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Background Oral anticoagulation (OAC) reduces thromboembolic events and mortality in patients with atrial fibrillation (AF). Anticoagulation rates have substantially increased over recent years. Still, a number of patients are not receiving guideline recommended OAC. Purpose To investigate clinical factors and reasoning associated with non-prescription of OAC in a current German registry. Methods The German AFNET 2 registry is a prospective multi-center registry on atrial fibrillation comprising a total of 3491 patients from all levels of medical care (general practitioners, cardiologists, hospitals; enrolment 5/2014 to 3/2016). The registry was conducted in collaboration with the EORP program of the ESC. Here, only patients with non-valvular AF and at least two clinical risk factors for stroke (using CHA2DS2-VASc score) were considered. Results The study population consisted of 2856 patients, 58.4% male, mean age 75.5±7.8 years, mean CHA2DS2-VASc score 4.1±1.5, mean HAS-BLED score 1.8±1.0. Overall, the rate of OAC was 94.3%. 54% of these received Vitamin K antagonists (VKA) and 46% NOAC. 2.3% received antiplatelets only. Patients newly initiated on OAC mostly received a NOAC (82.5% of patients). Anticoagulation rate was lower in elderly patients (age Conclusions Within registries, the guideline recommended use of OAC is very high in Germany indicating high guideline adherence by prescribing physicians. However, use of antiplatelet therapy was associated with non-prescription of OAC. In addition, a high HAS-BLED score appears to be a relevant argument for withholding proven OAC for stroke prevention in patients with AF. Acknowledgement/Funding BMS Germany; DZHK

In selected patients, biventricular pacing leads to improvement in left ventricular (LV) performance, especially in the presence of pre-existing marked asynchrony of LV contraction. Improvements are sustained in the great majority of cases, and are accompanied by reduced symptoms, increased walking distance and reduced need for hospitalization. The degree of asynchrony of LV contraction and the amount of myocardial scarring are important parameters that determine the response to cardiac resynchronization therapy (CRT). Improvements in haemodynamics are due not to a positive inotropic effect of pacing but rather to elimination of an unsynchronized energy-wasting contraction pattern. Mortality trials are in progress to assess the effect of CRT on total mortality, arrhythmic mortality and mortality from heart failure.

The members of the Task Force on Sudden Death dedicate this paper to the memory of our former friend and colleague, Professor Ronald W. F. Campbell. Ronnie spent his life working in the field of sudden cardiac death; he contributed much and helped many. But his own life fell victim to this very problem, sadly illustrating its unexpected nature. With Ronnie’s memory in mind the Task Force has worked diligently to describe the extent of our expanding knowledge in this field, hoping that our small contribution might help to appease his sad and sudden death.

Objectives This study is designed to examine the immediate and short-term outcomes of patients who have undergone slow pathway ablation/modification for atrioventricular nodal reentrant tachycardia. Background Targeting the slow pathway has emerged as the superior form of treatment for atrioventricular nodal reentrant tachycardia. This technique has been found effective and is associated with a low complication rate. However, little is known of the long-term outcome of patients undergoing this procedure. Methods Over a 40-month period the slow pathway was targeted in 379 consecutive patients with proven atrioventricular nodal reentrant tachycardia. The case records of all patients were examined. Accurate follow-up data is available in 96% of patients a mean of 20·6 months after the procedure. Results The initial success rate was 97%. The incidence of complete heart block was 0·8% and the mean fluoroscopy duration was 27·3min. The recurrence rate was 6·9%. Age, number of pulses and fluoroscopy time were positively associated with either initial failure or recurrence. A total of 11·3% of patients were still taking antiarryhthmic medication at follow-up. Conclusions Targeting the slow pathway is an effective form of treatment for atrioventricular nodal reentrant tachycardia. The technique has a high initial success rate, a low complication rate and a low recurrence rate at long-term follow-up. Slow pathway modification is associated with similar success rates and recurrence rates as slow pathway ablation and may confer theoretical long-term benefits.

Objectives The Cholesterol Lowering Atherosclerosis PTCA Trial (CLAPT) is a prospective, randomized trial with blinded angiographic end-points to assess the effect of 2-year's treatment with lovastatin initiated 4 weeks prior to PTCA, compared to usual care on non-dilated coronary segments and on dilated coronary lesions in male patients with total cholesterol between 200 and 300mg.dl−1who underwent elective PTCA. Methods and Results Two hundred and twenty six patients were randomized 4 weeks prior to PTCA to special care (diet plus lovastatin n=112) or usual care (diet; n=114). One hundred and ninety-nine patients underwent PTCA at baseline and were finally included in the study. Quantitative coronary angiographic assessment was performed on blinded cinefilms at baseline (PTCA) and repeated after 4 and 24 months in 91% and 81% of the patients. The primary end-point was a change in the mean segment diameter of non-dilated segments. The mean lovastatin dose was 33mg.day−1. Total- and LDL-cholesterol decreased by 21% and 29% in the special care group and by 7% and 11% in the usual care patients. After 2 years, the mean segment diameter of non-dilated segments decreased by 0·03mm in the usual care group and 0·004mm in the special care group ( P =0·27). The decrease in the mean segment diameter of dilated lesions was 0·17mm (usual care) and 0·06mm (special care) ( P =0·04) after 4 months; 0·16mm (usual care) and 0·002mm (special care) after 24 months, respectively ( P =0·05). In both groups, the mean segment diameter of dilated lesions increased between 4 and 24 months after PTCA compared to a decrease in mean segment diameter of non-dilated segments ( P 50% diameter stenosis at follow-up) occurred in 28·4% of usual care and 22·2% of special care patients ( P =0·17). Conclusions Lovastatin reduced the progression of dilated lesions in men with elective PTCA. Independent of treatment allocation, the dilated lesions regressed and the non-dilated segments progressed during the study follow-up. Four weeks of pre-treatment with lovastatin did not influence the rate of restenosis. Lovastatin had no statistically significant effect on non-dilated segments.

