The aim of this prospective observational study was to assess efficacy and safety of the ablation procedure in patients with low LV ejection fraction (LVEF) and ventricular tachyarrhythmias originated from right ventricular outflow tract (RVOT) during long-term follow up. Fifty four consecutive patients with symptomatic premature ventricular complexes (PVC) or ventricular tachycardias (VT) with left bundle branch block (LBBB) pattern, inferior axis morphology and transition zone predominantly in V3-V4 were included in this study. The patients were followed up during 36 months after ablation procedure. The mean follow up period was 42.26 months. The long-term efficacy after one ablation procedure was 94.4% (51 patients) and after redo procedures - 98.1 % (53 patients). The LVEF increased from 422 at baseline to 565% after 36 months of follow up (p = 0.001). Radiofrequency catheter ablation in patients with low LVEF and ventricular tachyarrhythmias originated from RVOT is a safe and highly effective treatment during long-term follow up.

The clinical case report of successful catheter ablation of three patients with atrioventricular nodal reciprocating tachycardia is presented. All patients are close relatives (mother and two daughters). In order to diagnose AVNRT endocardial electrophysiological study was conducted and then radiofrequency ablation of the slow way atrioventricular connections was performed. The effect was confirmed during the control of endocardial and transesophageal electrophysiological studies.

To assess the functional recovery and remodeling of postinfarction myocardium, a combined technology of single-photon emission computed tomography (SPECT) and endocardial electrophysiological 3D reconstruction of the heart in patients with left ventricular dysfunction after myocardial infarction was used.

To assess effectiveness of cardiac resynchronization therapy in chronic heart failure associated with permanent atrial fibrillation, 90 patients aged 62.2±8.1 years (men: 90%) with the left ventricle ejection fraction of 28.8±5.6% were examined and treated.

Цель - оценить эффективность эндо- и эпикардиальной аблации желудочковых тахиаритмий у пациентов с аритмогенной дисплазией правого желудочка (АДПЖ) в течение отдаленного периода наблюдения. В период с февраля 2008 г. по февраль 2013 г. были проанализированы данные 72 пациентов с АДПЖ и желудочковыми тахикардиями (ЖТ), которым выполнялась эндо- (n = 72) и эпикардиальная аблация (n = 21) зоны ЖТ. Первичной конечной точкой исследования было отсутствие желудочковых тахиаритмий после оперативного вмешательства в течение отдаленного периода наблюдения. Вторичная конечная точка - осложнения оперативного вмешательства и динамика клинических данных. Период наблюдения пациентов составил 46,49,2 мес. для пациентов с первичной эндокардиальной аблацией и 39,73,5 мес. для пациентов, которым выполнялась эпикардиальная аблация ЖТ. Отдаленная эффективность аблации у пациентов с АДПЖ после одной процедуры эндокардиальной аблации без приема антиаритмических препаратов составила 57% (51 пациент), а после повторной эндокардиальной аблации - 86,2% (44 из 51 пациента). Эпикардиальная аблация выполнена 21 из 31 (67,7%) пациента. В конце периода наблюдения у 71,4% пациентов отсутствовали пароксизмы ЖТ. Четырем (19,1 %) пациентам с рецидивами ЖТ выполнена повторная аблация как со стороны эпикарда, так и со стороны эндокарда. Общая эффективность эндо- и эпикардиальной аблации после повторных процедур составила 84,7% (61 пациент). У пациентов с АДПЖ и желудочковыми тахиаритмиями эндо- и эпикардиальная аблация является высокоэффективным и безопасным методом лечения и устраняет ЖТ у большинства пациентов этой группы в течение отдаленного периода наблюдения.

This clinical case report shows a rare complication following pulmonary vein isolation, with the esophageal wall injured during the procedure and a hematoma developed on the wall.

Among 360 patients without structural heart disease, who were operated for ventricular arrhythmias (VAs), 46 (12,8%) patients had premature ventricular complexes (PVC) or ventricular tachycardias (VT) originated from papillary muscles and His - Purkinje system of the right (RV) and left ventricles (LV). The mean follow up period was 40.63.6 months. The long-term efficacy in patients with such VAs originated from RV after one or multiple ablation procedures was 78.6% (11 patients) and 92.9% (13 patients) respectively. In patients with VAs originated from LV, the efficacy after one or multiple ablation procedures was 81.3% (26 patients) and 90.6% (29 patients) respectively. Radiofrequency catheter ablation of ventricular tachyarrhythmias originated from papillary muscles and His - Purkinje system of the right and left ventricles allows for removing the above disorders in the overwhelming majority of patients during long-term follow up.

