Background Cardiac resynchronization therapy (CRT) by means of multisite biventricular pacing is an effective therapeutic option for the treatment of severe heart failure. The present study estimates how many open heart-surgery patients could benefit from the implantation of permanent left ventricular (LV) pacing leads. After routine preoperative screening, epicardial electrodes were implanted in selected patients. Lead performance and outcomes were investigated.Methods Primarily, 1059 patients were retrospectively investigated with regard to LV function, left bundle branch block and QRS duration. Afterwards, suitable patients were identified and epicardial electrodes [Medtronic 5071 (ME) or Enpath (EP)] were implanted during concomitant procedures. Mean follow-up time was 6.3 +/- 5.5 months.Results The retrospective study showed that 24 patients (2.3%) could potentially profit from CRT. After routine preoperative screening for CRT-responders, 22 patients (1.6%) were identified who finally received epicardial leads. No complications occurred. Acute capture threshold was 0.9 +/- 0.4 V (ME, n = 17) and 0.5 +/- 0.2 V (EP, n = 5). While leads in 18 patients were implanted as an upgrade to an existing pacemaker or implantable cardioverter-defibrillator (ICD) technologies (Group B), 4 patients underwent prophylactic implantation with no device attached (Group A). CRT-ICDs were implanted at follow-up in 3 Group A patients (75%). In Group B patients, the QRS duration decreased (from 189 +/- 35 ms to 152 +/- 16 ms, p < 0.02) and their postoperative mean NYHA functional class improved significantly (2.2 +/- 0.5 versus 2.8 +/- 0.6).Conclusion A small group of cardiac surgery patients may benefit from LV-lead implantation during concomitant procedures. A protocol for responder identification is useful. Existing devices should be upgraded to CRT systems. As CRT-ICD implantation is frequent, the additional costs and time are justified.

OBJECTIVE:Evaluation of the significance of the Wedensky Modulation (WM) examination for ventricular tachyarrhythmias (VT) in patients with coronary artery disease and implantable cardioverter-defibrillator therapy (ICD).DESIGN:Prospective, single-centre study conducted from 2004 to 2006.SETTING:University of Bonn, Department of Medicine - Cardiology, Bonn, Germany.PATIENTS:37 consecutive patients with coronary artery disease receiving an ICD for primary or secondary prevention.MAIN OUTCOME MEASURES:Correlation of a positive WM-Index (WMI) with established non-invasive Holter parameter, the occurrence of VT after ICD implantation with regard to primary or secondary prevention, and inducibility of VT during electrophysiological (EP) studies.RESULTS:The WMI was positive in 15 patients (67 (SD 8) years, 31% (SD 12%) EF) and showed significant correlation with heart rate variability (standard deviation of normal to normal intervals (SDNN): 143 (SD 80) ms vs 102 (SD 29) ms, p = 0.04, r = 0.45; total power (TP). 11 885 (SD 19 674) ms(2) vs 2229 (SD 1779) ms(2), p = 0.03, r = 0.384; very low frequency component (VLF): 2777 (SD 3039) ms(2) vs 1184 (SD 565) ms(2), p = 0.03; low frequency component (LF): 2955 (SD 5734) ms(2) vs 468 (SD 725) ms(2), p = 0.05, r = 0.375; high frequency component (HF): 4885 (SD 9939) ms(2) vs 382 (SD 609) ms(2), p = 0.05, r = 0.315) and turbulence (turbulence onset (TO): -0.002 (SD 0.008) vs +0.005 (SD 0.01), p = 0.05, r = 0.301; turbulence slope (TS): 3.4 (SD 3.1) vs 1.7 (SD 1.5), p = 0.04, r = 0.419). The positive predictive value of the WMI considering the inducibility of VT during EP testing was 100%. Those patients who received an ICD for primary prevention showed a higher WMI (p = 0.049) than the secondary prevention group. With respect to the occurrence of adequate VT episodes, a negative WM test result demonstrated a negative predictive value of 95%.CONCLUSION:The data presented show that the WM-Index predicts VT inducibility during EP testing and indicates a high negative predictive value regarding the occurrence of VT.

