180 degrees along its longitudinal axis (Fig.1). The following day a re-implantation of catheters was performed. Conclusions: The Reel syndrome should be considered in patients with device dysfunction. It frequently reported in patients with mental disorders, in obese patients with very lax subcutaneous tissues, in children and in very old people or in presence of large pacemaker pocket. In these cases the ixation of the pulse generator can be considered. Figure 1: www.jaib.com Chest X-ray showed a pacemaker lead coiling around pulse generator. 196 October, 2013 | Special Issue Takotsubo Cardiomyopathy After Permanent Pacemaker Replacement R. Marchenko, S. Durmanov, V. Bazilev Heart Rhythm Disturbances Department Federal Center of Cardiovascular Surgery Penza, Russia Abstract Introduction: Stress induced apical ballooning syndrome (Takotsubo cardiomyopathy) is a disorder with transient left ventricle dysfunction, ECG changes, release of cardiospeciic markers which can mimic myocardial infarction in presence of unaffected coronary arteries. Case report: A 61-year-old woman after dual chamber pacemaker replacement complained of acute chest pain, shortness of breath suggesting acute myocardial ischemia. Performed diagnostic procedures (echocardiography, coronary angiography, left ventriculography) revealed severe impairment of left ventricle contractility with its apical balloon-like dilation. Coronary arteries were not affected. Cardiospeciic markers were increased signiicantly. After treatment with beta-blockers, ACEIs, anticoagulants and diuretics the clinical and echocardiographic picture normalized at discharge. Cardiac markers normalized after one month of observation. This case represents a rare event when apical ballooning syndrome is associated with pacemaker replacement. www.jaib.com 197 October, 2013 | Special Issue Takotsubo Syndrome After Vertebral Arthrodesys for Cyphoscolios of the Adult M. Avella Department of Internal Medicine, Istituto Ortopedico Rizzoli, Bologna, Italy Abstract Case report: How much pain affects heart? I report a case of a woman 54 yrs old who underwent vertebral artrodesis for a primary cyfoscoliosis of the adult. Echocardiogram done before surgery was normal, no hypertension no metabolic alterations and others factors of cardiac risk. ECG was normal. After the operation pain was 8-9 in the NRS scale. Was done PCA with Morin associated with paracetamol (1 gr e.v every 6 h ) plus ossicodon 5 mg twice a day with very poor results. 2 days after the ECG demonstrate STsegment elevation in V1 –V2 – V3, the value of troponin Tn I was 1900. A coronarograpy was performed and didn’t show alterations of the coronaries. Ipocynesia of the apex with reduction of ejection fraction at 45 %.The patient was treated with beta- blockers ( metoprolol 100mg twice a day) cardioaspirin (100mg /die)Three days after there was a complete resolution of the pain with normalization of the index of cardiac necrosis. The ECG showed typical aspect of inferoseptal myocardial infarction. Echo cardiogram performed 10 days after showed a partial enhancement of myocardial contractility. We considererd this case typical for Tako tsubo syndrome. www.jaib.com 198 October, 2013 | Special Issue Ivabradine in Chronic Diastolic Heart Failure E. Simantirakis, E. Arkolaki, A. Patrianakos, E. Nakou, F. Parthenakis, P.Vardas Cardiology Clinic, University Hospital of Heraklion, Heraklion,Crete, Greece Abstract Introduction: Ivabradine has proved effective in patients with systolic heart failure.The aim of the present study is to evaluate prospectively the effect of ivabradine on diastolic function in addition to optimum guideline-based treatment, and its impact on exercise capacity and echocardiographic indexes of diastolic heart failure. Methods: We enrolled 30 patients with diastolic heart failure, NYHA class II/III and optimal medical treatment.Before the initiation of ivabradine and three months later the patients underwent clinical evaluation, cardiopulmonary test (exercise duration ED, peak oxygen uptake V02max) and echocardiographic evaluation (assessment of E-wave deceleration time EDT, isovolumic relaxation time IVRT, tissue Doppler assessment at the mitral annulus E/Em). Results: After 3 months of follow up heart rate has decreased from 85±5 to 68±3bpm. Exercise capacity ameliorated (ED from 6,1±1,9 vs 7.3±1,4, P<0.05, PeakVO2 ml/Kg/min from 15,6±2,1 to 17,9±2,8 P<0.05). Echocardiographic indexes have also improved EDT from 257±12 ms to 240±12ms p<0.02, IVRT from 83±9ms to 75±13ms, p<0.05, E/Em from 12,2±2,2 to 10,5±1,6 p<0,05). Conclusions: Addition of ivabradine to optimum medical treatment seems to improve functional status, exercise capacity and diastolic function. www.jaib.com 199 October, 2013 | Special Issue Arrhythmic Nightmare After Nimesulide Oral Load a Case Report, Ten Years After M. Costantini, C. Fachechi, G. De Jaco, A. Albanese S.C. Cardiologia, Santa Caterina Novella Hospital. ASL Lecce, Italy Abstract Case report: We describe here a singular case in wich a moderate oral charge of Nimesulide was followed by a true electrical storm, without any other plausible cause. 3.5.2003: an othewise healty 45 ys old man, without family history for cardiac sudden death, track-driver, take at work tree pills of Numesulide 100 mg, within 40 minutes, for back and shoulder pain. Nearly twenty minutes after the last assunction he felt suddenly faint , with diaphoresis, palpitation, dizzines, syncope. In ER, the ECG shown signiicant ventricular arrhythmias, consisting in more o less prolonged rapid (170-220 bpm) access of monomoric ventricular tachicardia, with QRS morphology consistent with right origin . Tipically, the arrhythmic access were strongly symptomathic, but self-extinguish (in this like torsade de pointes) , followed by precocious relapse. The patient never in the past felt similar symptom. The arrhythmic storm was resistent to any phamacological treatment we have tried: magnesium sulfate infusion, amiodarone infusion, lidocaine infusion, propafenone infusion, and ended up only nearly two hours after admission, without any relapse (when presumibly the blood level of nimesulide fall substantially). All biochemical data (including myocardial necrosis’s serum markers) were normal. The basal ECG (including QT interval ) was normal . Coronary angiography shown normal coronaries arteries. The patients refused electrophysiological endocavitary investigation and cardiac magnetic resonance exam (claustrophobia) . At follow up (almost ten years!) the patient (without any antiarrhythmic therapy) was asimptomathic, his dinamic ECG shows only sporadic isolated ventricular premature beats, his echocardiogram was normal, his stresstest was normal. He never felt again similar symptoms. He never taken again Nimesulide. Although is know that a lot of drug may trigger ventricular (even letal) arrhythmias, we don’t have any awareness that Nimesulide, one of the FANS more used in western countries, may have a similar potenctial adverse effect. The likely link between the drug assunction and the arrhythmic storm was strongly suggest by the temporal relationship between the two events and by the absence on any other plausibile cause . The absence of compliance toward cardiac RMN and electrophysiological investigation suggest us great caution, and we waited a lot of years before describe this case, in order to avoid any arrhythmic recurrent idiophatic syndrome. Nimesulide have in its molecular structure a methanesulphonanilide group (CH3.SO2.NH-), like dofelitide . Dofelitide, exerts Class III antiarrhythmic effects by inhibiting the cardiac rapid delayed rectiier potasium current (I (Kr)) encoded by HERG . This potassium-current inibition may in turn have a potenctial pro-arrhythmic effect, due to early after depolarization occurrence So, it ‘s not impossible that also nimesulide has a similar effect on the potassium current, with the same potectial pro-arrhythmic effects. Conclusions: In conclusion, this observation shows that numesukide have a potenctial pro-arrhythmic effects and suggests great caution in its use, overall in subjects with structural and/or electrical cardiac disease. www.jaib.com 200 October, 2013 | Special Issue Catheter Ablation of AF: Long-Term Results (Outcome) Radiofrequency Catheter Ablation to Paroxysmal Atrial Fibrillation Patients with Persistent Left Superior Vena Cava K. Minami, Y. Nakatani, M. Nakano, K. Ikeda, T. Sasaki, K. Nakamura, K. Kumagai, S. Naito. S. Oshima Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Japan Abstract Introduction: Persistent left superior vena cava (PLSVC) is the embryological precursor of the ligament of Marshall, which has been implicated in the initiation and maintenance of atrial ibrillation (AF). However little clinical data about the relevance of PLSVC in paroxysmal AF are available. Methods and results: Between January 2005 and December 2012, seven patients (4 men; age 55 ± 9.9 years) with symptomatic drug-refractory AF and PLSVC received a catheter ablation in our institution. All patients had paroxysmal AF and received circumferential pulmonary vein isolation (PVI). PLSVC was mapped with a circumferential mapping catheter following PVI, and ectopics originating from PLSVC was documented in two patients. They received isolation of PLSVC because PLSVC had electrical connections to coronary sinus and left atrium. In four patients, there was no electrical potential in PLSVC. During follow-up of 16 ± 9.8 months, six of the seven patients were in sinus rhythm and free from AF. Conclusion: PLSVC can be the arrythmogenic source of AF. PVI may not be suficient to suppress AF in patients with PLSVC, thus PLSVC isolation should be considered. www.jaib.com 201 October, 2013 | Special Issue Incidence and Severity of Pulmonary Vein Stenosis After Isolated Cryoablation and After Mixed Isolation with Cryoballoon and Radiofrequency C. Muñoz-Esparza, J. Martínez Sánchez, P. Peñaiel-Verdú, M. Salar Alcaraz, JJ. Sánchez Muñoz, J. Castillo Castillo, JM. López Ayala, M. Valdés Chávarri, A. García Alberola University Hospital Virgen de la Arrixaca, Department of Cardiology, Murcia, Spain Abstract Introduction / Purpose: It has been suggested that pulmonary vein (PV) stenosis is a rare complication of cryoballon ablation (CB). However, PVs stenosis frequency could be higher in mixed procedures in which radiofrequency (RF) is used to complete the isolation following pulmonary vein cryoablation. Methods: We analyzed the incidence of PV stenosis in 48 patients with drug-refractory paroxysmal atrial ibrillation (AF), who underwent in our center to ablation of VPs with mixed approach: initial CB, and additional RF with irrigated catheter (25 to 35 W) to complete the gaps if it were necessary. All patients had undergone cardiac computed tomography (CT) before ablation for detailing the anatomy and ostium diameter of PVs. Between 3 and 6 months post-procedure, we performed a cardiac magnetic resonance (CT in four patients) to evaluate the possible reduction in the VPs diameter regarding the prior study conducted before the ablation procedure. Results: Of the 158 target PVs, 40 (25%) required additional radiofrequency to complete the isolation. PVs stenosis was only observed in two PVs (1.3%), one mild and one moderate, and both veins were left inferior pulmonary veins. In the PVs with stenosis the cryoablation had been undertaken as single procedure, using a balloon of 23mm in diameter for the vein that developed mild stenosis and one of 28mm in which presented moderate stenosis. None of the stenosis provoked symptoms. There was no PVs stenosis in the group with additional RF application after the cryoablation. Conclusions: PVs stenosis is a rare complication of atrial ibrillation ablation with cryoballoon. In our experience, additional RF application after cryoablation to achieve complete isolation of PVs was not associated with an increased incidence of stenosis. www.jaib.com 202 October, 2013 | Special Issue Atrial Fibrillation Ablation: Predictors of Recurrence, Does Paroxysmal AF Rule the Outcome? F. Moscoso Costa, D. Cavaco, H. Dores, P. Santos, P. Carmo, G. Cardoso, S. Carvalho, F. Morgado, P. Adragão Hospital West Lisbon, Hospital Santa Cruz, Department of Cardiology, Lisbon, Portugal Abstract Introduction: Although having good initial results, during follow up recurrence rates after atrial ibrillation (AF) ablation are>30%. Ablation is recommended for patients with paroxysmalAF and nondilated left atrium (LA) but it is not uncommon to ind patients with paroxysmalAF having dilated LA and with nonparoxysmalAF having nondilated LA. Our goal was to determine independent predictors of recurrence and to evaluate whether LA enlargement or persistentAF determines worse outcome. Methods and Results: We evaluated 407 consecutive patients admitted for AF ablation from June-2005 to June-2010 pts, 23.6% female, 56±11 years. AF was paroxysmal in 69.3% (n=282), mean indexed LA volume 56±20ml/m2. FUp was made by in clinic evaluation (with ECG or 24hours Holter by protocol and driven by symptoms) and by phone interview whenever necessary. During a follow up of 21±11 months AF recurrence was 34% (139pts). Independent predictors of recurrence were female sex (OR-1.97;95%CI-1.21-3.23;p=0.007) and left atrial indexed volume over 61ml/m2 (OR-2.25;95%CI1.43-3.54;p<0.001). Type of AF at presentation was not predictor of recurrence. In patients with non dilated LA, 60 (22.4%) had non paroxysmal AF. In this subgroup, AF type at presentation had no statistic impact on recurrence (26.4%vs30.0%;p=0.62,paroxysmal vs non paroxysmal). If a patient presented with non paroxysmal AF, having a LA<61ml/m2 was associated with a signiicant better outcome 30% vs 56,1% (adjusted OR0.32,95CI-0.15-0.67). Conclusions: In our series a recurrence rate of 34% was observed during a follow up of 21±11 months. Female sex, LA indexed volume and not type of AF at presentation were independent predictor of recurrence. A LA<61ml/m2 was associated with better outcome irrespectively of AF type and thus patients presenting with non paroxysmal AF might still beneit from ablation if a non dilated LA is present. Adequate patient selection is still a main determinant to ablation success and early stages of disease characterized by lower LA volumes seem to be related with lower recurrence rates. www.jaib.com 203 October, 2013 | Special Issue Referral Bias Among Electrophysiologists Performin Atrial Fibrillation Radio-Frequency Ablation (Af-Rfa) Vs Electrphysiologists not Performing AF-RFA: A Randomized Evaluation N. Al-Shoaibi, H. Quiroga, A. Ha, C.A. Morillo, J. Healey, S. Ribas, S. Menon, S.J. Connolly Hamilton General Hospital, McMaster University, Hamilton, Canada Abstract Introduction: Patients with atrial ibrillation (AF) are commonly referred to electrophysiologists (EP) for management, which may include radio-frequency catheter ablation (RFA), drug therapy or both. We sought to determine whether EPs who perform AF-RFA are more likely to refer patients for this procedure compared to EPs who do not do this procedure. Methods: The study was performed in the outpatient arrhythmia clinic of a Canadian tertiary care University hospital which performs 20 AF-RFA procedures per month. Patients referred for management of AF were initially seen by one of 5 EPs (3 performing AF-RFA and 2 who did not). All 5 EP practice in a single group. Assignment of physicians to consecutive patients was performed by randomization of physicians. The primary outcome measure was whether or not the patient was referred for AF-RFA at the time of the initial consultation. Results: There were 128 patients seen for consultation during 10 months; 72(56%) by EP who performed AF-RFA. Patients who were seen by an AF-RFA performing EP were similar to those seen by a non-RFA EP regarding baseline characteristics including age, history of diabetes or hypertension. They had similar CHADS2, and HAS-BLED scores, similar rates of prior anti-arrhythmic drug failures and previous cardioversion. Of the patients seen by an AF-RFA performing EP, 30 (42%) were referred for ablation compared to 5 (9%) who were seen by EP who did not perform AF-RFA (p<0.0001).Patients referred for ablation by AF-RFA EPs were older (59 vs 50 years, P= 0.8), had larger LA diameter (40 vs. 37mm P = 0.6) and were less likely to have failed more than 1 anti-arrhythmic drug prior to consultation (80 vs. 100% P= 0.01) than patients referred by non-AF-RFA, EPs. Conclusions: In a randomized evaluation, EPs performing AF-RFA were 4 times more likely to refer a patient for RFA than EPs not performing the procedure. This difference occurred even though the participating physicians shared a group practice at an academic university hospital. These data indicate that physician bias has a major impact on clinical decision-making and that there is a need for tools to make clinical decisions more consistent. www.jaib.com 204 October, 2013 | Special Issue Tako-Tsubo Cardiomyopathy Following Catheter Ablation of Atrial Fibrillation F. Kilicaslan, O. Karaca, E. Guler, F. Kizilirmak, M. Biteker, A. Tokatli, O. Omaygenc, A. Olcay, E. Olgun Department of cardiology, Medipol hospital, Istanbul, Turkey; Golcuk military hospital, Kocaeli, Turkey Abstract Introduction: CCatheter ablation (CA) has emerged as an effective treatment modality for atrial ibrillation (AF). However, CA for AF is a very complex procedure and is associated with several major complications including neurologic events (stroke and transient ischemic attacks), pulmonary vein (PV) stenosis, atrioesophageal istula and pericardial effusion/tamponade. Stress cardiomyopathy (Tako-tsubo) is a unique form of reversible left ventricular (LV) dysfunction which is known to be related to conditions associated with marked sympathetic nervous activation. It is characterized by reversible LV dysfunction in the absence of coronary artery disease. Although the other complications are well recognized, to the best of our knowledge, only 2 cases of Tako-tsubo following AF CA have been reported so far. We are reporting a female patient who had Tako-tsubo cardiomyopathy following CA of AF. Case Report: A 58 years old woman with history of symptomatic paroxysmal AF was admitted for CA. She had been experiencing AF episodes during 2 years despite propaferone treatment. Her medical history was positive with hypertension and panic disorder. Physical examination and biochemical tests were unremarkable as well as her coronary angiography that was done 3 months ago. Transthoracic echocardiography revealed normal LV function with an LV ejection fraction (EF) of 68% and slightly enlarged left atrium (diameter: 42 mm). Initial electrocardiogram, X-ray and computer tomography of the heart and lungs were normal. CA procedure was performed with the patient under sedation, using intravenous midazolam. Following transseptal catheterization, electroanatomical mapping of the left atrium and the PVs was performed using the CARTO system (BiosenseWebster, Inc., Diamond Bar, CA, USA). PVs were isolated by ablating circumferentially at the antral portion of the PVs with an externally irrigated cooled-tip catheter at 35 W. 10000 units heparin was administered intravenously after transseptal puncture and additional doses were given to keep ACT level over 350 msec. At the end of the procedure, there was no complication. Next day, her examination and ECG were normal and she was discharged from hospital. The same evening, she was readmitted to hospital with dispnea and fatigue. On examination, her blood pressure was 70/40 mmHg and heart rate was 130 beats/min. Oxygen saturation was 70%. Inspratory rales over both lungs were remarkable by auscultation. ECG showed sinus tachycardia and negative T waves in precordial leads. Transthorasic echocardiography excluded pericardial effusion but showed apical diskinesis with LV EF of 35%. The right ventricle was normal in size and function. X-ray showed severe edema of both lungs. CT scan of the lungs showed no pulmonary emboli and PV stenosis. Acute severe heart failure was diagnosed. The patient was entubated and taken to coronary care unit where she had several episodes of ventricular tachycardia. With appropriate treatment and care, she recovered very quickly. She was extubated 2 days later and discharged 7 days later. Her EF was 50% on the third day of admission and 60% at the discharge. During a follow up of 3 months, she had no symptoms of heart failure and AF. Her EF was 60% at the follow up. Discussion and Conclusions: In conclusion, we report a case of acute heart failure following radiofrequency CA of AF which was most probably due to Tako-tsubo cardiomyopathy. Radiofrequency CA in the PV antrum may damage autonomic ganglionated plexi, leading to vagal withdrawal, thus resulting in enhanced sympathetic tone. Furthermore, considering her panic disorder, it is possible that the increased stress level of the patient had triggered the cardiomyopathy. www.jaib.com 205 October, 2013 | Special Issue Catheter Ablation of AF: Predictors of Success The Impact of Polynsaturated Fatty Acid on the Recurrence After Ablative Therapy in Patients with Persistent Atrial Fibrillation 1 W.J. Park, 1Y.J. Choi, 1S.H. Lee, 1D.G. Shin, 2H.S. Park, 2Y.N. Kim, 3M.H. Bae, 3Y.C. Cho, 4Y.S. Lee , 5 B.C. Jung cardiology department, Yeungnam university hospital, Daegu, Korea, 2cardiology department, Keimyung university hospital, Daegu, Korea, 3cardiology department, Kyungpook national university hospital, Daegu, Korea, 4cardiology department, Daegu catholic university hospital, Daegu, Korea 5 cardiology department, Fatima medical centre, Daegu, Korea 1 Abstract Background: The aim of this study is to access if patients treated with PUFAs had lower procedural failure rates compared to an untreated population Materials and Methods: From Jan 2009 to June 2011, ifty patients with catheter ablation for PeAF were enrolled. 