To assess effectiveness and safety of radiofrequency ablation of idiopathic ventricular tachyarrhythmia in 2007 2012, 452 patients aged 37.8±18.7 years (women: 54.4%) were examined and surgically treated.

Представлен клинический пример успешной катетерной аблации трех пациенток (матери и двух дочерей) с атриовентрикулярной узловой реципрокной тахикардией (АВУРТ). С целью диагностики АВУРТ было проведено эндокардиальное электрофизиологическое исследование, а затем выполнена радиочастотная аблация медленных путей атриовентрикулярного соединения. Эффект подтвердился при проведении контрольных электрофизиологических исследований.

Цель - оценить эффективность эндо- и эпикардиальной аблации желудочковых тахиаритмий у пациентов с аритмогенной дисплазией правого желудочка (АДПЖ) в течение отдаленного периода наблюдения. В период с февраля 2008 г. по февраль 2013 г. были проанализированы данные 72 пациентов с АДПЖ и желудочковыми тахикардиями (ЖТ), которым выполнялась эндо- (n = 72) и эпикардиальная аблация (n = 21) зоны ЖТ. Первичной конечной точкой исследования было отсутствие желудочковых тахиаритмий после оперативного вмешательства в течение отдаленного периода наблюдения. Вторичная конечная точка - осложнения оперативного вмешательства и динамика клинических данных. Период наблюдения пациентов составил 46,49,2 мес. для пациентов с первичной эндокардиальной аблацией и 39,73,5 мес. для пациентов, которым выполнялась эпикардиальная аблация ЖТ. Отдаленная эффективность аблации у пациентов с АДПЖ после одной процедуры эндокардиальной аблации без приема антиаритмических препаратов составила 57% (51 пациент), а после повторной эндокардиальной аблации - 86,2% (44 из 51 пациента). Эпикардиальная аблация выполнена 21 из 31 (67,7%) пациента. В конце периода наблюдения у 71,4% пациентов отсутствовали пароксизмы ЖТ. Четырем (19,1 %) пациентам с рецидивами ЖТ выполнена повторная аблация как со стороны эпикарда, так и со стороны эндокарда. Общая эффективность эндо- и эпикардиальной аблации после повторных процедур составила 84,7% (61 пациент). У пациентов с АДПЖ и желудочковыми тахиаритмиями эндо- и эпикардиальная аблация является высокоэффективным и безопасным методом лечения и устраняет ЖТ у большинства пациентов этой группы в течение отдаленного периода наблюдения.

To evaluate the efficacy and safety of ablation of ventricular tachyarrhythmias located in the pulmonary artery (PA), the data on 248 consecutive patients with ventricular tachycardia (VT) or premature ventricular contraction (PVC) of the right ventricle (RV) were analyzed over a period from February 2008 to March 2013. Localization of PVC/VT from LA was observed in 16 (6.5%) patients. The primary endpoint of the study was the absence of PVC/VT during long-term follow-up after a single and multiple ablation procedures. The secondary endpoints were surgery complications, the number of PVCs obtained by Holter monitoring during follow-up. The follow-up was 42.56.4 months. The longterm effectiveness of ablation of PVCs/VT from LA after one or more ablation procedures without the use of AAD was 93.8% and 100 % respectively. There were no postoperative complications in this group of patients. Neither cases of injury to the valve or wall of the pulmonary artery, nor spasms of the coronary arteries or other injuries were recorded. Average number of PVCs obtained by 24-hour Holter monitoring was 784 642 (range from 2 to 4000) as compared to 18371 12282 prior to surgery (p<0.001). In patients with ventricular tachyarrhythmias localized in the region of the pulmonary valve, radiofrequency ablation is a highly effective and safe treatment in the long-term follow-up.

