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Background: Although early improvement of haemodynamic parameters following successful cardioversion of atrial fibrillation (AF) has been well documented, the long-term benefits of sinus rhythm (SR) restoration are less obvious, mainly due to a high rate of AF relapses., Aim: To determine the impact of SR restoration and maintenance on exercise tolerance and heart failure progression in patients with persistent non-valvular AF during a one year follow-up period., Methods and Results: We studied 104 patients (33 females, 71 males, mean age 60.4+/-7.4 years) with mild to moderate stable heart failure and persistent AF with well-controlled ventricular rate who were scheduled for cardioversion. They underwent submaximal exercise testing 24 hours before cardioversion, as well as 1 and 12 months afterwards. Exercise capacity was determined during symptom-limited exercise testing, according to a modified Bruce protocol. Heart failure symptoms were assessed at the same time-points of follow-up., Results: SR was presented in 66 (63.5%) patients one year after cardioversion. In patients with SR, a significant improvement in left ventricular (LV) performance, exercise capacity and heart failure symptoms was noted. There was an increase in LV fractional shortening (29.9+/-7.6% vs 35.6+/-9.3%; p<0.001), maximal workload (4.7+/-2.3 vs 8.5+/-3.0 MET; p<0.001), exercise duration (125.3+/-115.3 vs 294.7+/-216.7 sec.; p<0.001), and improvement in the NYHA functional class (p<0.001). No such changes were observed in patients who had AF relapse during follow-up or in those who had unsuccessful cardioversion., Conclusions: Successful cardioversion of persistent AF resulted in a significant improvement of exercise capacity and a decrease in heart failure symptoms during one year follow-up period only in patients who maintained SR.

Background: Although increased left atrial size (LA) has been long regarded as one of the factors negatively influencing the long-term maintenance of sinus rhythm (SR) following cardioversion (CV) of atrial fibrillation (AF), some reports suggested that CV might be effective also in patients with large LA.Aim. We sought to determine the role of LA enlargement in long-term SR maintenance after CV of persistent AF., Methods: 104 consecutive patients (33 females, 71 males, mean age 60.4+/-7.4 years) were assigned to SR restoration and maintenance with serial antiarrhythmic drugs. Transthoracic echocardiographic (TTE) variables were recorded prior to CV. Generalised additive logistic regression was used to investigate the impact of LA enlargement on the long-term SR maintenance., Results: SR was present in 63.5% of patients after one year of follow-up. Increased LA area >28 cm (RR 1.72; 1.09-2.71; p<0.02) and increased fractional shortening values in ranges between 26-40% (1.2; 1.01-1.44; p<0.05) were significantly associated with SR maintenance after one year. In order to determine the influence of the LA diameter on the probability of SR maintenance, we analysed mean LA(ar) values prior to and after CV. Patients with large LA(ar) (28 cm(2)) presented a significant decrease of LA size (31.45+/-3.07 cm(2) vs 28.94+/-3.81 cm(2); p<0.008) during the first 30 days after SR restoration. In the group of patients with LA(ar) 28 cm(2) we noted decrease in LA size by 2.57+/-3.2 cm(2), whereas in patients with a smaller LA volume this decrease was significantly lower, being 0.47+/-2.9 cm(2) (p<0.004)., Conclusions: LA enlargement does not preclude a favourable outcome after CV of AF. The decrease in LA area occurring during 30 days following CV favours long term SR maintenance.

Background: In some patients with acute pulmonary embolism (APE) thrombi may lodge at the levels of the bifurcation of pulmonary trunk and extend into both main pulmonary arteries, forming so-called saddle embolism (SE)., Aim: To assess the incidence of SE and whether it is associated with an increased risk of complicated clinical course., Methods: We studied 150 consecutive patients (94 females, 56 males) aged 63.6+/-16.7 years with APE confirmed with contrast enhanced spiral computed tomography or transesophageal echocardiography., Results: SE was detected in 22 (14.7%) patients. Mean age (SE vs N-SE) was 64.3+/-17.4 vs 63.5+/-16.6 years, heart rate 100.8+/-14.1 beats/min vs 97.8+/-21.1 beats/min, systolic blood pressure 126.2+/-20.1 vs 127.1+/-23.3 mmHg and blood pulsoximetry 92 (68-98) vs 91 (30-98) % (all differences NS). In patients with SE, echocardiographic signs of the right ventricular overload, defined as right to left ventricular end - diastolic ratio >0.6 with right ventricular hypokinesia and/or maximal tricuspid peak systolic gradient >30 mmHg with shortened acceleration time of pulmonary ejection <80 ms, were more frequent (77.3% vs 51.6%, p=0.04), as was the mid-systolic deceleration of pulmonary ejection velocity (77.3% vs 49.2%, p=0.04). Mortality and complicated clinical course rates were similar in patients with SE or N-SE (mortality: 4.5% vs 13.3%, NS, and complicated clinical course: 34.4% vs 25.0%, NS)., Conclusions: Saddle pulmonary embolism is frequent, especially in patients with echocardiographic signs of impaired pulmonary ejection pattern. Saddle embolism does not indicate unfavourable clinical outcome and probably should not influence treatment selection.