19 patients with PUFA after ablative therapy and 31 patients without PUFA were enrolled in group 1 and 2. Group 1 continued PUFAs during entire follow-up period. Results: 2 patients in group 1 and 13 patients in group 2 had recurrence of AF. The recurrence rate in group 1 was signiicantly lower than group 2 (10.5% vs. 41.9%, p=0.026). Other prognostic factors for recurrence were sex, hypertension, prevalence period, and use of beta-blocker before and after ablation in univariates analysis. However, multivariates analysis by cox-regression revealed that the use of PUFAs after ablation of PeAF was not signiicant predictors of recurrence [Hazard ratio (HR), 0.89; 95% Conidence interval (CI), 0.34 to 5.27; p>0.05]. Conclusion: The role of PUFA in upstream therapy after radiofrequency ablation was not clear in this study. Therefore, larger randomized studies will be needed. www.jaib.com 206 October, 2013 | Special Issue Echocardiographic and ECG Predictors of Late Arrhythmia Recurrence After Radiofrequency Catheter Ablation of Atrial Fibrillation A. Ardashev 1, E.A. Dolgushina 2, E.G. Zhelyakov 1, A.V. Konev 1, V.N. Ardashev 3 Federal Scientiic and Clinical Centre of FMBA, Moscow 2 Clinical Hospital of the Academy of Science 3 Central Clinical Hospital, Moscow, Russia 1 Abstract Objectives: To verify predictors of late arrhythmia recurrence in pts underwent de novo circumferential and linear ablation of atrial ibrillation (Aib) using 3D mapping system based on three years of follow-up period. Materials and methods: 214 patients ( an average age – 53.65 ± 11,5 years, ranged - 22 to 76 years) underwent an index RFA of Aib (43 women). There were 84 paroxysmal (39.25%), 63 persistent (29.44%) and 67 long-lasting persistent (31.31%) Aib pts involved. According to the atrial arrhythmia recurrence at the follow-up period all patients were divided into two groups: blanking period recurrence – 25 pts and late atraial arrhythmia recurrence (up to the 3 years of follow-up) - 52 pts. In 137 pts there was no any recurrence of arrhythmia observed within the 3 years after de novo RFA. Average TT ECHO parameters at the beginning of protocol (214 pts): LV EDD - 55.4 ± 9.5 mm, LV ESD - 37 ± 8.6 mm, LV ESV - 63.57 ± 35.10 ml, LV EDV – 158.14 ± 44.92 ml, EF 60.76 ± 13.54%, LA - 43.9 ± 7.8 mm. Valves characteristics: in 165 pts mitral valve was intact, prolapsed mitral valve was diagnosed in 41 pts. Mild mitral regurgitation (MR) was veriied in 108 patients, severe MR - in 87 pts and total MR in 19 pts. Although in 194 pts tricuspid valve was intact mild tricuspid regurgitation (TR) was veriied in 125 patients, severe TR - in 74 pts and total TR in 11 pts. In 205 pts aortic valve (AoV) was intact. Mild AoV regurgitation was veriied in 40 patients, severe regurgitation - in 7 pts and AoV stenosis in 2 pts. ECG indings: anterior branch hemiblock was noted in 8 pts (3,7%), left bundle branch block - in 4 pts (2%), right bundle branch block - in 9 pts (4,2%). We used nonparametric statistics methods to estimate value of ECHO and ECG parameters to predict recurrence of arrhythmia. Results: Three-year eficiency of single RFA procedure was 79%. In patients with atrial arrhythmia recurrence initial TT ECHO parameters exceeded following characteristics: LA - 44.7 ± 5 mm, LV ESD - 37.1 ± 5.9 mm, LV EDD - 57.6 ± 7.2 mm. EF less then 57% marked recurrent arrhythmia time coarse. Intraventricular conduction block as well as severe mitral or tricuspid regurgitation is associated with worse prognosis while mitral prolapse consisted with mild regurgitation predicts three-year arrhythmia-free outcome. Conclusions: Nonparametric analysis of ECHO and ECG parameters can predict arrhythmia recurrence in pts underwent an index Aib ablation within the 3 years of follow-up. www.jaib.com 207 October, 2013 | Special Issue Decreased Left Atrial Appendage Velocity Does not Predict Recurrence at Long-Term in Patients who Underwent Cryoballoon Ablation for Atrial Fibrillation A. Altin, B. Candemir, C.T. Kaya, M. Kilickap, S. Aghdam, A. Ongun, K. Vurgun, O. Akyurek, M. Guldal, C. Erol Ankara University School of Medicine, Ankara, Turkey Abstract Objectives: Although catheter ablation for atrial ibrillation has been shown to improve in left atrial (LA) reverse remodelling, effect of cryoballoon-ablation (CBA) on LA appendage velocities (LAAV) has not been examined in depth. We aimed to determine the change in LAAV after CBA and to analyze its association with late AF recurrence rate at 6 months. Methods and results: Pre-procedural and post-procedural (6 months) LAAV were measured by TEE in 33 consecutive patients with paroxysmal AF who underwent CBA for AF. Mean LA diameter was 43.1±0.4cm and 17 patients were male (51%). At 6-month follow-up, 10 (30%) patients had symptomatic and/or long-lasting recurrence in ECG or holter recordings. Mean pre-proc LAAV was 55.5±29.5cm/sec and mean post-proc LAAV was 43.5±18.1cm/sec with a mean difference of -11.9±33.2cm/sec. Elderly patients with coronary artery disease and higher CHADS2VASC scores had signiicantly increased risk for AF recurrence while more LAAV decrease in recurrence group did not reach statistical signiicance, but showed a trend. Table-1 summarizes patient characteristics according to AF recurrence. Conclusions: Although presence of coronary artery disease, higher CHADS2VASC scores and older age predicted increased likelihood for AF recurrence after CBA for AF, LAAV decrease was similar in patients with or without late AF recurrence. Table 1: www.jaib.com Patient characteristics according to presence of recurrence at 6 months. No Recurrence (n=23) Recurrence (n=10) Age 51.9±12.2 64.0±11.7 0.013 Male Gender 12 (52) 5 (50) 1.000 Hypertension 12 (52) 7 (70) 0.455 Diabetes 2 (9) 3 (30) 0.149 Coronary artery disease 4 (17) 6 (60) 0.035 Heart failure 0 (0) 2 (20) 0.085 CHADS2VASC Score 1.4±1.0 3.3±1.7 0.007 Systolic pulmonary artery pressure (mmHg) 31.1±6.5 40.6±12.7 0.086 Left atrial diameter (cm) 4.3±0.4 4.3±0.4 1.000 Preprocedural LAAV 56.9±30.1 52.3±29.7 0.814 Postprocedural LAAV 46.0±16.9 37.8±20.4 0.092 Difference in LAAV -10.8±33.7 -14.4±33.7 0.092 208 p October, 2013 | Special Issue Gastroesophageal Relux Disease Predicts Atrial Fibrillation Recurrence After Pulmonary Vein Isolation L. Lioni, K. Vlachos, M. Efremidis, K. Letsas, A. Sideris Second Department of Cardiology, Laboratory of Cardiac Electrophysiology Evangelismos General Hospital of Athens, Athens, Greece Abstract Introduction: Gastroesophageal relux disease (GERD) has been associated with increased risk of atrial ibrillation (AF). This study aimed to investigate the effect of GERD on pulmonary vein isolation (PVI) outcomes in patients with paroxysmal AF. Methods: 88 consecutive patients (60 males, 55.63±13.13 years) with symptomatic paroxysmal AF underwent (PVI). All subjects underwent pre-procedural assessment for the presence of GERD by clinical symptoms and empiric trial of acid suppression with a proton pump inhibitor. Results: Clinical evaluation revealed GERD in 34 (38.6%) patients. Following a mean follow-up period of 8.31±3.05 months, 63 (71.6%) patients were free from arrhythmia recurrence. The incidence of GERD was signiicantly higher in patients with AF recurrence (80%) in relation to those who maintained sinus rhythm (22.2%) (p< 0.001). Coronary artery disease (p=0.02) and hypertension (p=0.02) were also signiicantly associated with AF recurrence. Furthermore, patients with AF recurrence displayed an increased left atrial diameter (LAD) (p<0.01). In multivariate regression analysis, GERD and LAD were signiicantly and independently associated with AF recurrence (p<0.05). Conclusions: In this study population GERD was an independent predictor of AF recurrence after PVI. www.jaib.com 209 October, 2013 | Special Issue The Role of Baseline Level of Serum High Sensitivity C-Reactive Protein in Long-Term Recurrence After Ablative Therapy in Patients with Persistent Atrial Fibrillation W.J. Park, 1Y.J. Choi, 1S.H. Lee, 1D.G. Shin, 2H.S. Park, 2Y.N. Kim, 3M.H. Bae, 3Y.C. Cho, 4Y.S. Lee, 5B.C. Jung 1 cardiology department, Yeungnam university hospital, Daegu, Korea, 2cardiology department, Keimyung university hospital, Daegu, Korea, 3cardiology department, Kyungpook national university hospital, Daegu, Korea, 4cardiology department, Daegu catholic university hospital, Daegu, Korea 5 cardiology department, fatima medical centre, Daegu, Korea 1 Abstract Background: We evaluated the relationship of serum high-sensitivity chronic reactive protein and the recurrence rate in patients with ablative therapy of persistent atrial ibrillation. Materials and Methods: From March 2010 to January 2012, 43 patients with irst catheter ablation for PeAF. Study population was categorized into 2 groups by baseline hs-CRP level of 0.181 mg/l. The mean follow-up duration was 386±240 days. The recurrence was deined as the presence of any atrial tachyarrhythmia. Results: Higher hs-CRP (n=11) groups had higher CHADS2-VASc score (2.9±2.1 vs. 1.5±1.0, p=0.047). LA diameter was signiicantly longer (46.7±4.6 mm vs. 42.5±5.6 mm, p=0.033) and E/E’ was higher (14.6±5.6 vs. 9.6±3.0, p=0.03) in higher hs-CRP. The trend of high recurrence rate was observed in higher hs-CRP (54.5% vs. 21.9%, p=0.061). In adjusted model, the higher hs-CRP [Hazard ratio, 5.22; 95% conidence interval (CI), 1.45 to 18.74; p=0.011)] were signiicant risk factor for the recurrence. Conclusions: Baseline hs-CRP levels before the irst AF ablative therapy had a signiicant prognostic value in predicting long-term recurrence. www.jaib.com 210 October, 2013 | Special Issue Surgery for Cardiac Arrhythmias Minimally Invasive Thoracoscopic Hybrid Treatmentof Lone Atrial Fibrillation: Early Results of Monopolar Versus Bipolar Radiofrequency Source C. Puntrello a, F. Lucà a, M. La Meir b, G.F. Gensini c, L. Pison d, F. Wellens d, J. Maessen d, S. Gelsomino c Department of Cardiology, Paolo Borsellino Hospital, Marsala, Trapani, Italy; bDepartment of Cardiac Surgery, University Hospital, Brussels, Belgium; c Department of Heart and Vessels, Careggi Hospital, Florence, Italy; d Department of Department of Cardiology and Cardiothoracic Surgery, University Hospital, Maastricht, he Netherlands a Abstract Introduction: We compare results of a hybrid monopolar vs. a hybrid bipolar thoracoscopic approach employing radiofrequency (RF) sources for the surgical treatment of lone atrial ibrillation (LAF). Methods: From January 2008 to June 2010, 19 patients (35.1%) underwent RF monopolar/monolateral RF ablation, whereas 35 (64.9%) had RF bipolar/bilateral thoracoscopic ablation. One-year time-related prevalence of postoperative AF was 13.3 (11.0–17.4) and 5.2% (4.2–6.7), in monopolar and bipolar groups, respectively (P < 0.001). It was 21.1 (17.6–24.9) vs. 8.2% (5.1–11.6) in long standing persistent (P < 0.001), 13.2 (10.6–17.8) vs. 3.8% (1.4–6.9) in persistent (P < 0.001) and 5.6 (2.8–8.3) vs. 3.2% (1.0–6.5) in paroxysmal AF (P = 0.64). At 12 months, estimated prevalence of anti-arrhythmic drugs was 26 (22.4–30.1) and 18.0% (15.5–21.7, P = 0.04), whereas prevalence of Warfarin use was 48.2 (44.2–52.2) and 29.0% (26.2–33.1, P < 0.001) in the monopolar and bipolar groups, respectively. Left atrial (LA) reverse remodelling occurred in 47.3% of monopolar patients (n = 9) and in 77.1% of bipolar patients (P = 0.03). Results and conclusions: AThe hybrid bilateral approach with a bipolar device for the treatment of LAF showed a good 1-year success rate independently of the AF type and seems to be the better choice for longstanding persistent and persistent LAF. www.jaib.com 211 October, 2013 | Special Issue Prevention of SD By ICD Factors that Determine the Chance of Survival from Cardiac Arrest L. Borghi, S. Durciu, G. Kurtidis, G. Gidaris, S. Xusein, G. Kuravanas, P. Zinapi, T. Exiara, S. Molla, A. Koutsogianni, L. Simoglu, C. Nikolau, A. Gotsis Emergency department of Sismanoglio hospital, Komotini, Greece Abstract Introduction: We registered 64 patients who reached the emergency department with pain or dyspnoea and we studied the factors that determine the chance of survival from cardiac arrest. Methods: A retrospective study of 64 patients: 48 men and 16 women with cardiac arrest, 43 out of the hospital and 21 in the emergency department, aged 62±17 years were treated during the period 2002-2012. We registered the irst rhythm, the presence of the ambulance when the cardiac arrest occurred out of hospital and the time of reanimation. Results: The mean time of transport to the hospital by ambulance was 9 minutes. According to the irst cardiac rhythm on the monitor 48 patients needed deibrillation (ventricular ibrillation or no pulse tachycardia) and others prolonged CPR.. Only 21 patients had cardiac arrest witnessed in the point of the accident out of the hospital and 49.patients survived but reanimation was unsuccessful for 15 patients. The time of reanimation varies from ten minutes to 3 hours and 25 patients needed intubation. Conclusions: The two basic modiiable factors that determine the chance of survival from cardiac arrest in the community are: the early beginning of life support from citizens and the rapid ambulance response. More collaboration between the cardiologist and qualiied nurses is needed in cardiac arrest in the hospital. The duration and coordination of the reanimation are very important factors because the insistence of the C.P.R granted sometimes survival when it was least expected. www.jaib.com 212 October, 2013 | Special Issue Diagnostic Value of Postural-Induced Changes in the QT Interval in Patients with the Congenital Long QT Syndrome M. heodorsson 1, V.N. Batchvarov 2, E.R. Behr 2 St George’s, University of London, UK 2 Cardiovascular Sciences Research Centre, Division of Clinical Sciences, St. George’s University of London, UK 1 Abstract Introduction: In established cLQTS patients the QT interval can be normal or slightly prolonged, with signiicant prolongation needed for diagnosis on standard resting ECGs, meaning there are potentially undiagnosed people susceptible to SCD. Simple autonomic manoeuvres such as postural changes can aid the diagnosis of cLQTS. Methods: Continuous 12-lead ECGs were digitally recorded in 38 patients with congenital LQTS genotype and 30 healthy controls (each in whom two recordings were made) in the supine and abrupt standing position, both for 5 minutes. Through specialised software the QT interval was measured and corrected using Fridericia’s formula. Results: On standing, healthy subjects demonstrated average QT shortening by 16 and 17ms respectively. In cLQTS patients the QT interval prolonged by an average of 1ms, with a maximum prolongation of 64ms observed. Conclusions: The similarity of results in healthy subjects suggests the test is reproducible, with expected prolongation elicited amongst cLQTS patients. Therefore this technique can help more accurately establish the LQTS diagnosis, especially in patients with cLQTS in whom the resting ECG is non-diagnostic, whilst being simple, safe and easily performable at bedside. www.jaib.com 213 October, 2013 | Special Issue Hypertrophic Cardiomyopathy - Causes of Death in Patients with an ICD P. Magnusson, F. Gadler, S. Mörner Dept of Medicine, Karolinska Institute, Stockholm, Sweden Abstract Introduction: CHypertrophic cardiomyopathy (HCM) is a genetic, heterogenous, disease with a prevalence of 1/500. Symptoms are exertional dyspnea, angina, dizziness or syncope. In some patients there seem to be an increased risk of sudden cardiac death. Life threatening ventricular arrhythmias can be treated by an ICD. However it is a progressive disease with a risk of congestive heart failure. Methods: From The Swedish ICD-Registry we found 370 patients with an ICD due to HCM between 1995 and 2012. A total of 50 patients died during the same period. The Cause of Death Registry classiied the main cause of death in 42 of these until 2010. Main cause of death. N= numder of patients. Cardiac causes were HCM (n=23), acute myocardial infarction (n=4) and ischemic heart disease (n=2) Age at time of death of the total 50 patients with an ICD due to hypertrophic cardiomyopathy. Remaining life expectancy for a 50 year old man is currently 31.5 years and for a women 34.5 (Statistics, Sweden 2012). Results: In the Swedish Cause of Death Registry we found cardiac causes as the main cause in 71% of patients with HCM and ICD. In 93% (39/42) this was a contributing cause of death. Average age at death was 67.5 yr (median 69) compared to normal population 81.5 yr for men and 84.6 yr for women Conclusion: Cardiac causes of death are still the limit for a normal life expectancy in HCM patients with an ICD. 1 1 2 2 1 Cardiac CVI 2 Cancer Dementia 3 Diabetes COPD Surgery 30 Sepsis Age at death (yr) 90 80 70 60 50 Serie1 40 30 20 10 0 0 www.jaib.com 5 10 15 20 25 30 214 35 40 45 Number of deaths; N=50 October, 2013 | Special Issue The Factors Affecting Psychological Quality of Life of Implantable Cardioverter-Deibrillator Patients Y. Kondo, M. Ueda, K. Miyazawa, M. Ishimura, T. Kajiyama, N. Hashiguchi, T. Kanaeda, Y. Sato, M. Inagaki, T. Kurita, Y. Kobayashi Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan Abstract Objectives: To analyze the factors affecting psychological quality of life of implantable cardioverter-deibrillator (ICD) patients. Methods: We investigated 214 patients from DEF-Chiba study which is a multi-center registry in Chiba Prefecture, Japan. All patients completed the Florida Shock Anxiety Scale (FSAS) at the time of registration. The FSAS is a tool designed to provide a quantitative measure of ICD shock-related anxiety. Multiple linear regression analysis was used to determinate the important predictors of log-transformed FSAS scores Results: Fifty females (23%) were enrolled in this study and the mean period from implantation to registration (F/U period) was 34±30 months. Ninety seven patients (45%) underwent an ICD for primary indication and 55 patients (26%) had experienced shock therapy. Deibrillation threshold (DFT) testing was performed in 114 patients (53%). Female gender, experience of shock therapy, and a secondary indication were selected as a predictor of ICD shock-related anxiety. While age, F/U period and DFT testing did not correlate with the FSAS score. Conclusions: Experience of shock therapy is the most important determinant of psychological distress in ICD patients. www.jaib.com 215 October, 2013 | Special Issue Ventricular Pre-Excitation Manifested in the Course of Aortic Valve Endocarditis Resulted In Multiple VFS and Severe Left Ventricular Dysfunction A. Bagherli, A. Khadem Departement of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada Abstract Case report: In our case the