С целью оценки результатов эпикардиальной радиочастотной катетерной аблации (РЧА) желудочковых тахикардий (ЖТ) у детей с аритмогенной дисплазией правого желудочка (АДПЖ) после неэффективной эндокардиальной РЧА обследованы 17 пациентов детского возраста. Электрофизиологическое исследование и процедура РЧА проводились по стандартной технике. Эпикардиальный доступ осуществлялся по методике, описанной Е. Sosa и соавторами. В течение периода наблюдения 26,22,5 мес. у 12 (70,6%) пациентов эпизоды ЖТ не наблюдались. Все пациенты с успешной РЧА не принимали никаких антиаритмических препаратов. Летальных исходов за время наблюдения не было. Рецидив ЖТ был зарегистрирован у 29,4% пациентов, что потребовало повторных РЧА, коррекции антиаритмической терапии или имплантации кардиовертера-дефибриллятора. Таким образом, трансперикардиальная РЧА является эффективной альтернативной методикой лечения ЖТ у детей с АКПЖ в случае расположения аритмогенного субстрата эпикардиально.

To assess effectiveness and safety of ablation of ventricular tachyarrhythmia (VTA) located in the area of the mitral-aortic contact (MAC) and mitral valve (MV) fibrous ring, the data of 132 consecutive patients with VTA originating from the left ventricle (LV) were analyzed. VTA originating from the areas of MAC and MV were revealed in 21 patients (15.9%). Frequent symptomatic ventricular premature contractions (VPC) and/or VT paroxysms were found in all patients, antiarrhythmic therapy (AAT) being ineffective. Patients with structural heart disease were excluded from the study. 18,946±10,948 VPCs per day were documented. The sustained VT was documented in 4 patients (19%). In 20 patients (95.2%), monomorphic VPC/VT was observed. Cardioverters-defibrillators were implanted to 2 patients (9.5%) before the intervention. Antiarrhythmic therapy was ineffective in 21 patients (100%). The following 3 types of the ectopic foci location in patients with VPC/VT were identified: antero-lateral part of MV (n=7; 58%), posterior part of MV (n=2; 16.7%), and postero-septal part of MV (n=3; 14.3%). The total early effectiveness of ablation was 100% (21 patients). No PVC/VT recurrence was revealed in early post-procedure period. Antiarrhythmic therapy was discontinued in all patients with the effective radiofrequency ablation. No post-procedure complications were observed in the study patients. The follow-up period lasted for 38.6±7.4 months. The long-term follow-up data were obtained for 20 patients (95.2%). In one patient from the MAC group (4.8%), the VPC recurrence developed 4.5 months after the primary radiofrequency ablation. The late effectiveness of the ablation of VPC/VT from MAC/MV in absence of AAT was 95.2% (20 patients) after the single ablative procedure and 100% (21 patients) after the repetitive ablation. Thus, despite a relatively low prevalence, VTA originating from the MAC area and the MV fibrous ring, with a number of electrocardiographic features, can be successfully eliminated using radiofrequency ablation, which is a highly effective and safe method of treatment of the arrhythmia.

To assess effectiveness and safety of ablation of ventricular tachyarrhythmia located in the aortic sinus area, the data of 79 consecutive patients (including 46 women) aged 40.6±21.8 years with frequent symptomatic ventricular premature contractions (VPC) or ventricular tachycardia (VT) were analyzed. Arterial hypertension was documented in 9 patients (11.4%); diabetes mellitus, in 2 subjects (2.5%). The daily incidence of VPCs was 20,789±12,432. Sustained VT was documented in 17 patients (21.5%). Cardioverters-defibrillators were implanted to 11 patients (13.9%) due to hemodynamically significant VT with syncope. Antiarrhythmic therapy was ineffective in 79 patients (100%). According to the data of stimulation mapping, a significant correlation of the QRS complex morphology with the initial morphology of PVC or VT in 12 surface leads was found in 69 patients (87.3%), in 11 leads was documented in 9 patients (11.4%), and in 10 leads, in 1 patient (1.3%). The number of radiofrequency applications was 3.2±1.5. The duration of fluoroscopy and of the procedure was 7.6±4.2 min and 59.5±12.6 min, respectively. The early total effectiveness of ablation was 97.5% (77 subjects). The patients were followed for 46.6±9.4 months. Two patients (2.5%) were lost for follow-up 30 months after the procedure. The total effectiveness of the procedure after one procedure (without antiarrhythmic treatment) was 93.7% (74 patients), after repetitive procedures, 96.2% (76 patients). Thus, the radiofrequency catheter ablation of ventricular tachycardia originating from aortic sinus is a safe and effective technique of treatment confirmed during the long-term follow-up.