Lady1999199919991999 The European Society of CardiologyThe European Society of CardiologyThe European Society of CardiologyThe European Society of CardiologyThatcher: Copyright They are exactly what they say, guidelines, they are not the law. They are guidelines .Ms Baxendale: Do they have to be followed? Lady Thatcher: Of course, they have to be followed, but they are not strict law. That is why they are guidelines and not law and, of course they have to be applied according to circumstances.

Atrial fibrillation, a commonly encountered arrhythmia, has in recent years, been the subject of increased interest and intensive clinical research. There is also increasing awareness that atrial fibrillation is a major cause of embolic events which in 75% of cases are complicated by cerebrovascular accidents[1,2]. Atrial fibrillation is often associated with heart disease but a significant proportion of patients (about 30%) have no detectable heart disease[3]. Symptoms, occasionally disabling, haemo-dynamic impairment and a decrease in life expectancy are among the untoward effects of atrial fibrillation, resulting in an important morbidity, mortality and an increased cost for the health care provider[4]. The Working Group of Arrhythmias of the European Society of Cardiology created a Study Group on Atrial Fibrillation in order to establish recommen-dations for the better management of this arrhythmia and to promote multicentre studies. The purpose of this paper is to briefly outline the state of our knowledge on the clinical presentation, the causes, the mechanisms and therapeutic approaches currently available and to propose recommendations for management. Although atrial flutter can coexist with atrial fibrillation, it is considered a different arrhythmia and will not be covered in the present paper.

Objectives The primary objectives of this study were to assess the feasibility of temperature-controlled radiofrequency catheter ablation of left and right sided manifest accessory pathways in patients with Wolff-Parkinson-White syndrome and to gain more insights into biophysical aspects of temperature-controlled catheter ablation in humans. Background The electrode-tissue interface temperature and other biophysical parameters are among important variables determining the efficacy and safety of radiofrequency ablation of accessory pathways. Experimental studies have shown that radiofrequency-induced tissue necrosis can be accurately predicted by monitoring of catheter tip temperature. Methods 38 consecutive patients (14 f, 24 m; aged 42 ± 12 years) with anterograde conducting accessory pathways (left sided: n=22; right sided: n=l6) underwent temperature-controlled radiofrequency ablation (HAT 200S, Dr Osypka, Germany). The electrode temperature was monitored via a thermistor embedded into a 4 mm catheter tip. Power output was adjusted automatically during energy delivery in a closed loop system (preselected temp.: 70·1 ± 5·8°C). Results Accessory pathway conduction was successfully abolished in all patients after the delivery of 2·3 ± 2·1 radiofrequency pulses (range: 1–9, median: 2). Interruption of the accessory pathway as evidenced by loss of preexcita tion occurred after 5·9 ± 5·4 s. At the time of the interruption of the accessory pathway the catheter tip temperature measured 54·2 ± 11· 2 ° C in patients with left and 44·9 ± 5·0° C in patients with right sided accessory pathways, respectively ( P

Objective: The aim of this prospective study was to analyse the yield of programmed ventricular stimulation at the right ventricular apex compared with the outflow tract. Methods: A stepwise randomized cross-over protocol of programmed ventricular stimulation with alternating stimulation at both sites was used in 66 patients who were studied because of sustained ventricular tachycardia (n = 30), ventricular fibrillation (n = 7), or non-sustained ventricular tachycardia and/or syncope (n = 29). Results: There were no significant differences between the results of stimulation from either right ventricular site with regard to the presence or absence of structural heart disease, spontaneous arrhythmia, ejection fraction or effective refractory periods. Overall, monomorphic ventricular tachycardia was inducible in 33 patients (50%); in 25 patients (75.8%), this arrhythmia was induced from both sites. However, in only 17 of these 25 patients (68%) did the induced monomorphic ventricular tachycardias have the same morphologies and similar (± 50 ms) cycle lengths. Ventricular fibrillation was inducible in 11 patients (17%), mostly by three extrastimuli (n=8; 73%). Conclusions : (1) stimulation from at least two right ventricular sites is desirable because of their independent contribution to the induction of ventricular tachyarrythmias, (2) the non-inducibility or inducibility at one ventricular site does not predict the effect at another stimulation site, (3) the effective refractory period at the right ventricular apex and outflow tract do not differ, (4) the inducibility of multiple ventricular tachycardia morphologies emphasizes the importance of documenting the cause of spontaneous arrhythmias with multiple electrocardiographic leads to ensure the correct interpretation of arrhythmias induced by programmed stimulation, (5) clinical or haemodynamic features cannot predict whether one or more stimulation sites will be required for induction of ventricular tachycardia. These results are important for the diagnostic evaluation and assessment of pharmacological or non-pharmacological interventions.