presence of accessory pathway in the Wolff-Parkinson-White (WPW) syndrome confers an increased risk of developing lethal arrhythmias and sudden cardiac death (SCD). The underlying arrhythmia causing SCD is VF triggered by pre-excited AF. In certain subset of patients, pre-excitation can be latent or intermittent, because of preferential conduction through AV node. In this case pre-excitation became manifest because of the damage and erosion of the AV node caused by aortic valve endocarditis and septal abscess. LV dysfunction may occur secondary to tachy-arrhythmias, either symptomatic or asymptomatic, that trigger achycardia induced cardiomyopathy (TIC). The rate and duration of tachy-arrhythmias inluence the speed at which TIC develops and LV dysfunction may occur as early as 24 hours after the onset of tachy-arrhythmia. Nonetheless, resolution of LV systolic function occurs with adequate rate control or ablation. In this case; eccentric ventricular activation secondary to pre-excitation, in a vulnerable myocardium (post operative phase and pre-existing LV dilatation) contributed to the development of cardiomyopathy. This process was reversed by ablation of the accessory pathway and implantation of CRT, which resulted in normalization of LV function and reversal of dilated cardiomyopathy. www.jaib.com 216 October, 2013 | Special Issue A Case of Left Ventricular Aneurysm of Uncertain Etiology Presenting as Ventricular Tachycardia H. Baccar, A. El Jery, S. Marouen, M. Gzara, A. Marouen Cardiology department, Charles Nicolle university-Hospital, Tunis, Tunisia Abstract Introduction: Idiopathic LV aneurysms without identiiable underlying cause are rare. However, they may be associated with life-threatening ventricular tachyarrhythmias and cardiac arrest, even as a irst manifestation of the disease. Case report: We present a case of ventricular tachycardia originating from an inferobasal left ventricular aneurysm. A 67-year-old woman patient presented with complaints of palpitation, breathlessness, and dizziness of two-hour onset. The electrocardiogram showed wideQRS tachycardia with right bundle branch block morphology compatible with ventricular tachycardia. The electrocardiogram recorded after conversion showed a sinus rhythm, normal QT interval and a 0,5 mm-ST depression in the lateral leads. Echocardiographic examination disclosed a dyskinetic aneurysmal region in the inferobasal segment of the left ventricle. Coronary arteries were normal on angiography. Cardiac magnetic resonance imaging (CMRI) showed an important focal thinning in inferobasal segment shaping up an aneurysm of 30×10 mm. No myocardic delayed enhancement was noticed,except in the aneurysmal region. Electrophysiologic study was not performed. A 24-hour Holter electrocardiographic recording, performed 2 weeks after oral administration of amiodarone and atenolol, detected 1240 ventricular premature complexes (right bundle branch block pattern) . A cardioverter deibrillator was successfully implanted. www.jaib.com 217 October, 2013 | Special Issue Implantable Cardioverter-Deibrillators for Prevention of Sudden Cardiac Death in Patients at High Risk for Life-Threatening Tachycardia A. Baimbetov, B. Iskakova, T. Moldabekov, S. Ivanova, N. Kosibayeva, D. Marat, S. Borovsky Cardiology Deparrtment of Republican Scientiic Center for Emergency Medicine, National Medical Holding, Astana, Kazakhstan Abstract Objectives: To demonstrate our results of cardioverter-deibrillator implantations in patients with chronic heart failure to prevent sudden cardiac death. Materials and Methods: From 2011 to 2013 in our center there were implanted 42 cardioverter-deibrillators, including 29 men (age 49 ± 13.7 years) and 13 women (age 45 ± 9.5 years). The main cause of high risk of sudden cardiac death (SCD) was ischemic heart disease with myocardial infarction (33 patients). 8 patients with dilated cardiomyopathy, and 1 patient had idiopathic ventricular tachycardia.10 patients with ischemic heart disease had a permanent atrial ibrillation, these patients received single-chamber ICDs. 30 patients out of 42 received CRT-D (implantable cardiac resynchronization therapy device with life-saving therapy to prevent sudden cardiac death) and 2 patients received dual chamber ICDs. 37 patients had indications for primary prevention of SCD. 5 patients had indications for secondary prevention of SCD, who had recorded episodes of sustained ventricular tachycardia and required emergency intervention. All patients were followed up. Testing and reprogramming of ICDs and CRT-Ds were carried out in terms of 3, 6 and 12 months, as well as after initial implantation and after device delivering therapy. During and post-operative complications were not observed. All patients received optimal heart failure drug therapy, including betablockers, ACE inhibitors, also diuretics and digoxin appropriately, when it is demand. Results: 9 patients received ICD therapies. 4patients received inappropriate shocks in response to atrial ibrillation with rapid ventricular rate. After selection of antiarrhythmic therapy with amiodarone and digoxin and after correction of ICD tachycardia discrimination parameters, recurrent episodes of inappropriate shocks were not observed. The remaining 5 patients received appropriate ICD therapies as anti-tachycardia pacing (ATP) in one case, and in 4 cases deibrillation shock up to 34 joules in response to a stable ventricular tachycardia with a rate of 200-210 beats per minute. Conclusions: Implantable cardioverter-deibrillators reduce mortality from life-threatening tachycardia in patients at high risk of SCD. Opportunely correction of ICD parameters with additional features of supraventricular tachycardia discrimination, appropriate treatment of the underlying heart disease and related tachyarrhythmia contribute to reduce the number of inappropriate shocks and improve the quality of life for patients. www.jaib.com 218 October, 2013 | Special Issue Eficacy of Implantable Cardioverter Deibrillators in Patients with Idiopathic Ventricular Tachyarrhythmias H.S. Park, Y.N. Kim, S.H. Lee, D.G. Shin, B.C. Jung, M.H. Bae, Y.C. Cho, Y.S. Soo Lee, D.W. Hyun, J.K. Kim, D.K. Kim Keimyung University Dongsan Medical Center, Yeungnam University Hospital, Daegu Fatima General Hospita, Kyungpook National University Hospital, Daegu Catholic University Medical Center, Andong General Hospital, Pusan National University Yangsan Hospital, Inje University Busan Paik Hospital, Korea Abstract Background: Most cases of sudden cardiac deaths are caused by sustained ventricular tachyarrhythmias and implantable cardioverter deibrillators (ICD) are recommended for patents resuscitated from sudden cardiac death or life-threatening ventricular tachyarrhythmia. However the prognosis or eficacy of ICD therapy in patients with idiopathic ventricular tachyarrhythmias are uncertain. The purpose of this study was to evaluate the eficacy of ICDs in patients with idiopathic ventricular tachyarrhythmias. Methods: The patients who implanted ICDs from 8 general hospitals in Young-Nam Province of South Korea were retrospectively enrolled in this study. The clinical data from the patents who implanted ICDs after events of idiopathic ventricular tachyarrhythmias were reviewed and analyzed. Idiopathic ventricular tachyarrhythmias included idiopathic ventricular ibrillation (VF) and life-threatening idiopathic ventricular tachycardia (VT). Results: Among 358 patients, 65 patients (43 males, mean age 55.4 ± 16.5 years) implanted ICDs because of idiopathic ventricular tachyarrhythmias. The patients consist of 36 patients (55.4%) with VF and 29 (44.6%) with VT, respectively. Mean follow up duration was 27.1 ± 26.8 months and mean ejection fraction was 61.6 ± 7.9%. Total mortality was 4.6 % (3 patients) and 30.8% (20 patients) experienced at least one appropriate therapy. However, survival analysis didn’t show any differences of clinical events between two types of ventricular tachyarrhythmias. Conclusions: This study demonstrated that about 35.4% of ICD implanted patients with idiopathic ventricular tachyarrhythmias experienced at least one appropriate shock or all-cause death. But, there were no differences in incidence of clinical events between the types of tachyarrhythmias. www.jaib.com 219 October, 2013 | Special Issue An Elevated Deibrillation Threshold During Routine ICD Testing is Associated with an Increased Risk of Appropriate ICD Interventions J.L. Bonnes, J. Jaspers Focks, S.W. Westra, M.A. Brouwer, J.L.R.M. Smeets Department of Cardiology, Radboud University Nijmegen Medical Centre, Nijmegen, he Netherlands Abstract Introduction: A strategy of routine ICD testing is under discussion. So far, few studies have addressed the potential clinical value of identiication of patients with elevated deibrillation thresholds (DFTs). We investigated the relation between the DFT at implantation and the occurrence of appropriate ICD therapy. Methods: After ICD implantation (n=419), routine deibrillation testing was performed with sequential shocks (15-25-35 joule). Cumulative incidences of appropriate ICD therapy were compared between patients with low (≤15 joule) and elevated DFTs (>15 joule). Results: In total 67 (16%) patients had an elevated DFT and 352 (84%) had a low DFT. The cumulative incidences of appropriate ICD therapy are shown in the Table (p=0.03). Elevated DFT and history of sustained VT were independently associated with appropriate therapy [HR 1.99 (95% CI 1.19-3.33)]; [HR 2.57 (95% CI 1.52-4.36)]. Conclusions: During routine testing, an elevated DFT was observed in one-out-of-six patients. The 1-2 year incidences of appropriate ICD therapy were twice as high in these patients as compared with patients with a low DFT. Our indings question whether routine testing can be omitted safely in all patients. www.jaib.com Appropriate ICD therapy Elevated DFT n=67 Low DFT n=352 One-year incidence 26% 13% Two-year incidence 31% 23% 220 October, 2013 | Special Issue Prevention of Sudden Cardiac Death with Implantable Cardioverter Deibrillator in the Elderly: A Single Centre Experience K. Polymeropoulos, A. Vosnakidis, P. Ioannidis, J. Zariis Cardiology Department, “G. Papanikolaou” Hospital, hessaloniki, Greece Abstract Introduction: We aim to compare survival, device interventions and complications between elderly (age >75 years) and younger patients (age < 75 years) treated for prevention of Sudden Cardiac Death (SCD) with Implantable Cardioverter Deibrillator (ICD). Methods: We enrolled 156 patients (136 men), mean age 65±12 years, with an ICD. Group A included 118 patients aged < 75 years (75.6%) and Group B included 38 patients aged > 75 years (24.4%). Results: Appropriate ICD intervention was noted in 39 patients in Group A (33.1%) and in 7 patients (18.4%) in Group B (OR=2.18 95%CI 0.88-5.4, p=0.09) during 25±17 months. Inappropriate intervention was recorded in 15 patients in Group A (12.7%) and in 6 patients (15.8%) in Group B (OR=1.28 95%CI 0.46-3.59, p=0.62). There were 19 patients with complications (16.1%) in Group A and 3 patients (7.8%) in Group B (p=0.2). We recorded 13 (11%) and 4 (10.5%) deaths respectively (p=0.93). Conclusions: Age showed a trend to inluence appropriate ICD interventions, without affecting survival, inappropriate device interventions and complications between elderly (age>75 years) and younger aged patients in our study population. www.jaib.com 221 October, 2013 | Special Issue Prevention Of Sudden Cardiac Death With Implantable Cardioverter Deibrillator: A Single Centre Experience K. Polymeropoulos, A. Vosnakidis, P. Ioannidis, J. Zariis Cardiology Department, “G. Papanikolaou” Hospital, hessaloniki, Greece Abstract Introduction: To evaluate the effect of Implantable Cardioverter Deibrillator (ICD) on survival and compare the device interventions in patients treated for primary or secondary prevention of Sudden Cardiac Death (SCD). Methods: We included 156 patients (136 men), mean age 65±12 years, who received an ICD (99 for secondary prevention). The follow-up duration was 25±17 months. Results: AAppropriate ICD intervention was demonstrated in 12 patients (21.1%) in primary prevention group and in 34 patients (34.3%) in secondary prevention group (OR 1.96 95%CI 0.91-4.2, p=0.082). Time to irst appropriate intervention was 6.92 and 4 months respectively (p=0.196). Inappropriate ICD intervention was observed in 12 patients (21.1%) in primary prevention group and in 9 patients (9.1%) in secondary prevention group (OR 2.6 95%CI 1.04-6.79, p=0.04). Time to irst inappropriate intervention was 7 and 15.8 months respectively (p=0.21). There were reported 17 deaths, 9 in secondary prevention group (p=0.34). Conclusions: Appropriate ICD interventions are present in both primary and secondary prevention groups with similar survival rates. Primary prevention ICD patients experienced more often inappropriate ICD interventions. www.jaib.com 222 October, 2013 | Special Issue Long-Term Surveillance of The Patients without Veriied Ventricular Dysrhythmia Treated with ICD for Secondary Prevention of Sudden Cardiac Death S. Misikova, A. Boho, B. Stancak, E. Komanova Cardiology Clinic, Arrhythmology department, East Slovakia Institute of Cardiovascular diseases, Kosice, Slovakia Abstract Introduction: In clinical practice, there are lots of patients resuscitated for the disturbance of consciousness without satisfactory explanation of cause. Non-hospital conditions do not allow identifying ventricular rhythm disorders all the time. The aim of this study was to analyse the occurrence of ICD therapy in the patients with veriied syncope episodes, whereas ventricular dysrhythmia was not conirmed and ICD was implanted. Methods: A total of 384 patients with the history of syncope without satisfactory explanation of cause were retrospectively evaluated. All of them underwent electrophysiologic testing (EPT) showing no evidence of sustained ventricular tachycardia. However, the ICD system was implanted in 40 patients. Results: In 17 patients (42,5%) a minimum of 1 ICD therapy was recorded. There were no ventricular rhythm disorders observed in the remaining 23 patients. The negative predictive value of EPT was 57,5%. Conclusions: The decision about the requirement of the ICD implantation in the patients with unsolved syncope episodes has to rely on clinical facts. Regarding this, it is possible to predict the origin of the syncope and begin with the best treatment strategy. Patients with ICD therapy (n = 17) www.jaib.com Patients without ICD therapy (n = 23) Age (years) Period to 1. ICD therapy (months) Age (years) Period of follow up (months) Mean ± SD 47 ± 20 15 ± 18 60 ± 11 32 ± 13 Median (IQR) 55 (18-74) 9 (1-72) 61 (43-82) 34 (1-52) 223 October, 2013 | Special Issue Usefulness of Implantable Cardioverter-Deibrillators in Survivors of Cardiac Arrest with Coronary Spasm and Inducible Ventricular Arrhythmia S. Tao, K. Otomo, Y. Ono, Y. Yamauchi, K. Hirao Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan Abstract Introduction: Coronary artery spasm is one of the causes of life-threatening ventricular arrhythmia and sudden cardiac death, but indication of implantable cardioverter-deibrillator (ICD) is controversial. Our aim is to clarify the clinical features and long term prognosis in patients with coronary artery spasm and ventricular arrhythmia. Methods: We retrospectively investigated 41 survivors of cardiac arrest without underlying cardiac diseases. All patients underwent coronary angiography, acetylcholine provocation test, electrophysiological study, and ICD implantation. Results: In 9 patients (60.1±12.0 years old, 8 males) multi-vessel spasm was induced by acetylcholine injection. Ventricular ibrillation (VF) was induced by electrophysiological study in 6 patients (Group A), while VF was not induced in 3 of them (Group B). All patients were treated with calcium channel blockers, and patients in Group A were treated with antiarrhythmic drugs as well. During mean follow up of 50±40 (16-146) months, 2 patients in Group A received appropriate ICD shocks to VF. No patient in Group B received ICD shocks. Conclusions: ICD is useful to prevent sudden cardiac death in patients with coronary artery spasm and inducible ventricular arrhythmia. www.jaib.com 224 October, 2013 | Special Issue Is Right Ventricular Pacing Associated with an Increased Incidence of Appropriate Implantable Cardioverter Deibrillator (ICD) Therapy? C.M. Seifer, A. Farag Section of Cardiology, University of Manitoba, St Boniface Hospital, Winnipeg, Canada Abstract Introduction: Pacemaker induced ventricular arrhythmias have been documented in the pacemaker population. We hypothesize that right ventricular (RV) pacing in ICD patients is associated with an increased incidence of appropriate ICD therapy. The objective of this study is to compare the incidence of appropriate ICD shocks in patients who RV pace >30% versus patients who RV pace <30%. Methods: Consecutive patients with de novo ICD’s inserted were included. Patients were divided into two groups: >30% RV pacing (group 1) and <30% RV pacing (group 2). Results: Sixty-one patients were included. The baseline characteristics of the groups are presented in igure 1. Ten patients in group 1 received an appropriate shock compared to 7 patients in group 2; p=0.4. In subgroup analysis, there was no signiicant difference between patients who RV paced >75% vs those who paced <10% (p=0.52). Conclusions: In this population of ICD patients, there was no difference in the incidence of appropriate therapy in patients with a moderate to high rate of ventricular pacing as compare to patients with minimal or no ventricular pacing. Figure 1: www.jaib.com Baseline Characteristics Baseline characteristics RV pace group n= 30 (Group 1) RV no pace group n= 31 (Group 2) P value Mean Age (yrs) 69.8 61.4 0.007 Men (%) 76 74 1.000 Ischemic cardiomyopathy 60 77 0.393 NYHA class (mean) 2 2 1.000 Ejection Fraction (mean) 34 31 0.295 225 October, 2013 | Special Issue The Incidence of ICD System Modiication is not Increased After Implantation without Intraoperative Testing D. Bastian, S. Kracker, K. Goehl Division of Cardiology and Electrophysiology, Medizinische Klinik 8, Klinikum Nuernberg Sued, Nuremberg, Germany Abstract Introduction: CThe incidence of ICD system modiication after negative intraoperative deibrillation testing is recently around 5% (range 0 to 17%). The study goal was to evaluate, whether “schockless“ ICD implantation without intraoperative correction based on adverse test indings affects the rate of postoperative system revision. Methods: 1In a prospective single-center observational study, 609 patients underwent transvenous ICD implantation without intraoperative testing. Deibrillation eficacy was validated prior to hospital discharge by applying two 10 J safety margin shocks. Results: Postoperative device-related complications requiring surgical intervention occurred in 5 cases (0.8%): lead dislocation n = 3, increased pacing threshold n = 1, lead connection failure n = 1. The incidence of system modiication was 4.8%: shock path reversal n = 23, implantation of a subcutaneous shock lead n = 6 (n = 4 (0.7%) for deibrillation failure, n = 2 for no safety margin). Compared to other clinical trials with intraoperative testing, “schockless” implantation did not result in an increased rate of postoperative revisions (tab. 1). Conclusions: The incidence of system modiication was not increased after ICD implantation without intraoperative testing. Tab. 1 Incidence of ICD system modiication in different trials www.jaib.com 226 October, 2013 | Special Issue Our Experience in Device Implantation in Patients with Persistent Left Superior Vena Cava A. Tokatli, F. Kilicaslan, M. Uzun, B.S. Cebeci Department of cardiology, Golcuk military hospital, Kocaeli, Turkey; GATA Haydarpasa hospital, Istanbul, Turkey Abstract Introduction: Persistent left superior vena cava (PLSVC) is the most comman venous congenital malformation. Positioning of pacemaker (PM) leads through PLSVC may be challenging. We report three patients with PLSVC who had PM/ICD implantation at our center. Cases reports: Case 1. A 58 year-old-woman with dilated cardiomyopathy was admitted to our hospital with symptoms of congestive heart failure. ECG showed normal sinus rhythm and left bundle branch block with a QRS duration of 140 ms. Echocardiography demonstrated severe left ventricular (LV) dilatation. LV ejection fraction and end diastolic diameter were 32% and 64 mm, respectively. Biventricular ICD was recommended. During implantation, PLSVC and absence of right SVC were diagnosed by venography. Active ixation deibrillation lead was screwed in to RVOT. Active ixation atrial lead was screwed in to right atrium anterolateral wall. Balloon occlusion coronary sinus (CS) angio was not possible because of huge size of the CS. We performed left coronary angiography (CAG) to see the CS branches. After CAG, we could be able to cannulate posterior branch of CS. However, LV lead implantation was not possible due to high pacing threshold, diaphragmatic stimulation and unstable lead position. Therefore, LV lead was implanted epicardially after several days. She was asymptomatic and lead measuraments were found normal during follow up. Case 2. 