To elucidate the long-term prognosis of recipients of implantable cardioverter-defibrillator (ICD) for prevention of Sudden Cardiac Death (SCD). We followed 311 ICD implanted patients (86.5% male), mean age 65.3 ± 12.2 years, 182 for secondary prevention, for 25±17 months. Appropriate ICD

Left ventricular aneurysms (LVAs) can be congenital or acquired. They develop most frequently after myocardial infarction. Other causes include hypertrophic cardiomyopathy, arrythmogenic right ventricular cardiomyopathy, myocarditis, chest trauma, sarcoidosis or Chagas disease [1, 2]. LVAs without identifiable cause are considered as idiopathic. Most of LVAs are asymptomatic and are occasionally identified during routine diagnostic procedures. However, in rare cases LVAs may be associated with life-threatening ventricular tachyarrhythmias (mostly ventricular tachycardia, VT) and sudden cardiac death, even as a first manifestation [3]. In most of the cases VT has right bundle branch block morphology consistent with left ventricular origin. Idiopathic LVAs are anatomically distinguished from congenital diverticula, which are characterized by a narrow communication with the ventricle [2, 4]. In this report we describe an interesting and rare case of idiopathic LVA associated with sustained monomorphic VT, ventriculoatrial conduction and intermittent Wenckebach block. Management strategies are discussed and our treatment approach is presented. Case Report A 72-year old woman was admitted to our hospital with palpitations, dizziness and fatigue from a few hours ago. The patient had a history of heart failure (NYHA II) from three years ago and also an episode of paroxysmal atrial flutter two years ago. She was free of angina and had no cardiovascular disease risk factors. The family history was unremarkable with respect to cardiac arrest, unexplained syncope, ventricular tachyarrhythmias, or cardiomyopathy. At the time of presentation to the emergency department the patient was receiving carvedilol, valsartan, and furosemide. The baseline 12-lead ECG revealed a sustained monomorphic VT with RBBB morphology and left axis deviation (Fig. ​1A1A). Since tachycardia was poorly tolerated with systolic blood pressure of 80 mmHg an electrical cardioversion was applied and the rhythm was restored to sinus (Fig. ​1B1B). The ECG, physical examination and laboratory tests after the cardioversion were unremarkable. Fig. (1A) ECG on admission showing the ventriculat tachycardia (VT) with RBBB morphology, (B). Restoration of VT to sinus rhythm with electrical cardioversion, (C). Induced VT with LBBB morphology during the electrophysiology study, (D). Electrogram during the ... The chest X-ray revealed an increased cardiothoracic index. The transthoracic echocardiogram showed dilated left ventricle with a lateral wall aneurysm, left ventricular ejection fraction of 40% and mild mitral regurgitation (Fig. ​2A2A). The coronary angiography revealed normal coronary arteries, whereas the left ventriculography further confirmed the lateral wall aneurysm (Fig. ​2B2B). Magnetic resonance imaging further confirmed the presence of the LVA (Fig. ​2C2C). Fig. (2A) Echocardiogram showing the left ventricular aneurysm (arrows), (B). Left ventriculography further depicting the lateral wall aneurysm (arrows), (C). Magnetic resonance imaging further confirmed the presence of an aneurysm with wall thinning (arrows). The patient was started on amiodarone per os and after two weeks an electrophysiology study was performed. The programmed ventricular stimulation in the right ventricular apex with 500/230-240 msec basic drive cycle and two extrastimuli reproducibly induced sustained monomorphic VT of 160 bpm associated with hemodynamic instability. That tachycardia, however, had different characteristics from the one at the emergency department as it was associated with left branch bundle block (LBBB) morphology and normal cardiac axis and was terminated by overdrive pacing (Fig. ​1C1C). The LBBB morphology was consistent with septal origin of the VT. Of note, during the inducible VT a 1:1 ventriculoatrial conduction with intermittent Wenckebach block was recorded (Fig. ​1D1D). A cardioverter defibrillator (ICD) was implanted for the secondary prevention of VT and the patient was discharged 2 days after ICD implantation on treatment with carvedilol, amiodarone and angiotensin converting enzyme inhibitor. During a follow-up period of six months no ventricular arrhythmias occurred.

Cardiac resynchronization is an established treatment modality in patients with heart failure NYHA class III-IV on optimal medical treatment, QRS duration of at least 120-130 ms and ejection fraction <35%. Nevertheless, a propor- tion of patients, up to 20-30%, are considered non-responders as they are not improved by cardiac resynchronization ther- apy (CRT). This report describes a 63-year-old patient with ischemic cardiomyopathy, severe mitral regurgitation, and fragmented QRS complex in several leads. The patient had LV dyssynchrony identified by echocardiographic tissue Dop- pler imaging. A biventricular pacemaker was implanted successfully, and resulted in improvement in LV dyssynchrony, LV dimensions, mitral regurgitation and symptoms. Fragmented QRS complex as a marker of ventricular dyssynchrony may play a role in identifying patients who may benefit from cardiac resynchronization therapy.