In order to assess prognosis after myocardial infarction, various methods have been used: estimation of ejection fraction, Holter monitoring, detection of ventriculur late potentials using signal-averaging techniques, programmed ventricular stimulation of the heart to test the inducibility of ventricular tachyarrhythmias, and parameters that assess heart rate variability. Left ventricular dysfunction is the major determinant for prognosis after myocardial infarction, but left ventricular end-systolic volume may be better than overall ejection fraction. The presence of an ‘arrhythmogenic substrate’ may be detected by recording low-amplitude, fractionated activity or by artificially introducing premature ventricular extrasystoles using programmed ventricular stimulation. The signal-averaged ECG represents an independent tool for risk assessment. In some studies, signal-averaging and programmed ventricular stimulution proved to be more sensitive for the prediction of sustained ventricular tachycardia than for sudden death. The risk of an arrhythmic event in patients with an abnormal signal-averaged ECG or an abnormal result of programmed ventricular stimulation is increased, although the majority of these putients still do not experience a fatal or life-threatening arrhythmia. This high number of false-positive results limits the practical applicability of the signal-averaged ECG but also of other techniques such as long-term ECG recording. Recent interest has focussed on heart rate variability, which is considered an index of sympatho-vagal interaction after acute myocardial infarction. Patients with decreased heart rate variability have a poorer prognosis than those with normal parameters. Patency of the infarct-related artery is a major factor that governs the potentially beneficial effects of thrornbolyic therapy. Many, but not all, studies have shown a reduced prevalence of late potentials after successful thrombolysis or in the presence of an open infarct-related artery. Effective thrombolytic therapy may prevent the development of an abnormal electrophysiological milieu after myocardial infarction. Finally, neurological factors such as depression have been shown to be independent risk factors for mortality after acute myocardial infurction. The role of psycho-social factors and their mechanisms of action need further attention since they open the door for behavioural modification. In conclusion, there are several promising new techniques for indentification of patients at risk of ventricular tachyarrhythmias. These techniques seem to be superior to more conventional methods such as long-term ECG monitoring as well as exercise testing. Methods which determine the arrhythmogenic substrate might be combined with a parameter of left ventricular ejection fraction because of the paramount importance of left ventricular pump function. However, due to the large proportion of false-positive results obtained with any of these methods, it seems unlikely that they will clearly surpass the others and be sufficiently accurate for risk assessment in the individual patient.

Up to now there have been no descriptions in the literature of endocardial catheter mapping and successful radiofrequency catheter ablation of the right sided accessory pathway during sustained atrial fibrillation. We attempted ablation of a right posterolateral and a right lateral accessory pathway during sustained atrial fibrillation with rapid anterograde conduction over the accessory pathway in two patients with Wolff-Parkinson-White syndrome. In both patients (aged 47 and 52 years), sustained atrial fibrillation occurred during the electrophysiological study to assess accessory pathway conduction properties. The mean ventricular rate during atrial fibrillation was 180 and 170 beats.min-1, respectively. Both patients were successfully ablated with a single radiofrequency impulse. At the successful ablation sites, a potential of the accessory pathway was consistently recorded preceding the onset of preexcitation in the surface electrogram, by 25 ms in patient 1 and 30 ms in patient 2. The unipolar electrogram recorded from the ablation catheter showed a QS morphology and the accessory pathway potential preceded the intrinsic deflection by 10 ms in both patients. Onset of the ventricular electrogram (patient 1: -20 ms; patient 2: -15 ms) and its activation time (patient 1: -15 ms; patient 2: +5 ms) in relation to the onset of preexcitation in the surface electrocardiogram also indicated the close proximity of the ablation catheter to the accessory pathway. Preexcitation disappeared within 2 s after energy application in both patients. Thus, radiofrequency catheter ablation of right sided accessory pathways during sustained atrial fibrillation is feasible and may obviate the need for medical or electrical cardioversion.(ABSTRACT TRUNCATED AT 250 WORDS)

Ventricular late potentials detected at the end of the QRS complex by the signal-averaged ECG have been shown to predict arrhythmic events after acute myocardial infarction. Spectral turbulence analysis is a novel technique for detecting abnormalities of cardiac electric activation inside the QRS complex. The purpose of this study was to combine these two analysis methods in order to increase the predictive power of the signal-averaged ECG in post-infarction patients. The study comprised a prospective series of 778 males under 66 years of age who survived the acute phase of myocardial infarction. Signal-averaged ECG recordings were performed before hospital discharge 2 to 3 weeks after infarction. The original Simson method was used for recording and analysing the time-domain signal-averaged ECG. Spectral turbulence analysis was performed using the same averaged vector magnitude QRS complexes (Del Mar Avionics). During the follow-up period of 6 months, 33 patients (4.2%) had an arrhythmic event (sustained monomorphic ventricular tachycardia in 13 cases, ventricular fibrillation in eight cases and sudden cardiac death in 12 cases). The predictive power of late potentials in the time domain, spectral turbulence analysis and their combinations were tested together with clinical variables using the Cox regression method. The combination of late potentials and a spectral turbulence analysis score (one or both abnormal) had the greatest influence on the prediction of arrhythmic events: late potentials+spectral turbulence analysis (regression coefficient B=0.75; P=0.0014), Selvester ECG score >10 (B=0.44; P=0.027), history of previous infarction (B=0.49; P=0.018) and non-sustained ventricular tachycardia during long-term ECG recording (B=0.50; P=0.035). The combination of late potentials and spectral turbulence analysis reached a sensitivity of 76%, a specificity of 63%, a positive predictive value of 8% a negative predictive value of 98%) and a total predictive accuracy of 61%. Patients with late potentials and/or abnormal spectral turbulence analysis were significantly less often free of arrhythmic events compared to patients with normal findings (92% vs 98%, P