20-year-old man was admitted to our hospital with palpitation and syncope. Physical examination was normal. ECG showed sinus bradicardia. Echocardiography was normal. Holter ECG revealed long sinus pauses during symptomatic periods. We have recommended a dual chamber pacemaker. At the time of left subclavian puncture, PLSVC was found. We decided to perform the procedure through a right subclavian approach. A DDD-R pacemaker was implanted through right subclavian vein. Case 3. A 70-year-old man with a diagnosis of sick sinus syndrome was referred to our clinic for pacemaker implantation. ECG showed normal sinus rhythm. Echocardiography revealed mild mitral regurgitation with normal systolic function. Holter ECG indings were compatible with sick sinus syndrome. At the time of left subclavian vein puncture, PLSVC and absence of right SVC were diagnosed by venography. A DDD-R pacemaker was implanted through left subclavian vein Discussion and conclusions: Implantation of PM/ICD leads is very challenging in patients with PLSVC. The implantation procedure may be even more complicated in patients with PLSVC and absence of right SVC. The diagnosis can be conirmed easily by contrast venography. Device implantation by using several approaches is possible in these patients. GFigure. (A) Venography via right subclavian vein shows LPSVC and absence of right SVC; (B,C) anteroposterior and lateral view of chest x-ray shows right atrial and right ventricular leads and epicardially implanted left ventricular lead. Figure 1: LPSVC:left persistent superior vena cava; SVC:superior vena cava www.jaib.com 227 October, 2013 | Special Issue Brugada Syndrome in Infero-Lateral Leads: Higher Risk of Sudden Cardiac Death? A. Medeiros-Domingo, P. Iturralde, M.J. Ackerman, J.C. Makielski, C. Valdivia University Hospital Bern, Switzerland National Institute of Cardiology, Mexico Mayo Clinic, USA University of Madison WI, USA University of Michigan, USA Abstract Introduction: Brugada Syndrome (BrS) is characterized by ST segment elevation in right precordial leads and increased susceptibility to sudden cardiac death (SCD). Inferolateral location of the Brugada ECG pattern is seen rarely and potentially associated with higher risk of SCD. Methods: We studied a 24-year-old male without family history of syncope or SCD, who presented his irst syncopal episode at age 21 while dancing. Three years later, he had SCD while sleeping. Mutational analysis of SCN5A was performed using PCR, DHPLC and direct sequencing. The BrS-associated mutation was engineered by site directed mutagenesis and transfected into HEK-293 cells for functional chraracterization using the patch clamp technique. Results: AA sporadic de novo missense mutation, R893H-SCN5A (c. 2678 G>A) that localized to the DII pore of NaV1.5, was identiied and was absent in 2000 reference alleles. Cells expressing the R893H-SCN5A exhibit signiicant decrease in sodium current density of 1±1pA/ pF compared to 327±121 pA/pF in SCN5A+WT (n=6-14). Conclusions: The R893H-SCN5A mutation had a profound decrease in sodium current, which provides the molecular/cellular basis for the phenotype described for SCN5A mutations causing BrS and generates an atypical ST segment elevation in inferior-lateral leads and premature sudden cardiac death. www.jaib.com 228 October, 2013 | Special Issue Pacemaker Therapy & Transvenous Lead Extraction Anti Bradycardia Pacing of Cardiology University Hospital Tlemcen Algeria. About 500 Cases M.T. Abderrahim Department of Cardiology University Hospital, Tlemcen, Algeria Abstract Background: Pacing has largely entered its sixth decade. Since the irst introduction in 1958, the pacemaker models have evolved. They represent a real breakthrough in terms of technique. The indications for pacing are extensive and cover pathologies different prognoses. Materials: This study was conducted at the University Hospital Cardiology Service Tlemcen. We are interested in a fringe of 500 patients undergoing cardiac stimulation inal. In our study more than 84% of patients were male, which corresponds to a sex ratio of 5. In our series 20% of patients underwent stimulation type double room. The complication rate is estimated at 8% marked by secondary displacement sensor. Conclusion: The cardiology department of Tlemcen University Hospital is a major center for pacemaker implantation in the western region of the country with encouraging results despite a modest equipment to the standards required. www.jaib.com 229 October, 2013 | Special Issue Feasibility of an New Algorhithm (Acap Conirm) for Automatic Atrial Capture Testing J.A. Lapuerta Irigoyen, I. Valverde Andre, P. Vigil Escalera Cardiology Service, Hospital Cabuenes, Gijon, Spain Abstract Introduction: Acap Conirm (ACC) is a new algorithm offered by St. Jude Medical dual chamber pacemakers allowing for automatic atrial threshold determination. The aim of this study is to investigate the feasibility and short-term clinical and technical outcome of this test. Methods: Patients scheduled for DDD pacemaker implantation (Zephyr XL DR 5820) were enrolled into this prospective evaluation. Set-up test ACC viability and manual step-down (0,4ms) atrial threshold test as well as automatic threshold testing by ACC were performed at implant, 2 weeks and 3 months after implantation. Participants who successfully completed both an automatic and manual capture thresholds test during follow-up were compared. Results: Data from 79 patients (49M/30F, 70.4 ± 8.5 years old) were analyzed. Bipolar atrial leads (1882T and 1999T) were used. ACC activation rates are shown in the igure below. At 2 weeks and 3 months, threshold results from ACC and atrial manual capture test were: (0.63 ± 0.22 V versus 0.69 ± 0.22 V; r=0.94), and (0.59 ± 0.14 V versus 0.65 ± 0.17 V; r=0.87) respectively. The differences between automatic and manual measurements were ≤0.25V in all patients. Conclusions: The reliability of ACC is relatively low over a short follow-up. Automatic atrial thresholds measurements (ACC) can be programmed in only 47% of patients at 3 months. There is a good correlation between automatic and manual atrial thresholds. However, long-term clinical outcomes are necessary to conirm these indings. www.jaib.com 230 October, 2013 | Special Issue Correction of Chronotropic Incompetence with Rate-Responsive Device in a Ddd Pacemaker Population: Results from a Pilot Screening Study E. Occhetta, M.V. Di Ruocco, E. Facchini, L. Ferrarotti, A. Magnani, L. Plebani, P. Marino Clinica Cardiologica, AOU Maggiore della Carità, Novara, Italy Abstract Introduction: Chronotropic Incompetence (CI) is a sinus node disease variant. Rate responsive pacemakers (PM) are designed to simulate normal sinus node responsiveness and restore chronotropic competence. Methods: We report our experience about the incidence of CI in a population of patients implanted with a not rate responsive PM. During the 2012 routine PM follow-up, 18 DDD PM patients (15 m, 3 f; age76±12 years) with battery status in Elective Replacement Indicator (ERI) were identiied; they underwent telemetry detection of atrial pacing %, NYHA class, 6 minute walking test (6MWT) or atropine test, pharmacological history (44% was treated with beta-blockers). CI was deined by a sinus rate < 100 bpm at the 6MWT/atropine test, and an atrial pacing > 50%. Results: In 10/18 patients (55%) a CI was identiied (419+136 meters and 76.5+7.8 bpm sinus rate at 6MWT); they were reimplanted with a new DDDR PM; a single or a blended double sensor (accelerometer and/or minute ventilation) was activated. Conclusion: An appropriate CI detection at the elective PM replacement could improve the physiologic cardiac pacing with implementation of rate responsive algorithms. www.jaib.com 231 October, 2013 | Special Issue Cover Page Pacemaker Follow-Up After Tavi L.P. Papavasileiou1,2, K. Spargias3, G. Zervopoulos1, M. Chrisocheris2, A. Chalapas2, K. Bellos2,4, L. Santini2, G. Forleo2, T. Apostolopoulos1 Electrophysiology Pacemaker and ICD Unit, Hygeia Hospital, Athens, Greece. 2University Hospital of Rome “Tor Vergata”, Cardiology Department, Rome, Italy. 3Transcutaneous Heart Valves Department, Hygeia Hospital, Athens, Greece. 41rst Cardiothoracic Surgery Department, Hygeia Hospital, Athens, Greece 1 Abstract Introduction: Incidence of pacemaker (PM) implantation after Transcatheter Aortic-Valve Implantation (TAVI) is 6.5%-40%. Most common indications are: complete atrioventricular block (BAV), 1rst degree AV block and left bundle branch block (LBBB), sick sinus rhythm (SSS). Methods: We evaluated the follow-up (device interrogation) of 14 patients that underwent PM implantation after TAVI (reason of implantation was: 7 pts for BAV, 5 pts for 1rst degree AV block and LBBB, 2 for left and right bundle branch block alternance, 1 pts for 2:1 AV block). Results: Patients with preexisting right bandle branch block (RBBB) that underwent Corvalve implantation, patients with RBBB+LBBB alternance and with 2:1 AV block had 100% of ventricular pacing during follow-up. Patients with BAV that underwent Edwards Sapien valve implantation, with restoration of conduction 24 hours after the procedure and pts with 1rst degree AV block and LBBB had 0% of ventricular pacing during follow-up. Conclusions: Implantation of PM after TAVI is performed too early in the post operatory period. The preexisting RBBB and the Corvalve implantation determine irreversible AV block. The presence of reversible AV block after TAVI with the Edwards Sapien valve and the presence of 1rst AV block with LBBB do not require pacing over time. www.jaib.com 232 October, 2013 | Special Issue Longevity of Medtronic Sprint Fidelis ICD Lead During Over 5-Year Long-Term Follow-Up T. Tokano, Y. Nakazato, S. Komatsu, M. Sugihara, K. Komatsu, M. Yamase, H. Hayashi, G. Sekita, M. Sumiyoshi, H. Daida Cardiology, Juntendo Urayasu Hospital, Urayasu, Japan Abstract Introduction: Medtronic Sprint Fidelis ICD Lead (FL) has been withdrawn from the market because of frequent conductor failure. The survival rate was estimated at approximately 85%, however, over 5 years longevity has not been well discussed. Methods: 1Study subjects were 67 cases (mean 61 year-old, 51 males) in whom FL was implanted. Cephalic venous access was dominant (57 cases). Capture/sensing threshold and lead impedances were measured every 3-6 months. The mean follow-up periods was 5.6±0.5 (range: 5-6.9) years. Results: Conductor failure occurred in 5 (7%) cases (Table 1). Regarding to these cases, younger age, preserved LVEF and female gender were considered to be high risk. Patient alert worked promptly to avoid inappropriate shock therapies in 2 of them. Conclusions: FL functioned normally in 93% during over 5 years follow-up in our institution, and it was higher comparing with previous studies. Cephalic venous access may have reduced the risk of conductor failure. However, patient alert must be activated in FL cases, and careful observation, e.g. using remote monitoring should be recommended, especially in high risk cases. Table 1: www.jaib.com Cases with Conductor Failure Gender Age (year-old) Underlying Disease LVEF Time to Failure (years) Outcome Female 59 Sarcoidosis 0.36 4.4 Artiicial Noise Female 50 CAD 0.55 3.5 Impedance↑ ↓ Patients Alert Male 35 HCM 0.40 4.3 Impedance↑ ↓ Patients Alert Male 54 CAD 0.58 2.8 Impedance↑ ↓Patients Alert Female 69 HCM 0.70 3.5 Artiicial Noise ↓Inappropriate Shock 233 October, 2013 | Special Issue Eficacy and Feasibility of Cardiovascular Implantable Electronic Devices Lead Extraction in Low Ejection Fraction Patients M. Nagashima, Y. Kazuno, M. Fukunaga, M. Goya, M. Nobuyoshi Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan Abstract Background: Low EF patients have more risk factors than normal EF patients needing lead extraction. However, the safety of lead extraction for low EF patients remains unclear. Methods: Between 2005 and 2012, we collected data of 199 consecutive patients who underwent percutaneous transvenous lead extraction and compared incidence of major adverse events (MAE; death, myocardial infarction, stroke, cardiac tamponade, PE, blood transfusion or pneumohemothorax ) between patients <35 EF and patients ≥35 EF. The endpoint of this study was incidence of major adverse events (MAE; death, myocardial infarction, stroke, cardiac tamponade, PE, blood transfusion or pneumohemothorax ) after procedure.. Results: There were 38 patients (19.1%) with low EF and 161 patients (80.9%) with normal EF. All patients underwent successful transvenous removal of endocardial leads. One of 38 patients (2.6%) had evidence of MAE in low EF patients. No signiicant difference of MAE was found in the low EF group (2.6 vs. 3.7%, P = 0.221). Conclusions: In low EF patients, percutaneous transvenous lead extraction could be performed safely without prolonged hospital stay. www.jaib.com 234 October, 2013 | Special Issue Cardiac Device Endocarditis With Infected Vegetations: A SingleCentre Experience and Consequences of Transvenous Extraction M. Nagashima, Y. Kazuno, M. Fukunaga, M. Goya, M. Nobuyoshi Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan Abstract Background: Removal of infected endovascular leads has often required for cure of systemic infection, but the perceived risk of embolic in the presence of large (> 10 mm) vegetations has been considered a relative contraindication to transvenous removal. Methods: Between 2005 and 2012, 119 patients who extracted due to infection (256 leads) were enrolled in this study. The primary endpoint of this study was incidence of pulmonary embolism (PE) after procedure in patients with and without large vegetation. The secondary endpoints were major adverse events and hospitalization period in each group. Results: Large vegetation (range 12-25mm) was found in 9 (15.1%) patients. All patients underwent successful transvenous removal of endocardial leads. In entire group, two patients had developed PE (11.1% vs 0%, p=0.005). There was no difference in hospitalization periods and MAEs between those with or without large vegetation (47.8±21.3 days vs 37.9±26.1 days, P value 0.13) (22.2% vs 7.92% , P value 0.09). Conclusions: Incidence of PE after procedure was signiicantly higher in patients with large vegetation. However, no signiicant difference of MAE and hospital stay was found. www.jaib.com 235 October, 2013 | Special Issue Lead Dependent Infective Endocarditis-A Diagnostic Challenge A. Polewczyk1 ,A. Kutarski2, A. Tomaszewski 2, K. Boczar3, M. Janion1,4 District Hospital, II Clinical Cardiology Department Kielce, Poland 2Medical University, Department of Cardiology Lublin, Poland 3Department of Electrocardiology, John Paul II Hospital, Krakow, Poland 4he Jan Kochanowski University, Department Sciences of Healthy Kielce, Poland 1 Abstract Background: Lead dependent infective endocarditis (LDIE) is a major complication of the treatment with the electronic devices. The diagnostic process in LDIE patients is very dificult because of nonspeciic symptoms delays of proper management. Methods: We analyzed the clinical data of 320 LDIE (mean age 66,3 ±15,0; 98 women) consecutive patients admitted to single Reference Center for transvenous leads extraction (TLE) procedure in years 2006-2012. The main symptoms,laboratory markers and echocardiographic indings were assessed. Results: 35,7% LDIE patients were determined by local pocket infection. The main symptoms of LDIE were nonspeciic: 58% patients complained of recurrent fever with shiver, 22% were treated from recurrent pulmonary infection; in 42% patients only weakness, dizziness and periodically dyspnoea were observed. The maximum number of hospitalization due to LDIE symptoms reached 5/year with the mean 1,5±0,83/year. Average time from irst symptoms to TLE was 7,3±11,8 months. Antibiotics before TLE admission were intermittently applied in 82% LDIE patients. Laboratory inlammatory parameters showed high variability: mean ESR value: 43,6 ±29,2, CRP 48,5± 65 mg/l, procalcitonin: 1,2 ng/ml ±3,6 with normal leucocytes level: mean 8,9 K/ul ±5,7. Blood culture (all excluding 3 pts received antibiotic before admission for TLE) detected bacteraemia only in 36,6% patients, periprocedural extracted leads culture indicated pathogens in 47,2% cases. Echocardiography demonstrated vegetations in 66,9% CDRIE patients; in 40,2% of them vegetations were visible only in transesophageal echo. Conclusions: Lead dependent infective endocarditis is a very serious disease with large diagnostic problem. The symptoms and laboratory results are nonspeciic, echocardiographic indings are authoritative in about 67% cases. LDIE patients need the comprehensive diagnostic process to accelerate proper treatment. www.jaib.com 236 October, 2013 | Special Issue Is Transvenous Leads Extraction More Hazardous Procedure in Patients With Lead Dependent Infective Endocarditis? A. Polewczyk1, A. Kutarski2, A. Tomaszewski 2, K. Boczar3, M. Janion1,4 District Hospital, II Clinical Cardiology Department Kielce, Poland 2Medical University, Department of Cardiology Lublin, Poland 3Department of Electrocardiology, John Paul II Hospital, Krakow, Poland 4he Jan Kochanowski University, Department Sciences of Healthy Kielce, Poland 1 Abstract Background: Transvenous leads extraction (TLE) consists the key-procedure in management of lead dependent infective endocarditis (LDIE). The assessment of TLE safety and effectiveness in this particular group of patients seems to be very important. Methods: Analysis of data 1220 patients treated by TLE in single Reference Center in years 2006-2012 was conducted with separated of 320 LDIE patients. The comparative assessment of factors inluencing to proceeding and effectiveness of TLE in LDIE and remaining patients was performed with evaluation of complete procedural success and clinical success in both groups of patients. Results: The results were demonstrated in the table Conclusions: The LDIE patients represented more TLE risk factors: older age, more number of the leads- particularly abandoned and loop of the leads. Despite that the present study demonstrated a very high safety and effectiveness of TLE procedure in the large group of LDIE patients with low number of major complications and periprocedural mortality, comparable with non-infective TLE group. This observation conirms that TLE should be the basic of the treatment this very serious disease. LDIE Control group- non LDIEP patients No of patients Mean age [years (SN)] Sex (women %) 320 66,3 ±15,0 98 (30,6%) 900 63,75 ±17,3 358 (39,8%) 0,02 0,005 Mean lead dwelling time before TLE [months (SD)] 89,1 (±63,7) 83,7 (±64,7) 0,20 Mean number of leads before TLE [SN] 2,2 ±0,82 1,9 ±0,78 0,0001 Unecessery loop of lead [%] 84 26,2% 167 18,6% 0,004 Number of abandoned leads (SD) 0,31 (±0,67) 0,23 (±0,57) 0,04 Procedure time [min (SD)] 112 (±53) 110 (±46) 0,52 Complete clinical success [%] 299 93,4% 874 97,1% 0,004 Major complications [%] 6 1,9% 10 1,1% 0,28 Periprocedural mortality [%] 2 0,6% 2 0,2% 0,25 www.jaib.com 237 October, 2013 | Special Issue A Novel Method to Manage ICD Lead Fracture in a Very High Risk Patient. Case Report G.M. Succi, J.E. Succi, J.M. Baggio, M.M. Mendonça, C.M. Succi, F.M.P. Succi Hospital Albert Einstein, São Paulo, Brasil Abstract Objective: To describe a novel method to deal with ICD lead fracture in very high risk patients with deep vein thrombosis . Case Report: We describe the case of a 71-year-old man, with a CRT-D device (Biotronik Lumax 340 HF-T) implanted for 28 months, presenting with inappropriate ventricular arrhythmia detection on home monitoring report. The patient had a medical history of long lasting systemic arterial hypertension, insulin dependent diabetes mellitus, two coronary stents implanted for two years, severe peripheral arterial disease with no palpable limbs pulses, Acute Myocardial infarction at the age of 27 and femoral vein stent implanted for 2 months due to deep vein thrombosis. During this last hospitalization, left subclavian vein thrombosis was also found. The patient was in use of aspirin, clopidogrel and warfarin. Device interrogation showed 5 episodes of high frequency noise in the right ventricular sense/pace channel interpreted as ventricular tachycardia (VT) or Ventricular Fibrillation (VF). Two of these episodes led to capacitor charge, which was aborted prior to shock delivery. HV1 and HV2 channels showed no abnormalities. Echocardiogram showed severe left ventricular dysfunction and LVEF = 27%. Left ventricular lead sensing and impedance were normal. Due to the high complication risk, oral anticoagulant and dual antiplatelet therapy regimen, deep venous thrombosis and the advanced heart failure clinical status, we decided not to put another ICD lead on. The strategy planned was to do a less invasive procedure under local anesthesia. Procedure description: With the patient under local anesthesia the ICD pulse generator was exposed with minimum dissection. The Left and Right ventricular leads sense/pace channels were then switched in the pulse generator inlet and the generator was put back in place. Total procedure time was 30 minutes and the telemetry at the end showed good ventricular sensing at the right ventricular channel (left ventricular lead). The postoperative course was uneventful and the patient was discharged in postoperative day 1. Thirty three days after the procedure the patient had episodes of ventricular arrhythmia (VT and VF) promptly detected and treated by the device, returning to normal synus rhythm. The patient had no sequelae after this appropriate shock delivery. Discussion: CRT-D patients tend to be high risk and with multiple comorbidities. Any medical intervention on them is accompanied by high morbidity/mortality risk. This patient had previous interventions indicating that deep venous access to put another ICD lead in would not be possible. There were no palpable peripheral pulses and an invasive arterial pressure line was not feasible, making general anesthesia a very high-risk approach. The surgical strategy adopted gave a secure path to ix the device problem. As long as the ventricular arrhythmia diagnosis are made by the right ventricular channel readings, the switch with the left ventricular lead provided a noise free tracing with safe diagnosis, that led ultimately to appropriate shock delivery in a life threatening episode. Conclusion: This unique and novel approach was possible even in this very high-risk patient and turned into a life saving procedure as demonstrated by the subsequent arrhythmia episode. We think that all the ICD manufacturers should make it possible to make this ventricular channel switch during a outward electronic evaluation by device telemetry. If this change were made many patients with sensing/ pacing right ventricular lead fractures would beneit from this. www.jaib.com 238 October, 2013 | Special Issue Journal of Atrial Fibrillation Speical Issue Figure 1: Noise detection in the right ventricular channel Figure 2: www.jaib.com Appropriate VT/VF detection and chock delivery with normal sinus rhythm following the shock 239 October, 2013 | Special Issue Effectiveness of the Topclosure 3S System in Prevention of Hematoma Formation Following Implantation of Cardiovascular Electronic Devices in Patients Prone to Bleeding M. Topaz, S.R. Meisel, R. Malka, A. Frimerman, M. Shochat, D.S. Blondheim, A. Asif, L.Vasilenko, Y. Levy, A. Shotan Heart Institute, Hillel Yafe medical center, Hadera, Israel Abstract Background: Cardiovascular implantable electronic devices (CIEDs) are frequently inserted while patients are on anticoagulant or antiaggregant therapy. As a result, the probability for hematoma formation and its consequences is higher. Objective: To evaluate the effectiveness of TopClosure® 3S System in preventing local hematoma formation following implantation of CIEDs in patients prone to bleeding complications due to anticoagulant or potent anti-aggregant treatment. Methods: A tDuring 10-11/2012 we identiied 20 patients prone to bleeding among our patients requiring CIED implantation. Patients were assigned alternately to TopClosure® 3S therapy, or to usual pressure dressings, the latter served as the control group. Ten days following surgery, wound dressings were removed and an independent surgeon evaluated healing stage prior to staple removal. Therapy outcome was assessed by permission to extract staples, need to continue antibiotics, or requiring further TopClosure® application. Results: Only one patient of the treatment group required additional antibiotic therapy and TopClosure® application (10%) compared to 6 patients in the control group (60%), who required additional antibiotic administration, deferral of staple removal, or further pressure dressing application. Conclusions: The use of the TopClosure®, following CIED implantation in cardiac patients on active anticoagulant and/or intense antiaggregant therapy, proved in this ongoing study to be safe and eficacious. www.jaib.com 240 October, 2013 | Special Issue Impact of Active Versus Passive Fixation Ventricular Leads on Pacemaker Longevity N. Kanasal, S. Menon, C.A. Morillo, J. Healey, S. Ribas, S.J. Connolly Hamilton General Hospital, McMaster University Hamilton, Canada Abstract Introduction: The choice between active vs passive ixation leads at the time of pacemaker implantation is primarily based on operators experience. However, there is a paucity of data on the clinical beneits such as device longevity and complication rate of using either type of lead ixation system. Methods: Consecutive patients who received a pacemaker at our academic center over a 6 month period were retrospectively analyzed. Either a passive or active ventricular lead chosen based on operators preference. Pacing threshold and impedance were collected 3 weeks post implant and used to calculated device longevity based on pacing at 60 beats per minute with pulse width of 0.4ms in a single chamber St. Jude Accent device. Longevity calculation also included safety margin at twice and three times pacing threshold, and pacing at 50% and 100%. Lead dislodgment rate was also collected. Results: Overall, 362 patients underwent pacemaker implantation (197 passive). At 3 weeks, 311 patients (167 passive) had complete follow up. Patient characteristics in both groups were similar in terms of age, gender and pacemaker indication. Both mean pacing threshold and impedance were signiicantly lower in the passive lead group compared to active lead group. Depending on percentage of pacing and safety margin parameters, Passive ixation lead could potentially save up to 2 years in battery life compared to active ixation lead (P< 0.001) (Table 1). Lead dislodgment rate was not signiicantly different among groups (2.5% vs 4.2%, p=NS). Conclusions: Passive ventricular leads have signiicantly lower pacing thresholds and may potentially prolong estimated battery life by 2 years. Passive ventricular leads did not have an increased risk of dislodgment. www.jaib.com Variable Passive Fixation lead (n=167) Active ixation lead (n=144) P value Mean threshold at 3 weeks (SD) 0.6mV ± 0.2 1.0mV ± 0.4 < 0.001 Mean impedance at 3 weeks (SD) 564Ω ± 11 640Ω ±103 < 0.001 Mean years of longevity (SD) at 50 % pacing with safety margin twice the pacing threshold 17.8 ± 0.6 16.7 ± 0.7 < 0.001 Mean years of longevity (SD) at 100 % pacing with safety margin twice the pacing threshold 17.2 ± 0.9 15.3 ± 1.2 < 0.001 Mean years of longevity (SD) at 50 % pacing with safety margin three times the pacing threshold 12.8 ± 2.9 11.2 ± 3.5 < 0.001 Mean years of longevity (SD) at 100 % pacing with safety margin three times the pacing threshold 10.3 ± 3.9 8.7 ± 4.5 = 0.001 241 October, 2013 | Special Issue High Failure Rate of the 5 French Sorin Hepta 4B Pacemaker Lead H.G.R. Dorman, J.M. Van Opstal, J. Stevenhagen, M.F. Scholten Medisch Spectrum Twente horaxcentrum Twente, Department of Cardiology Enschede, he Netherlands Abstract Introduction: The 5 Fr Sorin Hepta 4B lead is a bipolar transvenous pacemaker lead. We observed an unexpected high failure rate of this pacemaker lead. The aim of this study was to determine the performance of the Hepta 4B lead. Methods: In the Medisch Spectrum Twente, a total of 98 Sorin Hepta 4B right ventricular pacemaker leads were implanted. Analysis of the pacemaker database and patients’ charts was performed to assess the rate of lead-related complications of all implanted Hepta 4B leads, requiring lead replacement. Results: Median time of follow up was 5.5 (4.2 - 6.4) years. Of the 98 implanted Hepta 4B leads, 21% (21/98) were replaced. A total of 18% (18/98) of the leads showed electrical malfunction, leading to symptoms in 5% (5/98) of the patients. Electrical malfunction included impedance change, threshold rise and sensing problems. The Kaplan-Meier curve of lead failure free survival during follow-up is shown in igure 1. Conclusions: We report an extreme and unexpected failure rate of the Sorin Hepta lead. The most common complication was electrical dysfunction. The reason for this phenomenon has to be analyzed, but the co-radial multiilar design, allowing a smaller diameter of the lead, may explain this inding. (igure 2) Figure 2: Figure 1: Kaplan-Meier curve of lead failure free survival during follow-up. www.jaib.com 242 Schematic lead design of a contemporary co-axial pacemaker lead (A) and the small-diameter co-radial multiilar Sorin Hepta 4B lead (B). In the 5 Fr Hepta 4B lead the tip and ring electrodes are individually insulated. (With courtesy of Sorin Group) October, 2013 | Special Issue Use of Chest Computer Tomography (CT) Scan in Patient Undergoing Laser Lead Extraction Y. Okamoto, C. Balabanof, R. Carrillo Cardiac horacic Surgery, University of Miami, Miami, USA Abstract Introduction: The need for infected device extraction has been rising. There is no clinical information on the use of Chest CT scan before lead removal. Methods: From a prospective registry at a tertiary referral center from October 2008 to October 2012, 410 patients were studied. All patients had gated chest CT scans without contrast before laser lead extraction. Three-dimensional reconstructions were done to enhance diagnostic abilities. Results: Among 410 patients 74% were males and average age was 67±16 years. Mean EF was 35 ±14, NYHA 3.0± 0.7. Comorbidities were Coronary Artery Disease 53%, Diabetes Mellitus 38%, Hypertension 86% and Hemodialysis 8%. Indications for extraction were infection 54%, malfunction 41%. Devices extracted were pacemaker 32.9%, ICD 41.2%, CRT 25.8%. There were 16 patients (3.9%) with extracardiac leads. There were 32 patients (14.4%) with septic pulmonary emboli among 222 patients with device endocarditis. Conclusions: Gated CT scan of the chest is helpful in patients undergoing laser lead extraction in detecting leads in extracardiac location. Septic pulmonary emboli was identiied in patients with device infection. www.jaib.com 243 October, 2013 | Special Issue Is the Transvenous Extraction of Cardioverter-Deibrillator Leads And Left Ventricular Leads More Risky than that of Pacemaker Leads? Y. Kazuno, M. Nagashima, M. Fukunaga, M. Goya, M. Nobuyoshi Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan Abstract Background: Although there are reports showing that the extraction of implantable cardioverter-deibrillator (ICD) leads and cardiac resynchronization therapy (CRT) leads may be hazardous, clinical evidence suggests that such procedures are safe. We evaluated the safety of transvenous lead extraction of ICD or CRT-D, compared with that of pacemaker. Methods: Between August 2009 and September 2012, we collected data prospectively of 210 consecutive patients who underwent percutaneous transvenous lead extraction and compared incidence of major adverse events (MAE; death, myocardial infarction, stroke, cardiac tamponade, PE, blood transfusion or pneumohemothorax ) between PM and ICD or CRT implanted patients. Results: There were 129 patients (42.3%) with PM and 81 patients (57.7%) with ICD or CRT. All patients underwent successful transvenous removal of endocardial leads. Two of 81 patients (2.5%) had evidence of MAE in ICD or CRT group. No signiicant difference of MAE was found between two group (4.0 vs. 2.5%, P = 0.57). Conclusions: In patients with ICD or CRT, percutaneous transvenous lead extraction could be performed safely compared with PM lead extraction. www.jaib.com 244 October, 2013 | Special Issue Clinical Signiicance of Collateral Supericial Vein Across the Clavicle in Patients with Transvenous Permanent Device J. Hosoda, T. Ishikawa, K. Matsushita, K. Matsumoto, Y. Miki, Y. Kimura, Y. Ogino, Y. Taguchi, T. Sugano, T. Ishigami, S. Umemura Department of Cardiology, Yokohama City University Hospital, Yokohama, Japan Abstract Introduction: Obstruction of the access vein is a well-known complication after transvenous permanent device implantation. In that case, well-developed collateral supericial veins are frequently observed. We assessed the relationship between the venous obstruction and development of the supericial veins. Methods: A total of 100 patients scheduled for generator replacement were enrolled. The skin surface around the device was photographed. Contrast medium was injected into the peripheral arm vein, and venography was performed before generator replacement. Results: Venous obstruction was deined as a luminal diameter narrowing of > 75%. Venography showed the venous obstruction in 26 (26.0%) patients. We focused on a collateral supericial vein across a clavicle, because main routes of collateral circulation were through jugular veins. Of 100 patients, 42 (42.0%) had the supericial vein across the clavicle. Sensitivity of the presence of the supericial vein across the clavicle in the diagnosis of the venous obstruction was 96.2% and speciicity was 77.0% (p<0.001). Conclusions: The presence of the supericial vein across the clavicle is useful for the prediction of the venous obstruction in patients with transvenous permanent device. www.jaib.com 245 October, 2013 | Special Issue CRT: Techniques & Imaging Aspects Expression of Genes After Right Ventricular Apical Pacing E. Simantirakis, I. Kontaraki, E. Arkolaki, S. Chrysostomakis, A.P. Patrianakos, P.E. Vardas Cardiology Department,University Hospital of Heraklion, Heraklion, Crete, Greece Abstract Purpose: To assess in the peripheral blood alterations of genes related to contractile function, after right ventricular apical pacing in patients with preserved systolic function. Methods: We divided 30 patients into group A with ventricular pacing post-implant>90%, and group B (controls) with preserved atrioventricular conduction. At the time of implantation and 3 months later, we evaluated in the peripheral blood mRNA concentrations of sarcoplasmic reticulum calcium ATPase (SERCA) and β-myosin heavy chain (β-MHC), as well as left ventricular end-diastolic and end-systolic diameter and ejection fraction. Results: In group A at 3-months follow-up, mRNA levels of SERCA decreased (9,3±1,49 vs 4,04±1,33 p=0,021) and β-MHC mRNA levels increased (62,12±46,97 vs 424±245 p=0,127). Echocardiographic parameters remained unaltered.In controls all measured parameters showed no signiicant changes. Conclusion: Permanent right ventricular apical pacing is associated with alterations, in the peripheral blood, in genes regulating ventricular contractile function, while at the same time ventricular function has not yet deteriorated. www.jaib.com 246 October, 2013 | Special Issue The Inluence of Right Ventricular Apex (RVA) Pacing on Left Ventricular Ejection Fraction is Minimal T. Sakai, T. Muramatsu, R. Tsukahara Department of Cardiovascular Medicine, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan Abstract Introduction: It is not clear if RVA pacing is acceptable or not. Methods: We enrolled 230 patients who underwent permanent pacemaker implantation and were followed for at least one-year. Of these patients, we included those paced from the RVA (223 pts) with the following indications; atrioventricular block (AVB): 122, sick sinus syndrome (SSS): 86, atrial ibrillation and bradycardia (AFB): 12, and relex syncope (RS): 3. If a patient’s RV pacing ratio was over 40%, we used ultrasound cardiography to evaluate the impact on LVEF using a 50% cut-off. Results: Five patients (AVB: 4 and AFB: 1) were excluded due to an LVEF under 50% before implantation. Final qualifying cases for analysis included 82 with AVB, 2 with SSS, and 11 with AFB. The patients whose LVEF decreased below 50% during follow up were 14 AVB cases, 0 SSS cases, and 2 AFB cases resulting in a composite of 16.8%. Conclusions: Lead placement at the RVA seems acceptable. Therefore, RVA implantation can be thought as a base strategy and if necessary CRT-P upgrade is now common and easy to perform. www.jaib.com 247 October, 2013 | Special Issue Atrial Lead Location Plays an Important Role to Avoid Unnecessary Ventricular Pacing During Both Atrial Pacing and Atrial Sensing C. Suga, Y. Sugawara, T. Hayashi, T. Mitsuhashi, S. Momomura Department of Cardiology, Jichi Medical University Saitama Medical Center, Saitama, Japan Abstract Introduction: It is important to avoid unnecessary ventricular pacing (VP) to prevent adverse cardiac events in patients undergoing pacemaker implantation. However, right atrial (RA) pacing sometimes causes prolongation of PQ interval leading to increase of VP frequency. The purpose of this study was to determine if there was any favorable atrial lead location to avoid unnecessary VP. Methods: This study included 18 patients who had sinus rhythm and spontaneous atrio-ventricular conduction, and undergoing pacemaker implantation or electrophysiological study (11 males, mean age 62+/-18.5 years). Ventricular lead was placed in right ventricular (RV) apex or septum, and RA lead was placed in RA appendage (RAA), high RA septum (HAS) and low RA septum (LAS) in series in each patient. The following parameters were obtained from ECG and compared according to 3 atrial lead locations: P width, interval from atrial pacing (AP) spike to QRS (AP-QRS), and the shortest AV delay which enables avoidance of VP (Non-VP AVD) during AP, interval from onset of P wave to local A wave (P-AS), interval from local A wave to QRS (AS-QRS) and Non-VP AVD during atrial sensing (AS). Results: During AP, P width (112.8+/-26.8 vs 103.8+/-19.8 vs 88.8+/-26.5[ms], p<0.05), AP-QRS (186.1+/-42.6 vs 170.5+/-36.2 vs 146.4+/-33.9[ms], p<0.05) and Non-VP AVD (231.7+/-47.4 vs 209.4+/-48.9 vs 190.6+/-52.5[ms], p<0.05) were shortest during LAS pacing. During AS, LAS lead location resulted in the longest P-AS (5.6+/-18.9 vs 7.1+/-18 vs 28.6+/-32.9[ms], p<0.05), the shortest ASQRS (163.7+/-23.2 vs 164.2+/-24.7 vs 144.1+/-30[ms], p<0.05) and the shortest Non-VP AVD (180.6+/-31.9 vs 188.9+/-37.7 vs 157.2+/32.7[ms], p<0.05). Non-VP AVD correlated with AP-QRS (r=0.92, p<0.0001) and AS-QRS (r=0.73, p<0.0001). . Conclusions: LAS lead location resulted in shortest Non-VP AVD due to shortening of atrio-ventricular conduction during AP, and due to prolongation of the interval from onset of atrial activation to atrial sensing during AS. LAS atrial lead positioning seems to be most favorable to avoid unnecessary ventricular pacing under the presence of spontaneous atrio-ventricular conduction. www.jaib.com 248 October, 2013 | Special Issue Effect of Right Ventricular Pacing from Alternate Sites for Left Ventricular Function A. Baimbetov, S. Ivanova, N. Kosybayeva, D. Marat, T. Moldabekov, T. Eskaraev, B. Iskakova Cardiology Department, Republican Scientiic Center for Emergency Medicine, National Medical Holding Astana, Kazakhstan Abstract Objectives: To evaluate the effect of alternate sites