To compare effectiveness of management of subjects with newly diagnosed atrial fibrillation (AF) after aorto-coronary bypass grafting surgery (ACBG) alone and in combination with epicardial pulmonary vein isolation (PVI), 35 patients aged 62±5 years (28 men) were examined and surgically treated. The patients were randomized into two following groups: ACBG alone (Group I, n=17) and ACBG accompanied by epicardial PVI (Group II, n=18). Freedom from AF (AF burden ΰ /ο and 1.6±1.8 ΰ /ο in Group I and Group II, respectively (p<0.001). Two patients of 11 (18.2% of both groups) with AF recurrence had asymptomatic AF. During the follow-up period, no thromboembolic events in the study subjects were documented. Thus, in patients with newly diagnosed AF and indications for direct myocardial revascularization, ACBG in combination with epicardial PVI can prevent recurrence of AF.

To compare safety and effectiveness of pulmonary vein isolation (PVI) in combination with linear ablation (LA) or ganglionic plexus ablation (GPA), 264 patients with persistent and long-lasting persistent atrial fibrillation (AF) were examined and surgically treated. The patients were randomized into two following groups: PVI+LA (n=132) and PVI+GPA (n=132). The primary endpoint was freedom from any atrial tachyarrhythmia including AF, atrial flutter, and atrial tachycardia after the first ablative procedure recorded by loop recorders. The “blind period” data obtained within first 3 months following ablation was excluded from analysis. The circular PVI was performed to the patients of both groups. The anatomic area of GPA was determined by vagus response to overdrive pacing with the amplitude of 15 W, duration of 10 ms, frequency of 20 50 Hz, and duration of pacing up to 5 s. Target areas also included adjacent areas with complex fractionated atrial electrograms detected. In the PVI+LA group, ablative lines were made which connected the left inferior pulmonary vein with the mitral valve annulus (the left isthmus), as well as the line of the left atrium roof between two superior pulmonary veins. In 132 patients of the PVI+GPA group, 5.6±0.4 applications for each target area were made, additional 8.9±2.7 radiofrequency applications were performed in the areas with complex fractionated atrial electrograms. For each patient, the total number of 64.7±3.8 radiofrequency applications in the ganglionic plexus areas was carried out. The complete electric PVI and the cavo-tricuspid conduction block were achieved in all 264 subjects of both study groups. The duration of radiofrequency application was 58±11 min in the PVI+LA group and 69±4 min in the PVI+GPA group (p<0.001), the duration of procedure and X-ray exposure in the PVI+GPA group was longer than in the PVI+LA group (192±21 min and 153±37 min, respectively, p<0.001; 34±11 min and 29±15 min, respectively, p=0.002). After the single ablative procedure, during a 12 month follow-up period, 71 patients (54%) from the PVI+GPA group were free of atrial fibrillation/flutter/tachycardia as compared with 62 patients (47%) from the PVI+LA group (p=0.29). After 36 months of follow-up, 65 patients (49%) from the PVI+GPA group and 45 patients (34%) from the PVI+LA group were free of atrial fibrillation/flutter/tachycardia (p=0.035). The patients of both groups did not take antiarrhythmics. The percentage of patients with the left atrial flutter was significantly higher in the PVI+LA group than in the PVI+GPA group and made up 18% (24 patients) and 6% (8 patients), respectively (p=0.002). The number of AF recurrence (excluding atrial flutter) did not significantly differ in the study groups: 56 patients (42%) in the PVI+GPA group and 50 patients (38%) in the PVI+LA group after 12 months of follow-up (p=0.71) and 59 patients (45%) in the PVI+GPA group and 63 patients (48%) in the PVI+LA group after 36 months of follow-up (p=0.44). Within the follow-up period of 28.4±14.4 months, recurrence of atrial fibrillation/flutter/tachycardia occurred in 154 patients (58%). Re-ablation was carried out in 78 patients (59%) from the PVI+LA group and 55 patients (42%) from the PVI+GPA group (p=0.002). Other 21 patients (16%) with recurrence of atrial fibrillation/flutter/tachycardia refused of the repetitive procedure. After re-ablation, the procedure effectiveness in patients free of antiarrhythmic therapy was 68% in the PVI+GPA group and 52% in the PVI+LA group (p=0.006). Thus, in patients with persistent AF, PVI+GPA is a more promising technique than PVI+LA.