Introduction Radiofrequency catheter ablation has been demonstrated to be an effective and safe therapy in patients with so-called idiopathic ventricular tachycardia, whereas the benefit/risk profile for ablation of ventricular tachycardia in patients with chronic myocardial infarction and severely compromised left ventricular function still needs to be determined. The present report describes the unintended induction of transient third-degree atrioventricular block in a patient with remote myocardial infarction who underwent radiofrequency catheter ablation of ventricular tachycardia. Methods and Results Endocardial catheter mapping and radiofrequency ablation were performed in a 57-year-old patient with chronic recurrent ventricular tachycardia, who had previously suffered from anterior and posterior wall myocardial infarction. Additionally, the patient presented with complete right bundle branch block during sinus rhythm. Radiofrequency energy applied to a critical site of the reentrant tachycardia at the left ventricular basal septum during sinus rhythm induced third-degree atrioventricular block after 20 s of current delivery, which lasted for 24 h. At this site, a presumable left bundle branch potential was recorded during sinus rhythm. Conclusions Radiofrequency current application for ablation of ventricular tachycardia may induce third-degree atrioventricular block in patients with remote myocardial infarction. When current is delivered to target sites at the left ventricular basal septum, radiofrequency energy should be applied during sinus rhythm to allow continuous monitoring of atrioventricular conduction. Special caution should be given to patients with right bundle branch block during sinus rhythm.

The role of programmed ventricular stimulation (PVS) in patients at high risk of sudden death related to idiopathic dilated cardiomyopathy (DCM) is still controversial. The possible reason is that most study series have been too small or that only a few patients had documented sustained ventricular tachyarrhythmias. This study therefore, looked at PVS performed in 102 patients with DCM and documented sustained ventricular tachycardia (VT; n = 63) or ventricular fibrillation (VF; n = 39). Sustained VT was induced in 27 of 63 patients (43%) with documented sustained VT and in 14 of 39 patients (36%) with documented VF (ns). VF was induced in nine patients (14%) with a history of sustained VT and in seven (18%) with a history of VF (ns). At a mean follow-up of 32 +/- 15 months, sudden death occurred in 14 (14%) patients, a rate similar in both patients with documented VT and VF (ns). Incidence of sudden death at 36 months was 6% in patients with inducible sustained VT/VF compared to 29% in patients without inducible VT/VF (P0.05). A favourable drug regimen (response to drug and no intolerable side effects) was obtained by serial drug testing in 25 of all 102 patients (25%). A cardioverter defibrillator (ICD) was implanted in 32 patients, in 63% of whom discharges were observed during 18 +/- 11 months of follow-up; only one patient (3%) died suddenly. Thus, in patients with DCM, there was no relationship between documented and inducible ventricular tachyarrhythmias, and initiation of sustained VT or VF had little prognostic value for the prediction of subsequent sudden death. Wherever antiarrhythmic drug therapy was of limited value, implantation of an ICD may improve the prognosis of these high risk patients.

During the past decade, the high-resolution electrocardiogram as a non-invasive technique for the detection of ventricular late potentials has developed from an experimental method into a routinely applied non-invasive method for risk stratification of patients after myocardial infarction. Meanwhile, several approaches have been developed for the detection of ventricular late potentials including time–domain analysis, frequency–domain analysis and spectrotemporal mapping. Clinical applications are no longer limited to patients after myocardial infarction, but cover a wider spectrum of different cardiac diseases. This review focuses on some methodological aspects as well as on the results and current clinical applications of the analysis of the signal-averaged ECG in the time domain.

Sufficient data are available to recommend that the high-resolution or signal-averaged electrocardiogram can be used in patients recovering from myocardial infarction without bundle branch block to help to determine their risk for developing sustained ventricular tachyarrhythmias. However, no data are available regarding the extent to which pharmacologic or non-pharmacologic interventions in patients with late potentials have an impact on the incidence of sudden cardiac death. Therefore, controlled, prospective studies are required before this issue can be definitely answered. As refinements in techniques evolve, it is anticipated that the clinical value of high-resolution or signal-averaged electrocardiography will continue to increase in the future.