of right ventricular (RV) pacing on left ventricular (LV) function and hemodynamics in patients with bradyarrhythmias. Permanent right ventricular apical (RVA) pacing may result in altered LV hemodynamics and a higher incidence of heart failure. Methods: We observed 117 patients (age 58±27 years, 52 men) with AV block III, who underwent permanent dual chamber pacemaker implantation. To 63 patients RV lead has implanted middle area of RV septum (RVMS) and 54 patients’ RV lead has implanted traditionally to right ventricular apex (RVA). Color tissue velocity imaging was performed to analyze time to peak systolic velocity (Ts) in a 12 segment model of the LV for each pacing site. Measurements included standard deviation of time to peak systolic velocity (SD-Ts) for all segments, maximal difference in Ts between any 2/6 basal (Ts-B), any 2/6 mid segments (Ts-M) and maximal Ts difference between any 2/12 segments (Ts-12). Stroke volume was estimated using Doppler velocity time integral (TVI) in the left ventricular outlow tract (LVOT). QRS width for each site was recorded. Measurements were observed by transthoracic echocardiography and electrocardiography, before and 12 month later after implantation.. Results: Ts-12 was signiicantly higher with RVA - pacing (107 ms, p=0.003) compared to RVMS - pacing (81 ms) sites. SD-Ts was signiicantly higher with RVA - pacing (38.5 ms, p=0.01) than RVMS - pacing (28.7 ms). QRS duration was longest for RVA - pacing (157 ms) while signiicantly shorter RVMS - pacing (115 ms, p<0.001). LVOT VTI was signiicantly higher for RVMS - pacing than for RVA (p=0.0014) pacing. Conclusions: Right ventricular mid-septal pacing may reduce electro-mechanical dyssynchrony compared to RVA pacing and RVMS – pacing to effect better LV function and hemodynamics than RVA pacing in patients with permanent pacemaker implantation. www.jaib.com 249 October, 2013 | Special Issue Two Years Experience of a Dose-Reduction Oral Anticoagulant Therapy Program In Patients with Cardiac Stimulation Devices J.J. Ferrer Hita, A. Rodriguez-Gonzalez, R.A. Juarez-Prera, P. Machado-Machado, L.M. Perez-Hernandez, J.M. Raya-Sanchez, A. Lara-Padron, F. Bosa-Ojeda, F. Marrero-Rodriguez, I. Laynez-Cerdena Arrhythmia Unit, Cardiology Department and Haematology Department. Hospital Universitario de Canarias. La Laguna, Santa Cruz de Tenerife, Spain Abstract Introduction: Our purpose was to analyze our experience after starting an oral anticoagulant therapy (OAT) dose-reduction program in patients with a cardiac stimulation devices (CSD) indication. Methods: Prospective analysis of 88 patients with OAT referred for a CSD implant/replacement. We analyzed baseline characteristics, patients’ treatment and OAT indication. We analyzed thrombotic and bleeding risk for all patients. We adjust the OAT dose for an INR the day of intervention of 1.5-2 in patients with low thrombotic risk and 2-2.5 in high risk patients. We analyzed the incidence of hemorrhagic and thrombotic complications at baseline and at 45 days. Results: Variables associated with a higher incidence of complications were high haemorrhagic risk (p=0.001), low-weight heparin use (p=0.006) and >9 french introductors use (p=0.01). Older patients, high thrombotic risk, the implantation procedures and chronic renal failure showed a slightly but non-signiicant increase in the degree of complications (p=0.09, 0.08, 0.06, 0.08 respectively). The rest of variables are shown in the table. Conclusions: Maintenance of OAT with dose-reduction in patients with CSD indication is a safety approach with a low risk of complications. Table : patients variables analyzed. Mean age (years) 73,6 ± 10,6 CSD Procedure Implants: 54 (60%) Replacement: 34 (40%) - Pacemakers: 30 - Pacemakers: 46 - ICD-CRT: 4 - ICD-CRT: 8 Preprocedure Thrombotic Risk High: 24% Moderate: 34% Preprocedure Haemorrhagic Risk High: 13% Low: 87% INR at procedure day 1,70 ± 0,38 Acute haemorrhagic complications Mild-moderate: 11 (12%) Acute thrombotic complications 1 (1%) Persistent later complications Hematoma and pocket infection: 2 (2%) Low: 42% Severe: 1 (1%) CSD: cardiac stimulation devices. INR: International Normalized Ratio. ICD: implantable cardioverter-deibrillator. CRT: resynchronization device. www.jaib.com 250 October, 2013 | Special Issue Early Physical Activation of Patients and Early Postprocedural Complications After Pacemaker Implantations R. Marchenko, S. Durmanov, V. Bazilev Heart Rhythm Disturbances Department Federal Center of Cardiovascular Surgery Penza, Russia Abstract Introduction: In existing guidelines ACC/AHA/HRS and ECS there are no clear instructions about periods of patient physical activation after pacemaker implantation procedures. Objectives: To assess the amount and structure of early postprocedural complications after primary pacemaker implantations in association with time of patient physical activation. Materials and methods: 259 patients after primary pacemaker implantations were included in our study with randomization 1:2. In the irst group (80 patients) coninement to bed was discontinued 3 hours after the procedure while in the second group (179 patients) – 1520 hours after the procedure. We assessed complications associated with lead displacement, pocket hematoma and others (embolism, pneumonia, stroke, etc.). During implantation procedures we used only leads with active ixation. Mean period of patient observation was 5 days. Results: The second group included more patients with dual chamber pacemakers (p=0,02), the duration of procedures was longer (p=0,0006), aspirin and warfarin administration was more common (p<0,0001 and p=0,03 respectively). Lead displacement was diagnosed in 5 patients, differences between groups were insigniicant (p=0,62). Pocket hematoma occurred in 13 patients and the differences were also insigniicant (p=0,97). We did not observe other complications in our patients. Pocket hematomas usually occurred to 4th day after the procedure. Aspirin administration seems to be an independent predictor of this complication (p=0,02). Conclusions: Early physical activation of patients after primary pacemaker implantations does not affect the rate of such complications as lead displacement or pocket hematoma formation. Administration of aspirin increases the risk of hematoma. Considering the time of hematoma occurrence it is suitable to check the pocket during irst 4 days after implantation. www.jaib.com 251 October, 2013 | Special Issue Cardiac Pacing in a Transplanted Heart: Special Features and 2-Year Follow-Up O.V. Sapelnikov, M.A. Sagirov, V.V. Sokolov, I.R. Grishin, A.S. Partigulova, D.I. Cherkashin, R.S. Latypov, A.Sh. Khubutia, R.S. Akchurin Cardiology Research Center; N.V. Sklifosovsky Scientiic Research Institute of First Aid, Moscow, Russia Abstract Background: Heart transplantation is becoming more popular in Russia nowadays. The transplanted heart is characterized by autonomic denervation, chronotropic incompetence and intermittent episodes of allograft rejection. Pacemaker-requiring bradyarrhythmias after cardiac transplantation are common, and rarely can lead to sudden cardiac death. Materials: In our study we included 14 patients who were undergone cardiac transplantation and permanent pacemaker implantation from 2009 up to 2011 yy. We used dual chamber devices with active ixation leads. Results: Recipients, aged 54±4 years (donors, 43 ±6 years), were monitored 24±5 months. Acute pacing thresholds were 1.2±0.25 V and 1.1±0.33 V for ventricular and atrial leads, correspondingly. Sensing of R-wave was 12.9±4.6 mV in acute postoperative period. One patient died from pneumonia within 1 month after transplantation. In all patients we programmed DDDR-mode with lower rate limit at 90 bpm , reduced it after 1 week up to 80, and after 6 months of observation - up to 70 bpm. After 1 year we found that the ventricular-pacing threshold slightly increased up to 1.6±0.3 V, and sensing of R-wave decreased to 8.8±3.2 mV. In two cases we observed a twofold decrease in sensing and increase in threshold, which was corresponded with chronic rejection 1A stage (ISHLT). Once we observed double sensing of P-wave (recipient’s sinus node signal) which required optimization of atrial sensing parameters. Conclusions: Our preliminary data showed that decrease in pacemaker sensitivity and increase in pacing threshold may be considered as the sign of chronic rejection syndrome. Thus, remote monitoring systems should be used for such patients . www.jaib.com 252 October, 2013 | Special Issue Placing Right Ventricular Lead into the Thinner Part of Interventricular Septum Tends Tto Shorten Paced QRS Duration V. Dmytro, L. Dmytro Diagnostic department, Institute of surgery of NAMSU, Kharkov, Ukraine Abstract Objectives: Nowadays the beneit and preferable spot of septal RV pacing is still controversial and not well established. Our aim was to investigate a correlation between QRS duration and position of electrode in the septum in bradyarrhythmic RV pacing depending on relative septum wall thickness (RSWT) evaluation. Methods: During the period of 2 years 56 patients with bradyarrhythmias were involved into investigation (age 72±8 yrs, 43% males (n=24)). In a month after pacemaker implantation we assessed QRS duration on ECG (KhAI Medica, Kharkiv, Ukraine) and the location of RV lead by conventional EchoCG (Cypress, Siemens, Germany) using standard and intermediate oblique echo views. Data received from EchoCG was decisive in determination of RV lead location with accepting for further analysis leads in septum area, including RVOT (21%, n=12), mid- (54%, n=30) and low (25%, n=14) positions. We assessed RSWT in place of lead implantation by equation RSWT=h/H (described on the picture), where (h) – septum thickness in the place of interest, (H) - average septum thickness, calculated as H=S/L, where (S) - septum square determined by planimetry, (L) - septum longest longitudinal dimension. Results: According to our data in 39% of patients (n=22) the thinner part of septum localized in the border of mid and low parts. In 48% of patients (n=27) the thickest place was in the high septum. In 16% of patients (n=9) septum has approximately equal width throughout. Average QRS duration was 155±17ms in RVOT, 143±15ms in mid-septum and 152±18ms in low-septum. In patients with lead implanted in the thinnest part of the septum (RSWT ≤ 1.05, 55%, n=31) duration of QRS was signiicantly shorter than those with RSWT > 1.05 (45%, n=25) – 142±15 ms vs. 153±17 ms (p – 0.07). Conclusions: Placing RV lead into the thinner part of interventricular septum tends to shorten paced QRS duration. RVOT in most cases in our group was not optimal pacing site because of anatomical features (thicker septum with longer paced QRS) that would contradict the common approach taken to physiological pacing in some studies. www.jaib.com 253 October, 2013 | Special Issue Pediatric Cardiac Resynchronization After Heart Transplant with Transvenous Dual Chamber Pacemaker Using Isolated Left Ventricular Pacing Via a Coronary Vein J.M. Baggio Jr, C.M. C. Aiune, J.Y. Aiune, A.V.L. Sarabanda, L.G.G. Ferreira, W.L. Gali, G.G. Gomes, G.M. Succi Institute of Cardiology-DF Department of Cardiology Electrophysiology and Cardiac Device Unit, Brasilia, Brazil Abstract Introduction: In children with atrioventricular (AV) block and pacemaker (PM) indication, the degree of pacing-induced dyssynchrony varies between the different pacing sites. Case Report: A 12-year-old child, with heart failure was treated by cardiac transplantation and developed transient graft failure managed with ECMO during 48 hours. A postoperative complete AV block occurred and a PM was indicated. To avoid LV desynchronization was proposed a transvenous dual chamber PM using isolated LV pacing via coronary sinus (CS). A guiding catheter was introduced into left subclavian vein and placed into the CS to perform a venogram. An endocardial pacing lead with active ixation mechanism was implanted into the anterior inter-ventricular vein branch. A second pacing lead was implanted at the right atrium. The leads were secured and connected to a dual chamber PM (Fig. 1,2). The post implant echocardiographic evaluation showed absence of inter-ventricular and intraventricular dyssynchrony. Conclusions: With the development of dedicated, transvenous, LV leads with active ixation mechanism, ventricular pacing via the CS is a viable and safety option to perform isolated LV pacing in children with AV block. www.jaib.com 254 October, 2013 | Special Issue Optimization of Clinical Responseto Cardiac Resynchronization Therapy Using Noninvasive Electrocardiographic Imaging And Echocardiography A. Revishvili, T. Dzhordzhikia, O. Sopov, E. Labartkava, S. Matskeplishvili, V. Kalinin Bakulev Scientiic Center for Cardiovascular Surgery, Moscow, Russia Abstract Background: The study aimed to evaluate impact of electrical and mechanical dissynchrony assessed by surface ECG based imaging technology combined with CT scan and echocardiography on the beneit of cardiac resynchronization therapy (CRT). Methods: We applied noninvasive mapping using 240-lead ECG combined with CT scan based anatomy (Amycard, RUS) to 6 patients undergoing CRT. Patients had EF≤35%, QRS duration of at least 120 ms, NYHA class III-IV. Atrioventricular and intrventricular intervals were optimized by echocardiography and electrocardiographic imaging guidance. Results: In all this cases we found an optimal coronary vein to position LV electrode in the latest electrically-activated area. During the average follow-up period of 6 months in all patients EF increased on 35, 6% from initial, end diastolic and end systolic volumes decreased signiicantly, NYHA class improved to I-II. Conclusions: Initial experience with noninvasive 3D mapping system combined with CT scan shows its clinical utility, feasibility to provide noninvasive characterization of coronary vein anatomy, epicardial activation sequence and precise determination of the latest activated region, and leads to maximization of the hemodynamic improvement after CRT. www.jaib.com 255 October, 2013 | Special Issue Ventricular Desynchronization Pattern in Right Apical Pacing or Left Bundle Branch Block G. Neri1, G. Masaro1, S. Vittadello1, D. Vaccari1, L. Leoni2, B. Bauce2, G. Buja2, A. Barbetta3, F. Di Gregorio3 1Cardiology Dept, San Valentino Hospital, Montebelluna, Italy; 2Cardiology Clinic, Padua University; 3Clinical Research Unit, Medico Spa, Rubano, Italy Abstract Introduction: Ventricular pacing results in QRS widening and increased electromechanical latency. The present study has assessed whether these effects mimic a condition of left bundle branch block (LBBB). Methods: Electrocardiographic and echo-Doppler evaluation was performed during routine follow-up checks in 20 pacemaker patients provided with intrinsic AV conduction (IAVC): 17 cases featured synchronous ventricular activation (QRS duration < 120 ms) and 3 were affected by LBBB. The time from the QRS onset to the start of pulmonary and aortic low (Q-Po; Q-Ao) was measured in the presence of IAVC as well as with sequential right-ventricular apical pacing (RVAP) Results: Mechanical interventricular desynchronization (Po-Ao delay > 40 ms) was demonstrated in all patients showing LBBB on the ECG. In contrast, RVAP acutely induced interventricular dyssynchrony in only 3/17 patients featuring synchronous IAVC (18%). When RVAP did not affect the interventricular synchronization, the electromechanical latency was increased in both right and left ventricle to a similar extent (Tab. 1). Conclusions: Unlike LBBB, RVAP generally delays the aortic and pulmonary ejection as well, suggesting a bilateral activation delay in the basal region. Table 1: LBBB Narrow QRS; VV dyssynchrony on RVAP Narrow QRS; VV synchrony on RVAP www.jaib.com Electromechanical activation parameters QRS duration (ms) Q-Po (ms) Q-Ao (ms) Po-Ao (ms) IAVC 149 ± 14 79 ± 4 140 ± 23 61 ± 27 RVAP 190 ± 12 118 ± 33 170 ± 21 44 ± 3 IAVC 86 ± 17 74 ± 12 87 ± 17 13 ± 13 RVAP 161 ± 13 86 ± 30 156 ± 20 70 ± 11 IAVC 86 ± 10 74 ± 17 82 ± 20 8 ± 14 RVAP 163 ± 19 132 ± 20 144 ± 23 12 ± 11 256 October, 2013 | Special Issue Relationship Between Paced QRS Duration and Underlying Conduction Disturbances in Patients with Normal Heart Function T. Tokano, Y. Nakazato, S. Komatsu, M. Sugihara, K. Komatsu, M. Yamase, H. Hayashi, G. Sekita, M. Sumiyoshi, H. Daida Cardiology, Juntendo University Urayasu Hospital, Urayasu, Japan Abstract Introduction: Wide paced QRS duration relects large ventricular conduction delay. The aim of this study was to detect relationship between paced QRS duration and underlying conduction disturbances. Methods: Study subjects were 125 patients with a DDD pacemaker (mean 76±9 year-old, 65 males, RV apical pacing in 61 and non-apical pacing in 63) and preserved LV function. Underlying conduction disturbances were sinus node dysfunction (SND) in 25, AH/BH block in 60 and HV block in 34 patients. Paced QRS duration was compared among those groups. Results: Paced QRS duration was signiicantly wider in patients with HV block (178 ± 12 msec) than in patients with SND and AH/BH block (159 ± 17 and 155 ± 14 msec, p<0.01). This tendency was similar if compared among the patients with non-apical pacing. Positive correlation between the intrinsic and paced QRS duration was also found (r=0.48, p<0.01). Conclusions: Patients with HV block showed wider paced QRS duration regardless of the RV pacing site. Conduction disturbance may exist more widely in the ventricle in patients with HV block, therefore, they are potentially candidate for CRT. www.jaib.com 257 October, 2013 | Special Issue CRT: Clinical Aspects & Optimization NT-PROBNP: Additional Value in CRT Patients? A. Magalhães, N. Cortez-Dias, D. Silva, C. Jorge, P. Carrilho-Ferreira, A. Bernardes, C. Coelho, P. Marques, J. Sousa Cardiology Department, Hospital de Santa Maria, Lisbon, Portugal Abstract Introduction: The role of NT-proBNP in diagnosis and prognosis in heart failure (HF) patients (pts) is well established. We aimed to assess the relation between NT-proBNP and response to CRT and evaluate its prognostic value in this group of pts. Methods: Prospective study of consecutive pts proposed for CRT. NT-proBNP was measure prior to implantation. Echocardiogram was performed at baseline, 3, 6 and 12 months after CRT. Prognosis was assessed by the combined endpoint of death or hospitalization for HF during the follow-up. Results: We studied 50 pts, 69±8years. At baseline, ejection fraction (EF) was 28±10% and NT-proBNP was 2751±3602 pg/mL. NTproBNP did not predict the EF reduction during the follow-up. The endpoint occurred in 12% of pts. NT-proBNP was signiicantly higher in those pts (p=0.017) and showed moderate accuracy in predicting an adverse outcome (AUC=0.80, 95%CI:0.66-0.94, p=0.017). Elevation of NT-proBNP was associated with a lower event-free survival (p=0.026) and with a higher risk of unfavorable outcome (HR:5.5, 95%CI:1.0130.2; p=0.049). Conclusions: NT-proBNP did not predict echocardiographic response to CRT. As in general HF population is a predictor of unfavorable outcome. www.jaib.com 258 October, 2013 | Special Issue Novel Non-Invasive Mapping Reveals Variable Electrical Synchrony During Multipolar Pacing - Potential New Tool for Vector Optimization J. Sperzel, S. Lehinant, M. Jung, M. Kuniss, S. Zaltsberg, T. Neumann Kerckhof Clinic, Department of Cardiology, Bad Nauheim, Germany Abstract Introduction: Left ventricular (LV) pacing and activation are important factors affecting CRT response. Recent advances in multipolar LV leads offer variable pacing conigurations. To evaluate activation patterns for various pacing vectors, a non-invasive biventricular mapping system (ECSYNC™, CardioInsight, OH) was used. Methods: CRT patients (n=10, 8 males, age 65±12, QRSd=178±16ms) with previously implanted quadripolar LV leads ( Quartet™, St. Jude Medical, MN) were evaluated during various follow-up visits (8±5 mo post-implant). LV lead positions included 6 posterolateral, 3 anterior, and 1 infero-apical. Patients had heterogeneous etiology including ischemic and nonischemic cardiomyopathy and various conduction disorders. In each patient, activation patterns and electrical synchrony were evaluated for each of the 10 pacing vectors using ECSYNC. Results: Visually