In der vorliegenden Studie analysierten wir die Anzahl von adäquaten und inadäquaten Therapieabgaben in zwei primärprophylaktischen Patientenkollektiven mit implantierbarem Cardioverter/Defibrillator (ICD). 55 Patienten wurden gemäß der MADIT-II(MII)-Einschlusskriterien implantiert, während 86 Patienten nach den SCD-HeFT (SH) Kriterien zur Implantation determiniert wurden.

Introduction: Cerebral embolism and stroke are feared complications of left atrial catheter ablation such as pulmonary vein (PV) ablation. In order to assess the thrombogenicity of left atrial catheter ablation, knowledge of both clinically evident as well as silent cerebral embolism is important. The aim of the current study was to examine the use of diffusion‐weighted magnetic resonance imaging (DW‐MRI) for detection of cerebral embolism, apparent as well as silent, caused by PV catheter ablation. Methods and Results: Twenty consecutive patients without structural heart disease undergoing lasso catheter‐guided ostial PV ablation using an irrigated‐tip ablation catheter were studied. Cerebral MRI including DW single‐shot spin echo echoplanar, turbo fluid attenuated inversion recovery, and T2‐weighted turbo spin echo sequences were performed the day after the ablation procedure. Ten patients also underwent preprocedure cerebral MRI. All ablation procedures were performed without acute complications. A mean of 3.2 ± 0.6 PVs were ablated per patient. No patient had neurological symptoms following the procedure. In 2 of 20 patients (10%), DW‐MRI revealed new embolic lesions, which were located in the right periventricular white matter in one and in the left temporal lobe in the other patient. There was no statistically significant difference in age, history of hypertension, left atrial volume, and procedure duration between the 2 patients with and the 18 patients without cerebral embolism following AF ablation. Conclusion: This is the first study using highly sensitive DW‐MRI of the brain to detect asymptomatic cerebral embolism after left atrial catheter ablation. Even small, clinically silent, embolic lesions can be demonstrated with this technique. DW‐MRI can be used to monitor and compare the thrombogenicity of different AF ablation approaches.

thrombus formation in the coronary arteries.Death is not easy to study but consequences of supraventricular tachyarrhythmias can be studied.Method: a retrospective study of serious complications of supraventricular arrythmias with a high heart rate was performed in patients referred to our clinic for ablation treatment.The study period was from January 1999 to may 2004.The following manifestations of the tachyarrhythmia were included: Syncope, acute left ventricular heart failure (within 24 hours of the start oft the arrhythmia), chest pain, and acute myocardial infarction, preexcitated atrial fibrillation with syncope or circulatory collapse.Results: during the study period, 725 ablations were performed to different arrhythmia substrates (AVNRT, WPW, AF, AFL, and EAT).190 serious manifestations of the arrhythmia were found: 128 (18%) syncope, 6 (1%) acute left ventricular heart failure, 35 (5%) chest pains, 18 (2.5%)acute myocardial infarction, 3 (0.4%) preexcitateded AF with syncope or circulatory collapse.Summary: during 5.5 years 725 ablations of supraventricular arrhythmias were performed.Serious complications due to a high ventricular heart rate were found in 190 (26%) of the patients.Most common were syncope and chest pain.18 patients fulfilled the criteria for acute myocardial infarction.

17.6%).Mean values of SAECG parameters for the entire group are: fQRS IxV.Sixteen pts showed increased dimensions of the RV in parasternal long axis (31-85 mm; 42.8 4-14.7 mm).No significant correlations was found between RV dimension and fQRS duration (r=0.21),LAS duration (r=0.39) and RMS voltage (r=-0.48).Conclusions: A high significance of LP (70.6%) was found in patients with ARVD.A normal finding of SAECG doesn't exclude the existence of ARVD.No correlation has been found between the SAECG parameters and RV dimensions in the echocardiographic parasternal long axis view.LP were also present in patients with minimal RV dilation.Some patients develop localized RV enlargements which can be detected only in particular echocardiographic views.

S u n d a y , 26 J u n e 2005 recurrence.VT/VF had been inducible in all pts with a recurrence, and MTWA had been positive or indeterminate in 9 of 10 pts, resulting in a high sensitivity (100% and 90%).However, PES and MTWA had been positive also in many pts without a recurrence, resulting in a low specificity (10%, 48%) and low positive predictive value (34%, 45%).Non-inducibility of VT/VF and absence of MTWA did have a high negative predictive value (100% and 91%).Conclusions: VT/VF inducibility and the presence of MTWA overestimate the risk of SCD recurrence.MTWA absence may identify low risk pts benefiting less from ICD treatment.