To assess effectiveness and safety of radiofrequency ablation (RFA) of ventricular tachyarrhythmia (VTA) located in the right ventricular inflow tract, 32 patients aged 39.7±19.1 years were examined and treated. The number of ventricular premature contractions (PVC) detected was 17,642±13,475; sustained ventricular tachycardia (VT) was documented in 7 patients (21.9%); implantable cardioverters-defibrillators (ICD) were implanted in 4 patients (12.5%). Antiarrhythmic therapy was ineffective in all patients. RFA was performed using the NaviStar ThermoCool irrigated electrode, with the irrigation velocity of 17 ml/min, maximal power or 40 W, maximal temperature of 43°C, and the duration of each application of 40 60 s. Freedom of VPC/VT throughout the follow-up period after single or repetitive ablations was the study primary endpoint. The secondary study endpoints were as follows: complications of the procedure and the number of VPC. In 20 patients (62.5%), VTA originated from the tricuspid valve area and, in 12 patients (37.5%), from the basal part of the right ventricle. In 29 patients (90.6%), the only morphology of PVC/VT was revealed; 3 patients (9.4%) had polymorphous PVCs. The number of points for 3D reconstruction of the right ventricular inflow tract endocardial surface was 37±11. The normal endocardial voltage in the right ventricular inflow tract was revealed in all patients. The number of radiofrequency applications was 10.6±3.2, with the fluoroscopy exposure of 6.6±2.8 min and the procedure duration of 59.7±10.2 min. In 2 patients (6.2%), RFA was not performed because of parahisian location of PVs and a high risk of development of complete atrio-ventricular block. In one patient (3.1%) with the PVC/VT location in the free wall, the RFA in the right ventricle was ineffective. Thus, the overall effectiveness of RFA was 93.8% (30 patients). The late effectiveness of the procedure after the single ablation was 87.5%, after repetitive procedures, 93.8%. Thus, RFA of VTA originating from the right ventricular inflow tract is a highly effective and safe technique of treatment which permits one to maintain the sinus rhythm during the entire follow-up period.

To assess the atrial fibrillation (AF) burden using insertable cardiac monitors within first months of post-operation period and reveal its correlation with the late recurrence of arrhythmia, 642 patients (478 men) aged 56±7.6 years with symptomatic AF resistant to antiarrhythmic therapy were included into the retrospective study. Radiofrequency isolation of the right and left pulmonary veins (IPV) was performed by separate collectors using irrigated electrodes. The entrance and exit block was confirmed during pacing or with the aid of Lasso catheter. The Reveal XT device (Medtronic) was implanted between ribs III and IV parallel to the sternum, 1 cm from its edge. Patients with the AF burden of 0.5% were considered non-responders. After the first ablation procedure, by the end of 12 month follow-up, 417 patients of 642 (65%) were responders. In accordance with the ROC curve data, the patients with absence and presence of AF recurrence were separated based on the AF burden recorded by implantable recorders (devices) within 2 months following ablation. The curse showed 85% of specificity and 90% of sensitivity. The corresponding AF burden threshold according to the implantable recorder data obtained within 2 months following ablation which permitted one to identify patients with a risk of late recurrence of AF was 4.5%. It corresponded to the overall duration of AF of 65.9 hours (2.75 days). The positive and negative diagnostic value was 78.7% and 93.9%, respectively. The majority of patients with the AF burden >4.5% had also prolonged episodes of arrhythmia exceeding 20 hours/day within two consecutive days during two first months of post-operation period. In the group of patients with persistent AF, the AF burden equal to 4.5% showed 91% of specificity corresponding to the 100% sensitivity. All patients with persistent AF and the AF burden 4.5% within the first two months after the operation can be used for selecting appropriate candidates for repetitive operation and medical treatment.