assessable and quantiiable changes in activation and electrical synchrony were observed for each pacing vector. LV activation time varied by 31±11ms within each patient, but QRSd was not useful in delineating such changes and only varied by a nonspeciic 14±4 ms. Figure shows a typical patient with delayed sinus LV activation and 3 variable pacing vectors. Vector 10 improves all but anterior LV, Vector 2 improves all but LV base, and Vector 8 provides best overall LV activation. Conclusions: For the irst time, patient speciic variability in ventricular activation for various LV lead conigurations were mapped and quantiied using a novel CRT mapping system, demonstrating its potential for lead optimization. www.jaib.com 259 October, 2013 | Special Issue Atrial Fibrillation in Heart Failure Patients with CRT: Do we Induce The Arrhythmia with Short AV or Long VV Delays? V. Puetz, I. Seifert, D. Schmitz, C. Naber, O. Bruder Coltilia Heart and Vascular Center Department for Cardiology and Angiology, Essen, Germany Abstract Background: Cardiac resynchronization therapy (CRT) is beneicial for patients with medically refractory heart failure due to severe left ventricular (LV) systolic dysfunction and interventricular conduction delay. A hemodynamically optimzied atrioventricular (AVD) and interventricular delay (VVD) during CRT is important to maximize the response to this treatment and lower the rate of non-responders. While long atrioventricular delays (AVDs) reduce the left ventricular illing time resulting in an incomplete mitral valve closure and diastolic mitral regurgitation, a premature closure of the mitral valve during short AVDs may limit the atrial contribution to LV illing. Thus a dilatation of the left atrium can result possibly favouring the incidence of atrial ibrillation. A low biventricular stimulation proportion during atrial ibrillation often worsens heart failure. Aim of this study was to retrospectively evaluate the impact of short AVDs and long VVDs on the occurrence of atrial ibrillation in CRT patients. Methods: In a total of 150 patients, we reviewed the programming of the AVD and VVD as well as the long-term Holter with regard to the occurrence of atrial ibrillation (episodes longer than 5 seconds). In 70 patients an automatic hemodynamic optimization was performed with the QuickOpt algorithm upon implantation with iterative optimizations during follow-up visits. Results: In 42 % of all patients episodes of atrial ibrillation were documented. Mean AVD in the atrial ibrillation group was 161 ms paced and 120 ms sensed, mean VVD was 31 ms (range 0 to -65 ms). While VVDs in patients without documentation of atrial ibrillation were signiicantly shorter (mean VVD 23 ms, range 0 to -70 ms, p<0.01), also only sensed AVDs were shorter in the non-atrial ibrillation group (mean 115 ms, p<0.01). Conclusions: Atrial ibrillation is a frequent arrhythmia in heart failure patient. During CRT, the programmation of long VVDs seems to favour the occurrence of atrial ibrillation in this group of patients. Thus, a hemodynamic optimization is crucial for heart failure patients with biventricular pacing. www.jaib.com 260 October, 2013 | Special Issue Does the Quickopt Algorithm Provide Feasible Results For AV and VV Delays? I. Seifert, V. Puetz, D. Schmitz, C. Naber, O. Bruder Contilia Heart and Vascular Center Cardiology and Angiology, Essen, Germany Abstract Background: In patients with medically refractory heart failure due to severe left ventricular (LV) systolic dysfunction and interventricular conduction delay biventricular pacemaker stimulation can result in an increase of exercise function and left ventricular ejection fraction. A hemodynamic optimization of the atrioventricular (AVD) and interventricular delay (VVD) is crucial to maximize the response to this treatment and lower the number of non-responders. Various methods for optimization include echocardiographic studies, invasive measurements and electrogram-based algorithms. Most methods are time-consuming, thus CRT devices are frequently programmed to empiric recommendation instead of being optimized. The QuickOpt algorithm (St.Jude Medical, USA) provides a quick automatic hemodynamic optimization in CRT devices. Aim of this study was the comparison of the resulting AVDs and VVDs from the optimization via QuickOpt and empiric programming. Methods: We reviewed the follow-ups of a total of 250 CRT patients with St.Jude Medical CRT devices (Promote, Unify, Promote Quadra) retrospectively. The AVDs and VVDs were documented, patients were assigned to the QuickOpt group if the algorithm was utilized for routine follow-ups. Results: In 38 % of all patients of the QuickOpt algorithm was employed for the hemodynamic optimization on a routine basis. Mean AVD in the QuickOpt group was 171 ms paced and 122 ms sensed, mean VVD was 50 ms (range 0 to -75 ms). Empiric AVDs and VVDs were signiicantly lower than the QuickOpt measurements (p<0.01). Mean AVD in the empiric group was 156 ms paced and 113 ms sensed, mean VVD was 15 ms (range 0 to -75 ms). In all devices both ventricles were paced simultaneously or LV before RV. Conclusions: The performance of a hemodynamic optimization is crucial for heart failure patients with biventricular pacing. Algorithms for the timing cycle adjustment may provide signiicantly longer results for optimized AVDs and VVDs. Further investigations are necessary to improve the process of hemodynamic optimization and duration of that process. www.jaib.com 261 October, 2013 | Special Issue CRT: Long-Term Outcome Outcome of Cardiac Resynchronization Therapy in Patients with Chronic Heart Failure A. Baimbetov, B. Iskakova, S. Ivanova, D. Marat, T. Moldabekov, S. Borovsky, V. Open’ko Cardiology Department, Republican Scientiic Center for Emergency Medicine, National Medical Holding, Astana, Kazakhstan Abstract Background: A lot of clinical studies have shown that, cardiac resynchronization therapy (CRT) in a combination of optimal medical therapy authentically improves quality of a life and increases life expectancy of patients with heart failure (HF). Objectives: To demonstrate our experience of cardiac resynchronization therapy (CRT) usage and evaluate the effectiveness of CRT with the help of implantable CRT-devices in patients with heart failure. Methods: Since 2010 to 2012 have been implanted 55 CRT devices to patients with HF (age 59±5,7; 24 female). 49 patients had HF III NYHA class, and the remaining patients had IV ambulatory class of NYHA. 37 patients’ HF has been caused by ischemic cardiomyopathy, and other cases of dilated cardiomyopathy. In every case left ventricular (LV) lead was implanted successfully into post lateral coronary vein. All patients took an optimal medical therapy. The SF-36 survey was used to evaluate the quality of life of the patients. Results: Postoperatively, patients received an ambulatory monitoring. Testing and selection of optimal parameters for biventricular pacing were performed regularly, taking into account the subjective feelings and exercise tolerance. AV-delay parameters were set considering the optimal AV-synchronization. Evaluation of intra-cardiac hemodynamics was performed using trans-thoracic echocardiography. According to echocardiography data, intra-cardiac hemodynamics has signiicantly improved after 6,3 ± 4,5 months: LVEF increased from 31±5,2% to 42±3,7%, LVED volume decreased from 257,8±45,2 ml to 214,5±23,8 ml, LVES volume decreased from 197,5±23,9 ml to 144,6±17,1 ml, the severity of mitral regurgitation decreased from 2,5±0,72 to 1,6±1,17 and tricuspid regurgitation decreased from 2,3±0,37 to 1,7±0,91. The functional class of patients’ HF improved to NYHA class II in all cases. Conclusion: Biventricular resynchronization pacing in patients with chronic HF, with the optimal medical therapy being chosen, markedly improves heart functions by eliminating ventricular dyssynchrony, accompanied with a decrease in the functional class of HF and improvement of the patients’ quality of life . www.jaib.com 262 October, 2013 | Special Issue Chagas Disease and Cardiac Resynchronization Therapy . Results and Predictors in 82 PP During Two Years of Follow-Up J.R. Castro Dorticos1, S. Dos Santos Galvao Filho2, J.P. Velasco Pucci2, J.T. Medeiros De Vasconcelos2, R. Cardoso Jung Batista1, B. Papelbaum2, C.S. Duarte2, L. Laite2, R. Marrero3, C.K. Lins2 University Hospital of Guadalajara, Guadalajara, Spain 2 Hospital Beneicencia Portuguesa of Sao Paulo, Clinic of Rhythmology Cardiac, Sao Paulo, Brazil 3 Institute of Cardiology, Havana, Cuba 1 Abstract Introduction: Cardiac Resynchronization Therapy (CRT) has resulted an effective treatment for heart failure (HF) in patients with systolic dysfunction and ventricular dyssynchrony. In Chagas disease (CD)however this teraphy dont have large studies and the records in the literature are limited to a few series cases .We present a cohort of 82 patients (pts) of our experience with CRT in CD. Methods: Between January 1992 and May 2012, 112 pts with CD and HF were submitted to CRT. Clinical records of 82 pts were analyzed retrospectively: 47 males (57.3%) and 35 females (42.6%) with a mean age of 54.25 years. Preoperatively, 27 pts (33%) were in NYHA class IV, 50 pts (61%) in NYHA III, 5 pts (6%) in NYHA II and none in NYHA I. All pts had intraventricular conduction disturbances: 50 pts (60.9%) with Right Bundle Branch Block (RBBB) + Left Anterior Fascicular Block (LAFB) and 32 pts (39%) with Left Bundle Branch Block (LBBB). Mean width of QRS complex was 186.1±31.31 ms. The echocardiogram showed important systolic dysfunction in all pts with mean Ejection Fraction (EF) of 27.71±10.44%. All 82 pts were submitted to CRT, 69 pts (84.14%) received a CRT pacemaker (CRT-P) and 13 pts (15%) a CRT deibrillator (CRT-D). The statistical analysis of data was performed using the program SPSS Statistics v. 20.0. In mean follow-up of 24.5±39.7 months we observed clinical beneits in 80% of pts. 19 pts (23%) were in NYHA class I, 47 pts (57%) in NYHA class II, and 16 (20%) remained in NYHA class III or IV (p < 0.0001). There was a signiicant reduction of the mean width of QRS complex after CRT (110.55±9.72 ms, p<0.0001). The PR interval decreased from 202.9 ms to 133.45 ms (p<0.0001). The number of hospitalizations also showed a signiicant reduction from 2.84 to 0.89 post intervention (p<0.0001). Results: In terms of medications, we found a signiicant reduction in the average doses of diuretics (from 60mg before to 35mg after surgery, p<0.0001) and a signiicant increase in the average doses of Beta Blockers (from 22.2 mg to 35 mg after surgery, p<0.0001). There was also a considerable improvement in EF from 27.71±10.44% pre implantation to 35.77±9.72% post treatment (p< 0.0001). We observed a total of 29 (35.36%) deaths, all in patients with CRT-P. 25 deaths (86.2%) were from cardiac causes and 13 (52%) were sudden. There no episodes of sudden death in the CRTD arm, but all patients in this arm had appropriate therapies for ventricular arrhytmias. Conclusions: There was no difference in results among patients with LBBB and RBBB+LAFB. The position of the left ventricular lead and the distance between the left and righ leads show signiicative diference in the acute response to the theraphy.CRT proved to be useful in the treatment of refractory HF of CD in the cases studied. Considering the high mortality for sudden cardiac death, even in the group of good responders with CRT-P, we should always consider the indication of CRT-D for those pts. www.jaib.com 263 October, 2013 | Special Issue Survival of Patients with CRT-D Compared to Survival With ICD M. Hudák, M. Kerekanič, E. Komanová, P. Olexa, J. Sedlák, S. Misíková, A. Bohó, B. Stančák Department of arrhythmias, he eastern slovak institute of cardiovascular diseases, Kosice, Slovakia Abstract Introduction: Wide QRS complex in patients with heart failure (HF) is associated with higher all-cause mortality rate compared to narrow QRS. Our aim was to evaluate survival of HF patients according to QRS duration and device implanted. Methods: We performed retrospective trial and enrolled 899 patients with advanced HF, optimal medical therapy and EF ≤ 35%. Patients were assigned to two groups according to QRS duration. First group (n=536) with narrow QRS (<120 ms) received ICD, second group (n=363) with wide QRS (≥ 120 ms) received CRT-D. The primary outcome was time to death from any cause. Results: During average follow-up of 827 days, the primary outcome occurred in 156 of 536 patients in the ICD group (29,1%) and 85 of 363 patients in the CRT-D group (23,4%). We found a tendency to better survival of CRT-D patients, but not statistically signiicant (p=0,24) (HR 0,85; 95% CI 0,65 to 1,11). Conclusions: We did not ind statistical signiicant difference in survival in both groups of patients. We assume good effect of CRT to eliminate adverse effect of dyssynchrony on survival. www.jaib.com 264 October, 2013 | Special Issue Ablation of Different Cardiac Arrhythmias Location of Accessory Pathway Affects Brain Natriuretic Peptide Levels in the Patients with Wolff-Parkinson-White Syndrome K. Kumagai, S. Naito, K. Nakamura, K. Minami, M. Nakano, K. Ikeda, T. Sasaki, S. Oshima Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan Abstract Introduction: AIn the patients with Wolff-Parkinson-White (WPW) syndrome, left ventricular dyssynchrony was caused by premature ventricular activation, and it sometimes causes ventricular dysfunction; however, relation between the location of accessory pathway and brain natriuretic peptide (BNP) levels was not fully elucidated. Methods and Results: 68 patients (48.6±19.9 years) with WPW syndrome who received a catheter ablation in our institution were studied. The patients were divided into four groups; those with manifest right or septal accessory pathway (MRS group, n=11), manifest left accessory pathway (ML group, n=24), concealed right or septal accessory pathway (CRS group, n=5), and concealed left accessory pathway (CL group, n=28). There were no differences in left atrial dimension, left ventricular dimension and left ventricular ejection fraction among these groups; however, BNP levels were signiicantly higher in MRS group compared to other groups (MRS group 98.9±85.7, ML group 32.8±86.8, CRS group 17.4±6.4, and CL group 37.1±51.5 pg/ml; P<0.05). Conclusion: Anterograde conduction with right or septal accessory pathway may cause left ventricular myocardial stretch and increase BNP levels. www.jaib.com 265 October, 2013 | Special Issue Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia with Targeting Lower Region of his Potential Recording Area M. Fujimoto, T. Ikeda, M. Kiyama, K.Okeie Department of Cardiology, Kouseiren Takaoka Hospital, Toyama, Japan Abstract Background: Catheter ablation (CA) for cure of atrioventricular (AV) nodal reentrant tachycardia (AVNRT) has been established; electrophysiologic slow pathway potential mapping or the anatomic approach within the triangle of Koch has been performed. These slow pathway ablation techniques have a high success rate. In this study, we would like to report an ablation technique of AVNRT; targeting a slightly low region from His bundle potential recording area. Subjects and methods: From December 2009 to July 2011, we performed CA of AVNRT in 14 cases with using CARTO system. 8 patients were male. The mean age was 57 years old. 12 cases had slow/fast AVNRT, and one had fast/slow AVNRT. His bundle potential recording area was marked in a igure of CARTO system. We targeted the region where was a little bit lower from lowest area of His bundle potential recording. Results: All cases presented junctional rhythm during CA. Loss of dual AV nodal physiology was achieved in 12 cases. 2 cases still had dual AV nodal pathology with a single-echo beat. Conclusions: The ablation of AVNRT; targeting a slightly low region from His bundle potential recording area, was also useful to eliminate slow pathway of AVNRT. www.jaib.com 266 October, 2013 | Special Issue Near Zero Fluoroscopic Exposure During Catheter Ablation of Supraventricular Arrhythmias: Multicenter Randomized No-Party Trial Preliminary Results M. Casella, aA. Dello Russo, §G. Pelargonio, “M. Del Greco, &G. Zingarini, *M. Piacenti, # A. Di Cori, “M. Marini, M. Zucchetti, aE. Russo, §M. Narducci, °P. Santangeli, °L. Di Biase, *E. Picano, # M. Bongiorni, °A. Natale, aC. Tondo a a Centro Cardiologico Monzino, IRCCS, Milan, Italy § Catholic University of the Sacred Heart, Rome, Italy # Department of Cardiovascular Disease 2, S. Chiara Hospital, Hospital University of Pisa, Italy “ Department of Cardiology, S. Chiara Hospital, Trento, Italy &Ospedale Santa Maria della Misericordia, ASL Perugia, Italy * CNR, Institute of Clinical Physiology, Fondazione G. Monasterio, Pisa, Italy ° Texas Cardiac Arrhythmia Institute at St Davis Medical Center, Austin, TX, USA a Abstract Introduction :Radiofrequency catheter ablation (RFCA) is the mainstay of therapy for supraventricular tachyarrhythmias (SVT). Conventional ablations require the use of luoroscopy Methods: From December 2009 to July 2011, we performed CA of AVNRT in 14 cases with using CARTO system. 8 patients were male. The mean age was 57 years old. 12 cases had slow/fast AVNRT, and one had fast/slow AVNRT. His bundle potential recording area was marked in a igure of CARTO system. We targeted the region where was a little bit lower from lowest area of His bundle potential recording. Results: RFCA was successful in all patients without complications. No signiicant differences were found between two Groups in mean procedure time (95±42 vs 90±36 minutes) and mean radiofrequency delivery time (430±361 vs 443±387 seconds). In 98/134 (73%) Group B patients electroanatomical mapping avoided luoroscopy entirely. We observed a reduction in luoroscopy time (1±2 vs 17±13 minutes, p< 0.001) and radiation dose (260±1158 vs 6447±11126 mGy/m2; p< 0.01) in Group B in comparison to Group A. Conclusions: This is the irst multicenter randomized trial showing that RFCA of SVT guided by the non-luoroscopic EnSite NavXTM mapping system is an effective and safe approach to achieve a clinically signiicant reduction in ionizing radiation exposure for patient and as a consequence for operator. www.jaib.com 267 October, 2013 | Special Issue The Impact of Lower Voltage Area and Gross Area of Left Atrium on the Prognosis After Electrophysiological Characteristics in Atrio-Ventricular Nodal Reentrant Tachycardia with Continuous Atrio-Ventricular Node Function Curve 1 W.J. Park, Y.J. Choi, 1S.H. Lee, 1D.G. Shin, 2H.S. Park, 2Y.N. Kim, 3M.H. Bae, 3Y.K. Cho, 4Y.S. Lee , 5B.C. Jung cardiology department, Yeungnam university hospital, Daegu, Korea, 2cardiology department, Keimyung university hospital, Daegu, Korea, 3cardiology department, Kyungpook national university hospital, Daegu, Korea, 4cardiology department, Daegu catholic university hospital, Daegu, Korea 5 cardiology department, Fatima medical centre, Daegu, Korea 1 Abstract Background :We sought to evaluate electrophysiological characteristics in AVNRT with continuous AV node function curve. Material and Methods: From September 2012 to February 2013, 12 patients who underwent catheter ablation for AVNRT were enrolled in Yeungnam University Medical Center. The study population was categorized into 2 groups. Group 1 included 6 patients with discontinuous AV node function curve and group 2 included 6 patients with continuous AV node function curve. The differences between pre- and post-catheter ablation were evaluated in each group. And the differences between 2 groups were also analyzed and compared. Results: In both groups, maximal AH interval during atrial pacing or atrial extra-stimulus test was shortened signiicantly after catheter ablation(in group1, 373.0±93.6vs. 190.7±21.0,p=0.009 in group2, 335.8±125.5 vs. 240.8±92.2, p=0.001). There was no signiicant difference including baseline cycle length, AH interval, anterograde AVN ERP and AV block cycle length between pre- and post-catheter ablation in each group. Retrograde conduction capacities were not evaluated in this study. Conclusions: The signiicant shortening of maximal AH interval after catheter ablation suggests successful elimination of AVNRT. www.jaib.com 268 October, 2013 | Special Issue Tetra Loop Pulmonary Vein Related Postablational Atrial Flutter E. Lyan, G. Gromyko, S. Yashin Cardiac Electrophysiology Department, Pavlov State Medical University, Saint-Petersburg, Russia Abstract Introduction :One of the mechanisms of atrial tachycardia (AT) after initial pulmonary vein (PV) isolation is PV-gaps related left atrial (LA) lutter. Tetra loop PV related atrial lutter had not been previously described. We report the case of tetra loop PV related LA lutter with inconsistent activation of coronary sinus (CS). Methods and results: Patient was reffered to catheter ablation of AT occured after initial PV isolation. CS showed inconsistent activation with variable cycle lenght (CL), where as other sites of LA had regular CL = 210 ms. Reconnections in all PVs was revealed and left PV antra was used as the electrical refferent. Activation mapping show tetra loop lutter conirmed by entrainment. Two loops were related to the double gap at the left PVs, enother two - to the double gap at the right PVs. Fronts collision at the site of mid CS was the cause of its inconsistent activation. Sequential PV reisolation led to organisation of CS activity, followed by AT termination. Conclusions: Tetra loop PV related macroreentry is unusual mechanism of AT and requires PV reisolation only. www.jaib.com 269 October, 2013 | Special Issue Comparative Analysis of Atrial Flutter Ablation Results in Elderly Patients J.L. Martínez-Sande, S. Raposeiras-Roubin, J. García-Seara, P. Cabanas Grandío, X.A. Fernández López, M. Rodríguez-Mañero, S. Gestal Romaní, E. Pereira López, J.R. González-Juanatey Cardiology Department Hospital Clinico Universitario Santiago de Compostela, Spain Abstract Background :Substantial progress in catheter ablation technique and safety has been made, giving the elderly an additional treatment option and chance for an improved quality of life. The aim of this study was to evaluate the inluence of age on the recurrence of atrial lutter (AFL) after a successful radiofrequency ablation, comparing the results of elderly people with those who are not.. Methods:408 consecutive patients (age: 19–91 years) with common AFL who underwent successfully radiofrequency ablation were included. The primary end-point was the AFL recurrence. We also analyzed the occurrence of atrial ibrillation, ischemic stroke and death. We use univariate and multivariate Hazard Ratio (HR) analysis. Cumulative probability of freedom from recurrence of AFL was calculated with the Kaplan–Meier method. Results: Patients were followed for a mean of 5.9 ± 3.1 years. 