Postextrasystolic acceleration of heart rate (HR), known as HR turbulence (HRT) is attenuated in patients with coronary artery disease at increased risk of adverse events. The influence of age and basic HR on HRT have not been evaluated in a large cohort of persons. In 95 healthy individuals, HRT onset (TO) and slope (TS) were calculated from 24-hour ambulatory electrocardiograms, as well as the turbulence timing (TT). Gender specific differences in TO and TS were compared in simple, linear, weighted regression model. The influence of age and the basic HR preceding ventricular premature contractions on HRT were examined. We found that, in men and women, TO decreases as basic HR increases (P < 0.01). In contrast, in men, TS decreased as basic HR increases, whereas in women, basic HR influenced TS only slightly (P < 0.01). A multiple, linear regression model revealed a decrease in HRT with increasing age in men. In conclusion, physiological acceleration of the HR within the first 11 beats after premature ventricular complex (VPC) was observed in >75% of healthy individuals. An accelerating HR preceding the VPC influenced HRT in men. An increasing age was associated with a decrease in HRT in men and a decrease in TO in women. These results illustrate the importance of physiological modulations of HRT when used for risk stratification, especially in older populations.

Attenuation of the oscillation of the heart rate, i. e.heart rate variability (HRV), is associated with an increasedrisk for mortality in patients with structural heart disease.Many of these patients also suffer from conduction disturbances,e. g. AV-nodal conduction delays. Whether the calculation of HRVin those patients is recommendable has not been investigatedyet. Therefore, we conducted a study consisting of 20consecutive patients in order to determine the formation of HRV,the influence of structural heart disease, the presence of anonsustained ventricular tachycardia (VT), and a reducedejection fraction (EF) on the HRV parameters during an electiveelectrophysiologic study.

Die pharmakologische und ablative Hybridtherapie des Vorhofflimmerns ist bei ausgewählten Patienten möglich, die eine Konversion von Vorhofflimmern in Vorhofflattern unter Antiarrhythmikaeinfluss aufweisen. Im Rahmen dieser Form von Hybridtherapie wird das Antiarrhythmika-induzierte typische Vorhofflattern einer Katheterablation unterzogen und die Vorhofflatter-induzierende Medikation zur Rezidivprophylaxe anschließend fortgeführt. Ziel dieser Behandlung ist es, entweder Vorhofflimmerfreiheit oder aber zumindest eine reduzierte Rezidivrate von Vorhofflimmern zu erzielen. Die bisherigen Studien belegen, dass die ablative und pharmakologische Hybridtherapie auch eine langfristig effektive Therapiemöglichkeit darstellt. Obwohl durch die Anwendung einer Hybridtherapie im Langzeitverlauf oftmals kein völliges Ausbleiben symptomatischer Vorhofflimmerepisoden erzielt werden kann, wird dennoch eine signifikant niedrigere Vorhofflimmerrezidivrate, eine Verbesserung der AF-Symptome sowie eine Steigerung der Lebensqualität beobachtet.

A 42 year old male patient presented with atypical ECG pattern at rest and reported that his brother died suddenly of unknown reasons at the age of 40. A performed pharmacological testing with ajmalin discovered strong ST-segment elevations in lead V(1) and V(2) in combination with an incomplete right bundle branch block. As a result, the diagnosis Brugada syndrome was established. The Brugada syndrome is a primary cardiac conduction disturbance without structural heart disease and is associated with an increased risk of sudden cardiac death caused by life threatening ventricular tachyarrhythmia. It is an inherited disease displaying an autosomal dominant mode of transmission with an incomplete penetrance, especially prevalent in females. In some regions like the southeast of Asia and Japan it is endemic. The mutation is linked to the sodium channel gene SCN5A. The annual mortality rate is estimated 30 per 100.000 persons. Today, exact diagnostic criteria do not exist. The diagnosis is based on the typical ECG pattern, combined with clinical symptoms, and a family history of sudden cardiac death. The currently suggested therapy consists of the implantation of an internal defibrillator.