To develop management strategy for patients with recurrence of atrial fibrillation (AF) in the early post-operation period based on the loop recorder data, 314 patients were included into the study. Group 1 included patients with no recurrence of arrhythmia in the early post-operation period; Group 2 consisted of 182 patients (58%) with recurrence of the arrhythmia. The subjects of Group 2 were randomized into Group 3 (n=88) or Group 4 (n=89); 5 patients were excluded from the study. The Group 3 subjects received only medical antiarrhythmic therapy. In Group 4, management of early post-operation period depended on the AF mechanism recorded by the loop recorder. In the case of the first occurrence of AF, only antiarrhythmic therapy was prescribed; if AF was induced by any trigger activity, the early re-ablation was carried out. The pulmonary vein ostia antral isolation by the common collectors was performed in all study subjects with creation of ablation lines on the roof of the left atrium and mitral isthmus. The loop recorder implantation was carried out as a final stage of the operation. After 12 months of follow-up, 120 of 129 patients of Group 1 (95%) were responders. Only 29 of 88 patients of Group 3 (33%) were responders (p<0.001, as compared with Group 1). In Group 4, 71 patients of 89 (80%) were responders (p=0.001, as compared with Group 1; p<0.0001, as compared with Group 3). In Group 3, 24 patients of 35 (69%) with the sudden AF onset were responders, as compared with only 6 patients of 52 (8 %) with the trigger AF onset (p<0.0001 as compared with the subjects with sudden AF onset). In Group 4, 22 patients of 32 (63%) with the sudden AF onset were responders (p=0.38, as compared with the patients with sudden AF onset in Group 3). Among 57 patients with the trigger AF induction, 49 ones (89 %) were responders (p=0.003 as compared with the sudden AF onset and p<0.001 as compared with the trigger onset in the patients of Group 3).

To assess late effectiveness of the following techniques of radiofrequency ablation (RFA) of atrial fibrillation (AF): pulmonary vein isolation (PVI), left atrium (LA) ganglionic plexus ablation (GPA), and their combination, according to the data of implantable loop recorders in patients with paroxysmal AF during a 2 year follow-up period, 327 patients were examined. The patients were randomized into three following groups: Group I (n=112) with PVI, Group II (n=108) with anatomic GPA, and Group III (n=107) with PVI in combination with GPA. The circular PVI was performed using the navigation system CARTO (Biosense Webster Inc.) by the commonly accepted technique, without linear ablations made in LA. During GPA, main accumulations of autonomic ganglionic plexuses concentrated in four LA areas were affected. At the end of procedure, loop recorders were implanted to all subjects. The follow-up period after the procedure was 24 months. Freedom from AF paroxysms (AF <0.5%) or any other arial arrhythmias according to the loop recorder data after a single ablation procedure was the primary endpoint. In Group I, 78.4±14.5 radiofrequency applications were performed. The sinus rhythm was restored in 16 patients (14.3%) during RFA; in 18 patients (16.1%), electric cardioversion was required. RFA of cavo-tricuspid isthmus was performed in 26 patients (23.2%). In Group II, 69.5±11.7 radiofrequency applications were performed. The sinus rhythm was restored in 14 patients (13%) during RFA; in 22 patients (20.4%), electric cardioversion was carried out. RFA of cavo-tricuspid isthmus was performed in 12 patients (18.5%). In Group III, the number of radiofrequency applications made up 102.7±12.4 (p=0.04 as compared with Group I and Group II). The sinus rhythm was restored during the procedure in 19 patients (17.8%); in 18 patients (16.8%), after the procedure, electric cardioversion was required. RFA of cavo-tricuspid isthmus was performed in 27 patients (25.2%) (p=0.2). By the end of follow-up period, 73 patients of Group I (65.2%), 69 patients of Group II (63.9%), and 84 patients of Group III (78.5%) were responders, i.e. had the AF percentage <0.5% according to the implantable loop recorder data. Thus, the combination of anatomic GPA and circular PVI is associated with an increased effectiveness of the procedure as compared with that of the isolated procedures of GPA and PVI, which ensures the sinus rhythm retention in 78.5% of patients with paroxysmal AF within the 24 month follow-up period according to the loop recorder data.