75 from 408 patients died, 55 presented AFL recurrence during the followup (5.6% in the irst year and 9.1% within the irst two years), 172 presented AF, and 17 had a stroke. Patients ≥75 years who underwent succesful ablation of common AFL have less recurrences than those younger patients, after adjust by confounding variables (HR 0.352, CI 95% 0.127-0.973, p=0.044). The age ≥ 75 years was not associated to AF incidence (HR 0.841, 95% CI 0.554-1.277, p=0.417), or stroke (HR 1.500, CI 95% 0.488-4.607, p=0.476) or death (HR 1.639, CI 95% 0,963-2.790, p=0.066). . Conclusions: Radiofrequency ablation of common AFL is a safe technique that should not be dismissed in the elderly patient. www.jaib.com 270 October, 2013 | Special Issue Impact of Radiofrequency Catheter Ablation of Frequent Ventricular Premature Beats for Renal Function O. Inaba, J. Nitta, K. Satoh, Y. Honda, S. Kuroda, M. Sekigawa, M. Kanoh, M. Suzuki, K. Muramatsu, A. Satoh, T. Yamato, Y. Matsumura, K. Asakawa, K. Hirao, M. Isobe Cardiology Department, Saitama Red Cross Hospital, Saitama, Japan Abstract Introduction :Catheter ablation (CA) of frequent idiopathic premature ventricular beats (iPVBs) was understood to improve hemodynamics. The objective of present study is to clarify the effect of CA of iPVBs for renal function. Methods: Forty-six patients (26 men; mean age 60 ± 13 years) undergone CA of iPVBs in our hospital were enrolled. We divided the patients into two groups. Group 1 (n=34) is patients with iPVBs that could be eliminated successfully (percentage of PVBs after CA a day < 2%), and Group 2 (n=12) is patients with unsuccessful CA. Basic clinical parameters and estimated glomerular iltration rate (eGFR) as an index of renal function before and after CA were studied retrospectively. Results: Baseline characteristics did not differ between the groups signiicantly without the origin of iPVBs. (Table) In Group 1, eGFR was improved after CA signiicantly (65.4 ± 14.9 vs 73.2 ± 15.6 , p=0.037) and eGFR before and after ablation were not different in Group 2 (63.5 ± 15.6 vs 62.1 ±16.4 , p=0.84 ), (Figure) Conclusions: Elimination of frequent iPVBs by CA could improve renal function. www.jaib.com 271 October, 2013 | Special Issue 6-Month Follow-Up of Ablations for Idiopathic Ventricular Extrasystole/Tachycardia Performed with Conventional Method: A Single-Centre Experience B. Candemir, M.Z. Torbati, V.K. Vurgun, A.T. Altin, O. Akyurek, M. Kilickap, O.U. Ozcan, M. Guldal, C. Erol Cardiology Department, Ankara University, Ankara, Turkey Abstract Background and objectives :Idiopathic ventricular extrasystoles (VES)/tachycardias originating from outlow tract (OT) are very commonly encountered in clinical practice. Ablations of these arrhythmias can be very dificult and time-consuming due to intermittent nature and complex anatomy of OT even if an expensive 3D electroanatomical mapping system is used. In this case report, we would like to present long term follow-up of 29 consecutive patients who underwent VPS ablation performed with conventional technique using pace-mapping and the earliest activation. Results: Of 29 patients, the mean age was 51.1±15.4 years and 67%(16) of them were female. All the patients were symptomatic and in sinus rhythm before the procedure and the mean daily VES burden percentage was 13.6±12.2. Using conventional mapping, the earliest activation spots were identiied in RVOT free wall (8, 27%), RVOT septum (14, 48%), left coronary cuspid (2, 6.9%), LVOT (2, 7%) and aortomitral continuity (3, 10%). Mean time of procedure was 96.7±33.1 min and mean RF time was 10.6±9.2 min. Acute procedural success was 93% (27) and at 1-month visit, all but 4 patients (86.2%) had signiicant symptomatic improvement with no symptoms at all (%86.2). While 23 patients were completely asymptomatic with no need for drugs at 6-month visit, the symptomatic status was unchanged in 5 and was deteriorated in one patient who had a change in drug regimen. Aside from 2 vascular complications as mild inguinal hematoma formation and 1 minimal pericardial effusion, no other major complication was observed. Conclusions: Ablation of idiopathic ventricular extrasystole/tacchycardia performed with a conventional technique still constitutes a safe and reliable method, and may be tried before the utilization of a 3D-mapping system as the initial choice. www.jaib.com 272 October, 2013 | Special Issue Safety and Eficacy Outcome of a Single-Centre Ventricular Tachycardia 24/7 Ablation Program L. Teischinger, C.A. Plass, H. Mayr, B. Frey Medizinische Abteilung, Landesklinikum St. Pölten, St. Pölten, Austria Karl Landsteiner Institut zur Erforschung ischämischer Herzerkrankungen und Rhythmologie, St. Pölten, Austria Klinik f. Innere Medizin II, Medizinische Universität Wien, Vienna, Austria Abstract Introduction :The purpose of our study was to assess safety and feasibility of a single centre 24/7 VT ablation program. Methods: 46 patients with a previously documented VT who underwent mapping and ablation from 10/2009 to 12/2012 were analysed retrospectively. Results: Indications for ablation were electrical storm in 34.1%, appropriate shocks on ICD in 27.3%, recurrent slow VT below ICD therapy threshold in 11.4% and clinical VT in patients without ICD in 27.3%. In 10 patients ablation was not attempted due to not inducible VT in the absence of an endocardial substrate. Procedural success was achieved in 35 of 36 patients (97.2%). A procedure related complication occurred in 3 patients. The 30-day mortality was 2.9%, 2 additional patients died within 1 year. During 3-34 months follow-up, VT recurred in 10 patients and was terminated by ATP in 7, by amiodarone in 1 and by shock on ICD in 1 patient. Fatal slow VT recurred in 1 patient. Conclusions: VT ablation is a safe and effective intervention, even in patients in extremis. Recurrence rate of electrical storm, ICD discharge as well as the need for consecutive ICD implantation is low. www.jaib.com 273 October, 2013 | Special Issue Comparison of Clinical Successof Catheter Ablation of Atrial Ablation Fibrillation Supported By 3D Models of Left Atrium Obtained from CT Scans and 3D Cardiac Rotational Angiography F. Lehar, Z. Stárek, J. Jež, J. Wolf, T. Kulík, A. Žbánková, M. Lukášová International Clinical Research Center 1st Department of Internal Medicine - Cardioangiology, St. Anne’s University Hospital, Brno, Czech Republic Abstract Introduction :The 3D cardiac rotational angiography (3DRA) is a modern method enabling to create CT-like 3D images. These 3D models are used to improve orientation during catheter ablation. The objective of the study was to compare clinical success of catheter ablation of atrial ibrillation (AF) supported by 3D models of the left atrium obtained from CT scans and 3DRA. Methods: This is a prospective, randomized study. 120 patients were randomized, 62 patients (29% persistent AF) who underwent catheter ablation supported by model from CT scan and 58 (34% of persistent AF) by using 3DRA. Clinical success was any documentation of AF within 6 months after catheter ablation. Results: Reccurence of arrhythmias was observed in 26% (3DRA group) vs. 31% (CT scan group) of patients (p<0.561). The luoroscopy exposure was 2,3 mGycm2 (3DRA group) vs. 10,2 mGycm2 (CT scan group) with p<0.001. The dose of contrast was signiicantly lower in 3DRA group (p<0.001). Conclusion: Clinical success of catheter ablation supported by 3DRA is comparable with CT scan. In addition, luoroscopy exposure and dose of contrast with this method is signiicantly lower. www.jaib.com 274 October, 2013 | Special Issue Rotational Angiography of Left Ventricle as a Support in Ventricular Tachycardia Ablation - Our First Experiences J. Wolf, Z. Stárek, F. Lehar, J. Jež, T. Kulík International Clinical Research Center - 1st Department of Internal Medicine - Cardioangiology, St. Anne’s University Hospital Brno, Brno, Czech Republic Abstract Introduction :Three-dimensional rotational angiography (3DRA) is a new imaging method used to guide ablation of the left atrium. The objective of this work was to create a protocol for imaging the left ventricle in support of ventricular tachycardia (VT) ablation. Methods: We used own protocol based on direct left atrial protocol for acquisition of raw image data of left ventricle in 13 patients. Models were manually segmented and fused with live luoroscopy on Philips EP Navigator workstation. The point-tagging system was used in 2 patients. In 5 patients were compared dimensions in raw image data obtained from 3DRA and from CT scan. In 2 patients we performed fusion of 3DRA model and electroanatomical map from EnSite Velocity system. Results: The 3D model was applicable for all patients. The 3DRA luoroscopy exposure was 12948 ± 4631 mGycm2. Correlation between 3DRA and CT measurements was found (r = 0,975, p < 0,05). Conclusions: The 3DRA seems to be applicable to guide VT ablations and beneit for the patient is lower radiation dose and lower dose of contrast agent compared to CT scan. Figure 1: EP Navigator live luoroscopy fusion www.jaib.com Figure 2: EnSite Velocity electroanatomical map fusion 275 October, 2013 | Special Issue Our Results in Patients who had Catheter Ablation from the Aortic Cusps A. Tokatli, F. Kilicaslan, M. Uzun, B.S. Cebeci Department of Cardiology, Golcuk Military Hospital, Kocaeli, Turkey; GATA Haydarpasa Hospital, Istanbul, Turkey Abstract Introduction :Catheter ablation (CA) is an effective treatment option in patients with symptomatic arrhythmias. Ventricular myocardial extensions to aortic valve and adjunctive tissue may be a source for different arrhythmias. For these reasons aortic cusp has emerged as an important ablation target. We report a case series of CA from the aortic cusps. Methods: We retrospectively analyzed our electrophysiology records of patients referred for ablation procedure between 2008 and 2012. We identiied 29 patients who had CA from the aortic cusps for different arrhythmias. The clinical, procedural variables and follow up data are reported. Results: Results are summarized in Table. The mean age was 30±8 years and ejection fraction was 63±4%. 16 (55%) patients had ventricular premature depolarization/ ventricular tachycardia orginating from outlow tract, 10 (35%) patients had anterior septal accessory pathways and 3 (10%) patients had atrial tachycardia. No patient had any complication related to CA including atrioventricular (AV) block. Among 10 patients who had anteroseptal accessory pathway ablation, 2 had early recurrence. Conclusion: CA from the aortic cusps is feasable, safe and effective. Ablation from the NCC may decrease the risk of AV block. Table : Clinical and procedural variables. Variables Results Age (years) 30± 8 BMI (kg/m²) 24± 3 EF (%) 63± 4 RF application (n) 4± 1 Procedure time (min) 53± 18 Fluoroscopy time (min) 23± 7 VPA/VT (n) 16 (55%) Septal accessory pathway (n) 10 (35%) Atrial tachycardia (n) 3 (10%) BMI:body mass index; EF:ejection fraction; RF:radiofrequency; VPA/VT: ventricular premature depolarization/ventricular tachycardia Values are presented as mean±SD www.jaib.com 276 October, 2013 | Special Issue Bi-Directional Ventricular Tachycardia Status Post Ablation at Anterior and Posterior Papillary Muscles J. Liao, Y.J. Lin, S.A. Chen Cardiology department, Taipei Veterans General Hospital, Taipei, Taiwan Abstract Case report :One 21-year-old girl with palpitation and near-syncope received electrophysiology study (EPS). Electrocardiography showed bi-directional ventricular premature complexes (PVCs). (igure 1) Echocardiography showed normal heart structure and function. Holter scan revealed daily PVC amount of 5836 and 77 episodes of non-sustained ventricular tachycardia (VT). Catecholaminergic VT was impressed. Programmed stimulation with extrastimuli under isoproterenol infusion induced non-sustained VT. Left ventricular (LV) voltage map showed no low voltage zone(LVZ). The earliest activation site located at the posteoseptal mitral annulus base with compatible pace map. Radiofrequency ablation (RFA) was done. Bi-directional PVCs recurred 9 months later and second time EPS was performed. Small-sized LVZ was found at anterior subannular area and we ablated the earliest activation site of bi-directional VT (VT1) at LV bottom. Two different types of monomorphic VT emerged after ablation under isoproterenol infusion with RBBB morphology, slightly negative polarity of V5-6, superior axis (VT2) and inferior axis (VT3) respectively. Local electrograms at antero-lateral side of LV showed highly luctuated prepotentials. The earliest activation site of VT2 was at basal part of antero-lateral LV with compatible pace map, while the earliest activation location of VT3 was at postero-medial LV. (igure 2) RFA was performed. After ablation, no VPCs or VT was inducible. VT2, VT3 VT1 www.jaib.com 277 October, 2013 | Special Issue Unusual forms of Junctional Ectopic Tachycardia G. Rondia, M. Massin, H. Dessy Pediatric cardiology departement Children’s University Hospital Queen Fabiola, Brussels, Belgium Abstract Case report :Junctionnal ectopic tachycardia (JET) is a rare cause of supraventricular tachycardia. We report two unusual cases : one transient in a neonate and one in an adolescent. § Case1 presented JET after birth with normal echocardiography. After a few hours, tachycardia resolved without any treatment. § Case2, an asymptomatic adolescent, presented arrhythmia on routine physical examination with JET on ECG, normal echocardiography and constant JET on Holter. During exercise, sinus rhythm dominated and JET reappeared during recovery phase. JET is a rare arrhythmia caused by an ectopic focus usually perinatal or following heart surgery, radiofrequency ablation of AVNRT and digoxin toxicity. In neonates, it’s a severe disease often refractory to medical treatment, except amiodarone and lecaïnide, with focus disappearance after months or years but only after a few hours in our case. In case2, JET appeared unusually at 13 years. No treatment was given since heart rates were not too high but average heart rates and cardiac function will regularly be controlled. Conclusions: We describe unusual forms of JET: one transient in a neonate and one in an asymptomatic adolescent. www.jaib.com 278 October, 2013 | Special Issue Complex Electrophysiology Intervention in a Patient with an Inferior Vena Cava Filter: Case Report Z. Starek, J. Jez, F. Lehar, J. Wolf 1st Department of Internal Medicine - Cardioangiology, International Clinical Research Center, St. Anne’s University Hospital Brno, Czech Republic Abstract Introduction:Catheter ablation is a routine treatment of arrhytmias. The presence of an inferior vena cava (IVC) ilter may complicate the procedure. We have no data on ablation of complex atrial arrhythmias with transseptal puncture in presence of an IVC ilter. Methods and results: A 70-year-old man with history of thromboembolic disease with an IVC ilter implantated in 2000 (Vena Tech TM LP Cava Filter, Braun). Patient suffered from left atrial focal tachycardia and postincisional atypical lutter (aortic valve replacement and double CABG in March 2011). Complex ablation was performed in a standard manner with two transseptal sheaths inserted through femoral vein. Angiography conirmed patency of the ilter and absence of thrombus. Filter was crossed with straight tip guidewires and subsequently with transseptal sheaths without complications. Atypical lutter was succesfully ablated in the lower interatrial septum, subsequent typical lutter in the cavotricuspid isthmus and focal atrial tachycardia in the left lateral atrium. Conclusions: Case report represents the irst case of a successful complex electrophysiology intervention in the left and right atrium with femoral venous access in patient with IVC ilter. www.jaib.com 279 October, 2013 | Special Issue Usefulness of the Multipolar Basket Catheter for Radiofrequency Catheter Ablation of Accessory Pathways in Ebstein’s Anomaly: A Case Report Y. Shirai, Y. Yokoyama, K. Ihara, K. Sugiyama, S. Maeda, T. Sasaki, M. Kawabata, T. Sasano, K. Hirao Heart Rhythm Center, Tokyo Medical and Dental University Hospital, Tokyo, Japan Abstract Introduction :Radiofrequency catheter ablation (RFCA) of accessory pathways (APs) in Ebstein’s anomaly tends to be tough because of the dificulty of identifying appropriate target sites along the atrialized right ventricle (RV). Methods: N/A Results: A 39 year-old male was admitted with resuscitated ventricular ibrillation. The electrocardiogram on admission showed delta wave, and echocardiography revealed apical displacement of the attachment of the septal tricuspid lealet. We performed RFCA, which needed large numbers of RF energy applications to abolish APs because of the existence of multiple APs and possibly their complex geometry. On the next day, the delta wave recurred, and we underwent 2nd session. We introduced multipolar basket catheter over the tricuspid valve to cover the atrialized RV, which made the identiication of earliest activation site during AP conduction easier. The irst RF energy application eliminated the AP conduction successfully. Conclusions: The multipolar basket catheter enables a simultaneous recording of the local electrograms along with atrialized RV in Ebstein’s anomaly where APs are located with spatial extent. This catheter was useful to decide the optimal ablation sites for elimination of APs. www.jaib.com 280 October, 2013 | Special Issue 281 Journal of Atrial Fibrillation Journal of Atrial Fibrillation www.jaib.com Authors SpeicalProile Issue Aug-Sep, October, 2013 2013 | Vol-6 | Special | Issue-2 Issue 282 Journal of Atrial Fibrillation Journal of Atrial Fibrillation www.jaib.com Authors SpeicalProile Issue Aug-Sep, October, 2013 2013 | Vol-6 | Special | Issue-2 Issue