Background: Paradoxical embolism due to the presence of patent foramen ovale (PFO) is a well-established possible mechanism of ischaemic stroke of unknown origin. Mechanical sealing of the interatrial septum seems to be the most effective method for the prevention of stroke recurrences., Aim: To assess prospectively the short- and mid-term results of transcatheter closure of PFO in consecutive patients with a history of cryptogenic ischaemic stroke., Methods: Between March 1999 and December 2002, thirty two patients with PFO (15 males, age from 19 to 55 years, mean 41 years) with a history of documented ischaemic stroke of unknown origin underwent transcatheter closure of PFO using an Amplatzer occluder. All procedures were performed under general anaesthesia and with transesophageal echocardiographic guidance., Results: In all patients the procedure was effective and no complications were observed. During the follow-up period of a mean of 25.9 months (>12 months in 22 patients), no new neurological events were recorded. Control transesophageal echocardiography was performed in 28 patients mean 22.3 months after the procedure and confirmed the correct positioning of the occluder. A significant (>30 bubbles of contrast) residual shunt was detected in two patients. One patient developed episodes of paroxysmal supraventricular tachycardia which were effectively cured by radiofrequency ablation., Conclusions: Transcatheter closure of PFO is safe, effective and devoid of side effects connected with extracorporeal circulation. This procedure may become the treatment of choice in patients with the highest risk of recurrent ischaemic stroke.

Background: Long-term maintenance of sinus rhythm (SR) after successful cardioversion (CV) of persistent atrial fibrillation (AF) carries a low risk of stroke and may avoid the risks associated with anticoagulation., Aim: To determine the clinical and echocardiographic predictors of maintaining SR during one-year follow-up., Methods: The initial study group consisted of 205 patients with persistent AF of whom 104 (33 females, 71 males, mean age 60.4+/-7.4 years) were randomised to SR restoration and maintenance. The results of transthoracic echocardiography, obtained before CV, were compared between patients who remained in SR and those in whom AF recurred during a one-year follow-up period, using the linear and logistic regression analysis., Results: SR was present in 63.5% of patients at the end of the follow-up period. Of several analysed echocardiographic parameters, an increased left atrial area (<28 cm(2)) (p<0.02; RR 1.72, OR 1.09-2.71) and an increase in the fractional shortening of the left ventricle (range 25-40%, p<0.05, RR 1.2, OR 1.01-1.44) were significantly associated with SR maintenance during a 12-month follow-up period., Conclusions: Left atrial area and left ventricular fractional shortening are the independent predictors of the maintenance of SR after successful CV in patients with persistent AF.

Background: Patients with atrial fibrillation (AF) can be managed either by maintaining sinus rhythm using antiarrhythmic drugs and/or electrical cardioversion, or by leaving patients in AF and controlling ventricular rate without attempts to restore sinus rhythm. Which of these two strategies is superior, has not yet been definitively established., Aim: HOT CAFE Polish Study (How To Treat Chronic Atrial Fibrillation) was designed to evaluate in a randomised, multicentre and prospective manner the risks and advantages of two therapeutical strategies - rate control or rhythm control, in patients with persistent AF., Methods: The study group consisted of 205 patients (71 females and 134 males; mean age 60.8+/-11.2 years) with a mean time of AF duration of 273.7+/-112.4 days; 101 patients were randomly assigned to rate control (Group I) whereas 104 patients were randomised to sinus rhythm (SR) restoration by DC cardioversion (CV) and subsequent antiarrhythmic drug treatment (Group II). At the end of follow-up (12 months) SR was present in 75% of patients., Results: The incidence of hospital admissions was higher in group II in comparison to group I (12% vs 74%; p<0.001). Mortality was similar in both groups (1.0% versus 2.9%, NS). In both groups a significant improvement of heart failure symptoms was observed during the first 2 months (p<0.02 and p<0.001). In group II exercise tolerability measured by maximal workload during treadmill test significantly improved compared with baseline (5.2+/-5.1 vs 7.6+/-3.3 MET; p<0.0001). In patients in whom SR was restored, the left ventricular function improved and an increase in the shortening fraction was observed (29+/-7% vs 31+/-7%; p<0.01). No thromboembolic complications were observed in patients left with AF. Three patients from group II suffered ischaemic stroke; in two cases stroke was associated with CV whereas in the third patient - with late AF recurrence., Conclusions: The HOT CAFE Polish Study did not reveal significant differences in mortality between the two treatment strategies in patients with persistent AF. Although patients with SR had better improvement in some haemodynamical parameters, the hospitalisation rate was higher and the incidence of stroke was not reduced compared with the rate control group.

A case of a 37-year-old male admitted to the hospital due to dyspnea and chest pain is presented. Electrocardiogram showed negative T waves in V1 and V2 as well as subtle ST segment elevation in all precordial leads. Cardiac enzymes were moderately elevated. The initial diagnosis was myocarditis or acute coronary syndrome, however, transthoracic echocardiography showed a marked right ventricular overload which suggested acute pulmonary embolism. The latter diagnosis was confirmed by transesophageal echocardiography which revealed thrombosis of both left and right pulmonary arteries. The patient received thrombolysis and anticoagulants, and his condition improved. He was discharged home and the course of a six-month follow-up was uneventful.