Aims Atrial fibrillation represents a frequent and potentially life-threatening arrhythmia in patients with accessory atrioventricular pathways. Radiofrequency ablation has become the curative treatment of first choice for these patients. Investigations after successful surgical pathway dissection reported an almost complete elimination of paroxysmal atrial fibrillation. However, there are only a few reports which include a small number of patients undergoing radiofrequency ablation. The purpose of this study was to examine whether successful radiofrequency ablation of accessory pathways prevents the occurrence of paroxysmal atrial fibrillation, and to identify possible predictors of atrial fibrillation recurrence. Methods and Results A total of 116 consecutive patients (mean age 4215 years) with manifest or concealed accessory pathways and documented paroxysmal atrial fibrillation underwent radiofrequency catheter ablation. The patients were reexamined at 6 and 12 months. Long-term follow-up information was obtained by questionnaire and/or by consulting the referring physician. Pathway conduction was abolished in 101 cases (87%). Late follow-up information was obtained from 91 of these 101 patients (90%) with successful ablation with a mean follow-up duration of 23·912·3 months. During follow-up, 25 of 91 patients (27%) experienced arrhythmias. Recurrent episodes of atrial fibrillation were observed in 18 of these 25 cases (i.e. 20% of the 91 patients). Differences between patients with and without recurrences of atrial fibrillation were examined for age, sex, associated cardiac disease, presence of multiple pathways, pathway location, atrial fibrillation inducibility during the procedure and cycle length of the atrioventricular reentrant tachycardia. Only older age was a significant independent predictor of atrial fibrillation recurrence (P=0·02). Eleven of 31 patients (35%) older than 50 years of age had atrial fibrillation recurrences during follow-up compared to seven of 60 patients (12%) under age 50. The recurrence rate of atrial fibrillation was even higher in patients older than 60 years (6 of 11 patients, i.e. 55%). In comparison, the occurrence rate of atrial fibrillation during follow-up in a control group of 100 consecutive patients with successful accessory pathway ablation, who did not have evidence of paroxysmal atrial fibrillation prior to ablation, was 4% and, thus, significantly lower than in the study group of the 91 patients (P=0·001). Conclusions The recurrence rate of paroxysmal atrial fibrillation after successful radiofrequency ablation of accessory pathways shows an age-related increase, being low in patients younger than 50 years of age (12%) and high in the older patients: 35% in patients older than 50 years and 55% in patients older than 60. These results have significant therapeutic implications concerning the decisions on pharmacological therapy after successful ablation in patients older than 50 years. Furthermore, these data will help physicians advise older patients properly about their risk of recurrence of atrial fibrillation after ablation.

Background The aim of this study was to investigate coronary compliance in patients early and 71.8 weeks after orthotopic heart transplantation. Methods Thirty patients (mean age 51.4 years, women n=6) underwent coronary angiography early after orthotopic heart transplantation (mean interval 11.6 ± 5.5 weeks), by which time 12 recipients had already been treated for episodes of rejection. A total of 153 different coronary segments were investigated using a mechanical 30 MHz intravascular ultrasound system. In all segments, the intimal index and the circumferential extension of the vessel wall, which had a three-layered appearance, were assessed. Systolic-diastolic changes in area, and pressure with respect to vessel wall area, were used to study normalized compliance. All measurements were repeated in a subgroup of 13 patients 71.8 ± 10.7 weeks after transplantation. Results At the first investigation, the mean intimal index of all estimated cross-sectional areas was 0.07 ± 0.10. The mean circumferential extension of the ‘three-layered’ coronary vessel wall was 74° ± 101°. No correlation could be found between normalized compliance and the intimal index (r= − 0.322, P

Aims Anatomical and electrogram-guided techniques have been used separately for slow pathway ablation in atrioventricular nodal reentrant tachycardia. The aims of the present study were to analyse electrogram characteristics of target sites and biophysical parameters using a combined anatomical and electrogram-guided technique for temperature-controlled radiofrequency catheter ablation of the slow pathway. Methods and results Using a temperature-controlled (pre-selected 60 °C) catheter system, 53 patients with atrioventricular nodal reentrant tachycardia underwent slow pathway radiofrequency ablation. Mapping was started posteroseptally near the coronary sinus ostium and continued towards the midseptal area if needed. The longest and latest atrial electrograms with an atrioventricular ratio of ≤0·5 were targeted. After a median of two pulses (mean 2·36 ± 1·33), atrioventricular nodal reentrant tachycardia was rendered non-inducible in all patients without complications. Successful sites had longer atrial electrograms (78·8 ± 9·8 vs 67·6 ± 13·3 ms, P

In 90 consecutive patients with coronary artery disease and sustained monomorphic ventricular tachycardia, who were treated with oral sotalol and underwent programmed stimulation to determine drug effectiveness, the influence of sotalol on induced ventricular tachycardia morphology was retrospectively examined. In 54 patients (60%) sotalol rendered the tachycardia non-inducible. However, contrary to drug-testing with class I antiarrhythmic agents, induction of multiple morphologies at baseline study did not predict failure of subsequent drug-testing with sotalol. In the remaining 36 patients (40%), in whom sotalol did not modify inducibility, 21 patients (i.e. a total of 23%) manifested at least one new morphology during electropharmacological testing on sotalol. This effect was independent of the degree of left ventricular dysfunction, infarct location and numbers of morphologies at baseline, but corresponded with drug-induced changes in refractoriness. This observation may be related to a proarrhythmic effect of sotalol. Slowing of ventricular tachycardia rate and changes in morphology may have implications in patients receiving implantable cardioverter-defibrillators or those undergoing ablative procedures.