Objective - Stored electrograms (EGMs) are diagnostic tools in modern pacemakers, providing data concerning arrhythmia occurrence and device function.We sought to validate the impact of stored EGMs on diagnosis and verification of arrhythmias presented after pacemaker implantation.Methods and results - We enrolled 71 consecutive patients (mean age 64 8 years, 5 1 men) with a standard indication for pacemaker implantation. The following pacemaker devices were implanted: DDDR = 57,VDDR = 5,VVIR = 9. EGM triggers were atrial tachycardia (AT), non-sustained ventricular tachycardia (NSVT) and ventricular tachycardia (VT). We retrieved and analysed 362 EGMs at 3 and 6 months after implantation. The EGMs were triggered by AT in 260 EGMs (72%), by NSVT in 80 (22%) and by VT in 22 (6%). In total, 243 episodes (67%) confirmed the arrhythmic events, while 119 episodes (33%) were classified as false-positive. They were divided into false-positive AT in 85 EGMs (33%), false-positive NSVT in 28 (35%) and false-positive VT in 6 EGMs (27%). The false-positive AT cases were caused by ventricular far-field sensing from the atrial channel in 34 EGMs (40%) and noise or myopotentials in 51 EGMs (60%). Most of the false-positiveVT and NSVT episodes were due to atrial fibrillation or atrial tachycardias in 21 EGMs (62%), while the rest were caused by noise in I I EGMs (32%) or ventricular T wave oversensing in 2 EGMs (6%).Conclusions - Stored EGMs in pacemaker patients were diagnostic in two thirds of arrhythmic episodes.They are useful tools to diagnose arrhythmias and identify sensing problems, and they contribute to optimal device programming and patient management.

Aim To report the results of ablation of atrial arrhythmias (AA) after previous open-heart surgery.Methods Nineteen patients [50 +/- 11 years, 11 women] underwent ablation of symptomatic AAs after previous open-heart surgery. In 11 patients mapping was performed using conventional multielectrode catheters. In the other eight patients CARTO electro-anatomical mapping system was used to supplement conventional mapping.Results After conventional mapping, 10/11 patients (91%) were found to have typical atrial flutter (AFL). The cavotricuspid isthmus was successfully ablated in these 10 patients. CARTO combined with conventional mapping showed that 7 of 8 patients had one macro-reentry right atrial circuit. The remaining patient had two focal atrial tachycardias. CARTO-guided ablation was successful in all eight patients (100%). After follow-up of 12 +/- 11 months, 2/18 patients (11%) had recurrence of either the same (n = 1) or a new (n = 1) AA.Conclusions AAs after previous open-heart surgery can be ablated successfully (>90%) with a low recurrence rate (111%) at 1-year follow-up. Typical AFL was found frequently (14/19 patients, 72%). This could be ablated successfully, often, after conventional mapping alone. CARTO helps to uncover peri-scar reentry and guide the ablation by creating a line of block connecting the scar to another landmark (unconventional isthmus). (C) 2004 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.

We present a case of inappropriate detection and therapy in a patient with an implantable cardioverter defibrillator. The device interpreted a supraventricular tachycardia as ventricular tachycardia due to unsensed P waves as a result of a relatively high level of atrial sensitivity setting. Subsequently, inappropriate therapy was delivered. The problem was resolved by decreasing the atrial sensitivity value.

Left ventricular dyssynchrony is an independent predictor for adverse cardiac events. Resynchronization therapy improves inter-and intraventricular dyssynchrony in patients with dilated hearts and intraventricular conduction delays.Tissue doppler imaging (TDI) is the only method able to detect regional myocardial asynchrony. Our purposeis to assess the impact of biventricular pacing on inter-and intraventricular asynchrony. Fourteen patients with advanced heart failure (NYHA class >= III), EF< 35%,QRS 165±15 msec, were studied before and 24 hours after implantation of a CRT system. Heart rate(HR),QRSduration,electromechanical coupling time for the left(Qaorta) and right ventricle(Qpulm) and their difference (Qpulm-Qaort) were calculated before and the day after implantation of a biventricular pacemaker.Tissue doppler velocities and timings (from the onset of the QRS complex to peak systole) were measured in 2 basal and 2 middle segments for longitudinal function(4C apical view).We calculated and compared the changes for both modalities(off and CRT-on). Statistical analysis was performed with the Wilcoxon Matched Pairs Test. CRT improves inter- and intraventricular asynchrony. Tissue velocity imaging revealed significant restoration of synchronous contraction in the basal parts of the left ventricle after CRT

To evaluate the efficacy and safety of slow pathway radiofrequency ablation (RFA) in patients with clinically documented but noninducible paroxysmal supraventricular tachycardia (PSVT) and dual AV nodal physiology. We studied 8 out of 142 patients referred for PSVT RFA. They had documented but noninducible PSVT, corresponding to an AV nodal reentrant tachycardia (AVNRT) and dual AV nodal physiology (evidenced by AH jump ≥ 50 msec and one or more atrial echo beats) during the electrophysiological study. The presence of an accessory pathway was excluded. There were six women, mean age of 53±14 years. RFA was performed via anatomic approach (targeting the inferoposterior region of the triangle of Koch) and mapping of the slow pathway potential. A mean of 4 ± 2 pulses were delivered, at a mean power of 34 ± 8 W. The acute outcome was 100% successful, without any echo beats or AH jumps. No arrhythmia occurred during a mean follow-up period of 19 ±3 months. Slow pathway ablation might be beneficial in patients with documented but noninducible PSVT and dual AV nodal physiology.