Ventricular arrhythmias are a frequent finding in patients with heart failure, and heart failure is a major underlying condition which is correlated to sudden death. Therefore, both sudden death and death from progression of heart failure strongly overlap. Besides long-term ECG recording, newer diagnostic techniques have been developed. The prognostic significance of the signal-averaged ECG in patients with advanced left ventricular dysfunction in the presence of coronary artery disease has been demonstrated; however, in patients with dilated cardiomyopathy, signal-averaging for detection of late potentials has not yet been clearly established as a useful diagnostic tool. Furthermore, heart period variability has been shown to correlate to overall mortality but not to a specific mechanism. Finally, programmed ventricular stimulation, though useful in patients with left ventricular dysfunction and/or heart failure in the setting of coronary artery disease, is of questionable significance in patients with dilated cardiomyopathy. With increasing degrees of left ventricular dysfunction, the efficacy of antiarrhythmic drugs decreases. On the other hand, with increasing degrees of heart failure, antiarrhythmic drugs demonstrate a greater negative inotropic effect, more frequent proarrhythmic effects, and more frequent bradyarrhythmias. Currently, several ongoing amiodarone trials are assessing different approaches of antiarrhythmic treatment in patients with heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)

A 61-year-old male patient was admitted to our hospital for syncope that was not preceded by symptoms. The status of the patient had already improved by the time the ambulance arrived. He had a regular heart rate and was perfectly orientated. Before this event he had been in New York Heart Association functional class III (dyspnoea after climbing one floor, no dyspnoea at rest and no angina). Over the past 3 years, he had experienced recurrent episodes of pre-syncope. Dilated cardiomyopathy had been diagnosed in 1993, with a left ventricular ejection fraction of 20%. He was on the following medications: captopril 25 mg three times daily; carvedilol 6.25 mg twice daily; furosemide 40 mg twice daily; and oral anticoagulation therapy. On arrival at our hospital his blood pressure was 100/60 mmHg, with a heart rate of 76 beats, min1. ECG demonstrated a complete left bundle branch block (LBBB) morphology, with a PR interval of 0-23 s and a QRS duration of 0.18 s. There was no ST-segment elevation. During the hospital stay 24-h Holter monitoring was conducted, demonstrating a normal sinus rhythm with rates between 48 and 99 beats, min~, with no pauses and no ventricular arrhythmia (

We report the case of a 47-year-old patient with a patent ductus arteriosus who underwent angiography and percutaneous intravascular ultrasound examination. The case illustrates that intravascular ultrasound contributes to the characterization of patent ductus arteriosus when a surgical or trans-catheter closure is planned, as calcifications of the wall as well as aneurysmal dilatations can be ruled out. Furthermore, measurements of the diameter of the ductus can be made.

Effective pulmonary capillary pressure and extravascular lung water were investigated in dogs (n=9) with normal heart function and after development of acute myocardial ischaemia. During control, no impairment of cardiopulmonary performance was observed. Extravascular lung water was in the normal range (8.1±2.8 ml. kg−1) and the effective pulmonary capillary pressure accounted for 1.36 ± 0.53 kPa (10.2±4 mmHg). No correlation between extravascular lung water and effective pulmonary capillary pressure was observed (r2=0.347, P =0.06). Arterial (RPA) and venous pulmonary resistance (RPV) were 70± 15% and 30±6%, respectively. Acute myocardial ischaemia was induced by one stage occlusion of the left anterior descending (LAD) coronary artery; measurements during the ischaemia phase were performed 60 min following LAD occlusion. Myocardial ischaemia resulted in moderate changes of cardiac output, heart rate and left ventricular end-diastolic pressure. Oxygenation deteriorated, but no hypoxaemia occurred in any animal and CO2 elimination remained unchanged. Extravascular lung water was elevated (16.5±7.9ml.kg−1, P ≤0.01), and effective pulmonary capillary pressure was higher when compared with the control state (2.32±1.05 kPa (17.4±7.9mmHg), P≤0.01). There was a significant correlation between both parameters (r2=0.528, P

In past decades, numerous experimental and clinical studies have improved our knowledge of the electrophysiological effects of sodium channel blockers, as well as of the mechanisms of arrhythmogenesis. However, the mechanisms of antiarrhythmic as well as potentially proarrhythmic drug action have been less well clarified. Sodium channel blocker agents have different effects on the normal, ischaemic, and failing heart since their antiarrhythmic actions depend on the substrate and the mechanisms of arrhythmogenesis, as well as other mostly interrelated cardiac and non-cardiac factors. Strict criteria of efficacy and safety have to be applied when sodium channel blockers are used for the treatment of ventricular arrhythmias.

Sufficient data are available to recommend that the high-resolution or signal-averaged electrocardiogram can be used in patients recovering from myocardial infarction without bundle branch block to help to determine their risk for developing sustained ventricular tachyarrhythmias. However, no data are available regarding the extent to which pharmacologic or non-pharmacologic interventions in patients with late potentials have an impact on the incidence of sudden cardiac death. Therefore, controlled, prospective studies are required before this issue can be definitely answered. As refinements in techniques evolve, it is anticipated that the clinical value of high-resolution or signal-averaged electrocardiography will continue to increase in the future.

Ventricular fibrillation (VF) is a well-known but rare complication of the Wolff-Parkinson-White syndrome (WPW). Clinical and electrophysiological data of 23 patients with spontaneous VF were compared with data from 100 consecutive patients with WPW without VF but with symptomatic supraventricular tachycardia. The 23 patients were collected in a multicentre retrospective study in seven European centres. VF occurred in only one patient who was receiving antiarrhythmic drugs, and was the first manifestation of the syndrome in six. No significant differences were found between those with VF and without VF in age, complaints of palpitations, syncope, and presence of structural heart disease. The retrograde effective refractory period of the accessory pathway, the atrial refractory period and the fastest atrial pacing rate with 1:1 anterograde conduction over the accessory pathway were similar in both groups. Significant differences were found for sex, permanent pre-excitation on the electrocardiogram, type of documented supraventricular tachyarrhythmias, shortest RR interval less than or equal to 220 ms during spontaneous atrial fibrillation (AF), inducibility of supraventricular tachycardias, ventricular effective refractory period less than or equal to 190 ms, mean shortest RR interval during induced AF less than or equal to 180 ms and presence of multiple accessory pathways.(ABSTRACT TRUNCATED AT 250 WORDS)

The prognostic significance of late ventricular potentials recorded from the body surface using high-gain amplification and signal averaging was assessed prospectively in 160 patients (mean age 56±8.3 years) after recent acute myocardial infarction (median day of study 25.5). Late potentials were recorded in 81 out of 160 patients (50.6%); a duration of less than 20 ms was observed in 33 patients (20.6%), whereas late potentials of 20 ms duration or more were present in 48 patients (30%). The mean duration of late potentials was 27 ± 16.5 ms. There was no significant correlation with the frequency and type of spontaneous ventricular arrhythmias during 10–24 h Holter monitoring. The follow-up period was 7.5±3.2 months (mean ±s.D.; maximum 15.8 months). In 136 patients (85%) the course after discharge was uneventful. Sudden cardiac death occurred in seven patients (4.4%) after 3.7± 3.4 months (range 0.7–8.3 months). Sustained ventricular tachycardia was documented in four cases 2.9± 1.3 months after myocardial infarction, all having late potentials. The overall incidence of ventricular tachycardia in patients with late potentials of 20 ms duration and more was four out of 48 patients (8.3%) increasing to 16.6% (three out of 18 patients) if only patients with late potentials greater than 40 ms were considered. Sudden cardiac death occurred in three of 79 patients (3.8%) without late potentials. In patients with late potentials less than 40 ms duration, the incidence of sudden death was 3.2% (two out of 63 patients), but it increased to 11.1% (two out of 18 patients) with late potentials of 40 ms duration or more. Ventricular tachycardia or sudden death occurred in 21.7% of patients with late potentials and anterior wall infarction compared to 5.4% in patients with late potentials and inferior wall infarction (P

The surgical therapy of hypertrophic cardiomyopathy (HOCM) has been shown to improve symptoms and the haemodynamic status. The prognosis after transaortic subvalvular myectomy seems to be relatively better compared to those patients with HOCM who undergo medical therapy. Complex ventricular arrhythmias have been shown to influence prognosis. Therefore, a study was undertaken to analyse the influence of surgery on ventricular arrhythmias in patients with HOCM. Thirty-one patients (23 male, eight female), mean age 44±13·6 years (range 13 to 72 years) underwent 48 h ambulatory monitoring pre- and postoperatively. Additionally 15 patients with hypertrophic non-obstructive cardiomyopathy (HNCM) were studied. Mean age was 49±11·5 years (range 28 to 69 years). Complex ventricular arrhythmias were defined as pairs (two consecutive QRS complexes) or non-sustained ventricular tachycardia (VT) (>3 QRS). Results in the operative group (HOCM) were as follows: The overall frequency of ventricular extrasystoles was low. There was no difference in the mean hourly ventricular extrasystole counts pre-operatively as compared to postoperatively. Thirteen patients had no pairs or VT pre- and postoperatively. Six patients had VT or pairs pre- and postoperatively. In five patients complex arrhythmias were detected only before surgery, whereas in another seven patients VT was first documented after operation. Overall, 11 patients had complex ventricular arrhythmias pre-operatively (pairs n = 3; VT n = 8, 3 to 8 QRS, rate 142±15 beats/mm). Thirteen patients had complex ventricular arrhythmias after operation (pairs n = 4; VT n = 9, 4 to 10 QRS, rate 150±40 beats/mm). Results in patients with HNCM were as follows: The overall frequency of ventricular extrasystoles was low, only three patients had a mean extrasystole count of more than 20 beats/h. Five patients had pairs and three patients ventricular tachycardia (5 QRS, rate 110 to 160 beats/mm). In conclusion, complex ventricular arrhythmias are common in patients with HOCM and HNCM. The incidence of these arrhythmias seems to be high even after operation. Whether they have the same prognostic value as in medically treated patients has to be established by further follow-up. Possibly complex ventricular arrhythmias are of lesser malignancy and better tolerated after surgical therapy of HOCM. Further studies are needed to evaluate the clinical significance of ventricular arrhythmias in patients with HNCM.

To assess the predictive value of ventricular late potentials and programmed ventricular stimulation, 379 patients without a history of sustained ventricular tachycardia, dizziness or syncope were studied prospectively. Group I included patients referred for coronary angiography. Group II consisted of patients who survived an episode of acute myocardial infarction and who were studied within 6 weeks after onset. During follow-up (mean 13 months), 16 patients died. Six of these patients died suddenly within one hour. The prevalence of sudden cardiac death was lower (0.8%) in group I compared to group II (3.0%). There was no correlation between results of both methods and the subsequent occurrence of sudden cardiac death. Symptomatic sustained ventricular tachycardia was documented in 10 patients (2.6%). Only one patient in group I later developed symptomatic sustained ventricular tachycardia in contrast to nine cases in group II. Symptomatic sustained ventricular tachycardia could be predicted in patients in the early postmyocardial infarction period (group II). By using various combinations of parameters, the highest predictive value for subsequent sustained ventricular tachycardia was reached by the following combination: Late potentials of 40 ms duration or more, induction of monomorphic sustained ventricular tachycardia at rates below 270 beats min-1 and interval after myocardial infarction less than 6 weeks. In conclusion, both techniques seemed to be promising for the identification of patients at risk of ventricular tachycardia after myocardial infarction.

Propafenone is a new antiarrhythmic drug with class-I action and some additional sympathicolytic activities. Due to its pharmacokinetic properties the drug is appropriate for long-term oral treatment. Propafenone is especially successful in suppressing ventricular arrhythmias and in preventing tachycardias in patients with WPW syndrome. So far, final conclusions concerning the side effects cannot be drawn.

Four hundred and thirteen defibrillations of alternating current-induced ventricular fibrillation were performed in 10 halothane-anaesthetized dogs (body weight: 24.5-30.5 kg). Success rates, energy demands, currents, peak voltages and impedance were determined. A transvenous catheter electrode system (Medtronic 6880, right ventricular apex and superior vena cava, distance 100 or 150 mm) and subcutaneous patch electrodes (Intec 67 L, 2nd/3rd and/or 3rd/4th left intercostal space) were used for bidirectional defibrillation. Loading voltages ranged from 600 to 850 V. With an electrode distance of 100 mm and a pulse duration of 2 ms separated by 1 ms, success rates were 100%, 40% and 0% for 850.650 and 600 V, respectively. With a 3-ms pulse duration, the corresponding rates were 100%, 60% and 50%. With a 2-ms pulse duration, successful defibrillation was achieved with energies lower than 15 J in 27%, with energies between 15 and 20 J in 77%, and 100% with energies higher than 20 J. Defibrillation currents were 4.4-9.3 A for pulse 1 (superior vena cava/ventricular apex) and 6.3-13.4 A for pulse 2 (patch/ventricular apex), respectively. Effective peak voltages ranged from 510 to 787 V and from 514 to 777V and averaged 89.6% of the loading voltages. Impedance values (peak voltage/current) were 75.5-117.7 (pulse 1) and 51.7-94.9 Ohms (pulse 2). Fifty consecutive defibrillations in one animal resulted in a decrease of impedance (114.6 to 84.9 Ohms, pulse 1:75.4 to 53.0 Ohms, pulse 2). Defibrillation of ventricular fibrillation can be achieved with acceptably low energies using a bidirectional transvenous/subcutaneous system, avoiding thoracotomy and general anaesthesia for implantation of the defibrillation system.

Catheter ablation of ventricular tachycardia (VT) was attempted in 24 patients (mean age 49 +/- 15.1 years) with a history of recurrent sustained VT resistant to previous antiarrhythmic drug therapy. 14 patients (58.3%) had also failed to respond to long-term administration of amiodarone alone and in combination with class I antiarrhythmic drugs. Endocardial catheter mapping during induced or spontaneous VT and/or pacemapping were performed to identify the site of origin of VT. Direct-current high-energy anodal shocks were delivered from a conventional cardioverter with stored energies of 100, 200 or 400 J via the distal electrode of conventional catheters. A total of 139 shocks was delivered during the ablation procedure. One patient died from wall perforation. Within 1 week of ablation, nine patients developed spontaneous recurrences of monomorphic sustained VT, identical to the clinical VT, and one patient developed a VT with a new morphology. In addition, four patients had a recurrence of their clinical VT after several weeks. In seven of 14 patients with spontaneous recurrences after the first ablation procedure and in three patients in whom VT was again inducible at the end of the first week, a second ablation procedure was performed. One patient with inducible VT after the first and second ablation sessions was given a third ablation procedure, and was discharged from hospital on anti-arrhythmic drugs which were successful despite being previously ineffective. After a mean follow-up period of 14.1 +/- 9.1 months, there were no spontaneous recurrences of sustained VT in 17 patients (71%) (nine without antiarrhythmic drugs and eight on antiarrhythmic drugs). In the remaining patients, incessant non-sustained VT (n = 2) or recurrent sustained VT (n = 2) occurred, and two patients died suddenly (at 2 and 21 months). There was no correlation between catheter mapping data or the results of pre-discharge electrophysiological study and clinical outcome during long-term follow-up. Complications related to catheter ablation included pulmonary oedema, cardiac tamponade, femoral artery occlusion, multiple episodes of ventricular tachycardia/fibrillation and thrombus formation, each in one patient (major complications; n = 7,29.1%), as well as transient third degree AV block, transient right or left bundle branch block, transient marked ST elevation or transient atrial tachycardia (minor complications; n = 8, 33.3%). The results suggest that catheter ablation might become an effective procedure for the non-pharmacological treatment of sustained VT.(ABSTRACT TRUNCATED AT 400 WORDS)